Journal of Vaccine Research 2024, Vol.14, No.2, 76-84 http://medscipublisher.com/index.php/jvr 78 7.7% compared to 14.1% among non-vaccinated students (Lau et al., 2019). Additionally, a systematic review of adolescent immunization programs indicated that strategies to improve HPV vaccine coverage resulted in a significant decrease in the prevalence of HPV and genital warts (Das et al., 2016). 3.3 Cost-effectiveness of school-based programs The cost-effectiveness of school-based vaccination programs has been a subject of interest in several studies. A systematic review emphasized the need for prospective, well-controlled trials to establish the cost-effectiveness of specific vaccination strategies in school settings (Cawley et al., 2010). In Africa, a comparison of school-based and supplemental vaccination strategies found that while both approaches achieved high vaccination coverage, school-based vaccinations were generally more expensive than supplemental immunization activities (Haddison et al., 2017). However, the review also noted that school-based programs did not negatively affect routine immunization services, suggesting that they can be a sustainable option for increasing vaccination coverage (Haddison et al., 2017). Additionally, the role of school nurses in vaccination programs has been highlighted as a cost-effective strategy to increase immunization rates, as their involvement has been shown to positively impact vaccination adherence (Guarinoni and Dignani, 2021). 4 Case Studies and Examples of Successful Programs 4.1 High-income countries 4.1.1 United States: successes and challenges In the United States, school-based vaccination programs have been instrumental in increasing vaccination coverage among children and adolescents. Mandated vaccination for school attendance has shown a positive impact on vaccination rates, although the implementation of these mandates has faced challenges, particularly with the human papillomavirus (HPV) vaccine, which has been controversial (Greyson et al., 2019). Organizational factors such as program leadership, communication with parents, and the role of school nurses have been identified as critical to the success of these programs (Perman et al., 2017). Despite these challenges, educational interventions and reminders have been effective in improving vaccination uptake (Siddiqui et al., 2022). 4.1.2 United Kingdom: program implementation and outcomes The United Kingdom has successfully implemented school-based vaccination programs, particularly for the HPV vaccine. The UK's approach has been characterized by strong government support and effective communication strategies, which have led to high vaccination coverage rates (Hardt et al., 2016). The use of grade-based eligibility criteria has also facilitated the implementation of these programs in school settings (Paul and Fabio, 2014). The success of the UK's program highlights the importance of tailored, culturally-appropriate approaches and robust organizational structures (Perman et al., 2017). 4.1.3 Australia: effective strategies and results Australia's National HPV Vaccination Program, which began in 2007 for females and in 2013 for males, has achieved substantial reductions in the prevalence of HPV and genital warts among young Australians (Skinner et al., 2015). The program's success can be attributed to a combination of educational interventions, decisional support tools, and logistical strategies such as in-school mop-up vaccination and consent form return strategies (Skinner et al., 2015). Australia's long history of school-based vaccination programs and high coverage rates underscore the effectiveness of these strategies (Skinner et al., 2015; Hardt et al., 2016). 4.2 Low- and middle-income countries 4.2.1 India: challenges and successes In India, school-based vaccination programs face significant challenges, including logistical issues and varying levels of parental knowledge about the importance of vaccinations (Lukusa et al., 2018). However, educational interventions targeting parents and community-based education campaigns have shown promise in improving vaccination coverage (Figure 1) (Lukusa et al., 2018). These interventions have led to substantial improvements in childhood vaccination rates, demonstrating the potential for school-based programs to overcome barriers in lowand middle-income countries (Lukusa et al., 2018).
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