Investigating HPV Vaccination in the Republic of Palau: Assessment of the School-Based Program from 2020 to 2024

Cervical cancer, caused primarily by human papillomavirus (HPV), causes substantial health burden in the Republic of Palau. Despite availability of the HPV vaccine through a school-based vaccination program for girls beginning in 5th grade, HPV vaccination coverage in Palau has declined since 2020. To understand why, this descriptive cross-sectional study analyzed data from the first opportunity for vaccination for all 5th grade girls enrolled at Koror and Babelthaob schools between August 1, 2020 and June 30, 2024. Data were retrieved from the Ministry of Education, School Health Program, and national Immunization Information System (IIS). The proportion of 5th grade girls who returned the consent form, responses to the HPV vaccine consent question, and vaccination coverage with at least 1 dose were analyzed. Among girls enrolled in Palau elementary schools during the period (n=467), although most consent forms were returned (n=434, 93%) and most girls (n=326, 70%) received consent for HPV vaccination, only 42% (n=198) received at least 1 dose of HPV vaccine according to IIS. Responses were missing for the HPV vaccine consent question on 17% of returned forms (n=73). Refusal of the vaccine was uncommon on returned forms (n=35, 8%), but there was an increase in refusals in the latest school year (n=25, 24% of 2023-2024 returned forms). An investigation into the process from the consent form to vaccination outreach in the schools is needed to understand why girls who received consent for vaccination did not receive the vaccine according to IIS. Improving the school-based vaccination program is critical to achieve 90% HPV vaccination coverage and reduce the cervical cancer burden in Palau.