Singapore has implemented a nationwide school-based human papillomavirus (HPV) vaccination program since 2019, aiming to significantly increase vaccination coverage and reduce the disease burden of cervical cancer through an institutionalized, systematic vaccination strategy. The “health-education-society” collaborative model it has established holds significant reference value for China. This article summarizes Singapore’s experience in implementing a school-based program for HPV vaccination, drawing on publicly available literature published by members of the Health Promotion Board and expert insights shared at VaxLab’s online technical workshop.
Background of the School-Based Vaccination Program
Singapore established its School Health Services in 1921, boasting a long history and a well-established system. Prior to the introduction of the HPV vaccine school immunization program, school-based vaccination services were primarily conducted in primary schools. These services mainly provided catch-up vaccinations for measles, diphtheria, and polio vaccines, as well as tetanus-diphtheria-pertussis (Tdap) booster shots for 10- to 11-year-old Primary five students.
In November 2010, the HPV vaccine was formally incorporated into Singapore’s National Childhood Immunisation Programme (NCIP). Its coverage was further expanded to include adults in November 2017. In 2019, Singapore launched HPV vaccination in schools, formally extending the school-based immunization service to the secondary school level.
According to 2016 estimates, HPV vaccine coverage among 26 years old was only about 25%. Key reasons include insufficient awareness, inconvenience due to multiple doses and high cost of vaccination. For instance, during the early stages of HPV vaccine introduction into the National Immunization Program, the vaccination cost was relatively high, second only to pneumococcal vaccines. At government polyclinics, a single dose costs approximately S$120, while the full 2-3 dose course costs around S$240-360. Even with the option to use MediSave, this represented a significant financial burden for some families.
Policy makers believe that implementing school-based immunization programs can help overcome these barriers. First, leveraging the long-established and well-established school-based vaccination system would facilitate targeted information delivery to students and parents. Second, administering vaccinations on school premises would enhance convenience for recipients. Third, vaccines administered through school programs would be fully subsidized by the government, reducing the financial burden on families.
School Immunization Program: Target Population and Catch-Up Schedule
Since 2019, Singapore has implemented a nationwide school-based HPV vaccination program. Based on evidence from cost-effectiveness studies, Singapore selected the bivalent HPV vaccine (Cervarix) as the preferred vaccine for its school immunization program. The school-based HPV vaccination targets female students entering Secondary 1 (12-13 years old) as the core cohort, following a two-dose schedule (0, 6-12 months) with a 12-month interval between doses.
Selecting first-year Secondary schoolgirls (aged 12-13) as the target vaccination group primarily considered the following three core factors: 1) HPV is primarily transmitted through sexual activity. Vaccination is most effective before exposure to infection. Vaccinating at younger ages would inevitably require discussing sensitive topics, causing discomfort for parents; 2) First-year secondary students are not required to take major national examinations, reducing parental vaccine hesitancy and interference with vaccination scheduling. Additionally, the two-dose vaccination schedule minimally impacts school timetables, allowing vaccination teams to administer doses to two grade levels during each school visit. Currently, students who miss vaccination at school can schedule appointments at the Student Health Center under the Health Promotion Board.
In 2019, all female students enrolled in Secondary 1 through 5 became eligible for the vaccine through a one-time catch-up program. A phased catch-up mechanism will be implemented, prioritizing coverage for those in Secondary Year 3 to 5 who were nearing graduation. Lower-secondary students were progressively vaccinated over the following two years to achieve full coverage across all age groups. Girls aged 15 and under received a two-dose regimen, while those over 15 received a three-dose regimen.
Cross-sectoral Collaboration, Service Provision, and End-To-End Management
The Health Promotion Board (HPB), a statutory board under Singapore’s Ministry of Health, administers the School Health Service and serves as the primary provider for the school HPV immunization program. HPV vaccination is offered on a voluntary basis, with the government covering the full cost.
The Health Promotion Board of Singapore is responsible for providing timely updates to schools under the Ministry of Education regarding the HPV vaccination program, its coverage, and implementation progress, including consent procedures and confidentiality measures. The Ministry of Education provides the Health Promotion Board with registration data for students in secondary schools. The Health Promotion Board also briefs principals and relevant school administrators to familiarize them with the workflow. Detailed vaccination letters are sent to each school principal. On the school side, teachers and relevant staff support program operations, including information dissemination and scheduling student appointments—determining when to bring which class to the health screening and vaccination site, and so forth.
The school health service team typically visits schools once every year. While administering the first dose of HPV vaccine to new Secondary 1 girls, they can also provide the second dose to students who have advance to Secondary 2. Vaccination procedures follow strict standardized protocols, including pre-vaccination health assessments, standardized administration techniques, on-site medical observation, and a mandatory 15-minute post-vaccination monitoring period. A mechanism for reporting and rapidly addressing adverse events is established.
As part of the implementation, the government also contracted private providers to assist with vaccination procedures for target and catch-up groups. These providers were also responsible for offering follow-up vaccination services to students deemed medically ineligible for vaccination on school-based vaccination days, as well as to catch-up group students who were about to graduate and leave school before completing their three-dose regimen. For women aged 18-26 who had already left school, targeted outreach via text messages guided them to book appointments through the government-developed Health Appointment System (HAS), establishing a seamless continuity of immunization services both on and off campus. The Health Promotion Board also conducted multiple meetings and training sessions for providers, including simulations of common scenarios encountered during vaccinations and corresponding response measures.
The project leverages the School Health Service’s Clinical Management System for end-to-end digital management, that includes an online Child Consent Portal (CCP) that integrates electronic informed consent, information push notifications, and status inquiry functions. After logging into the CCP, parents can enter their child’s medical history, current medications, known allergies, and electronically sign the HPV vaccination consent form. This consent covers all doses until the vaccination series is completed. Should parents decline vaccination, the system provides a dedicated section for them to state their reasons for refusal.
One week prior to school vaccinations, parents who have not completed the online form will receive reminders from the school and healthcare team. The online CCP information is transmitted to the Clinical Management System via the government’s dedicated encrypted network.
In project oversight, the Health Promotion Board established a dedicated HPV Control Room to monitor nationwide on-site vaccination efforts and vaccination rates. Following daily school visits, all nursing team managers participated in post-action assessment meetings. These sessions involved updating on-site vaccination statistics and troubleshooting practical challenges encountered. The Oversight Committee also conducted on-site visits to vaccination sites to supervise immunization procedures and identify potential oversights.
Communications, Mobilization, and Health Education
Prior to and during the implementation of the school-based vaccination program, Singapore adopted a multi-channel communication strategy grounded in scientific evidence to enhance trust and awareness of the HPV vaccine. In 2018, Singapore conducted a questionnaire survey among 2,098 parents from eight primary schools and eight secondary schools. Survey results showed widespread support—63.3% of respondents favored vaccination, with only 4.4% opposing introducing the HPV vaccination program, and 32.3% remaining neutral. However, only 44.0% of respondents were aware of the vaccine, and just 14.8% of family members had ever received it. Insufficient information was cited as the primary reason parents declined to consent to vaccination.
Based on these survey findings, the Health Promotion Board collaborated with the Singapore Cancer Society to launch a large-scale online platform campaign targeting parents of adolescents aged 13 to 17 from July to September 2019. Through digital media advertising and poster campaigns, the initiative aimed to enhance public trust in the HPV vaccine and emphasize its value in reducing cervical cancer risk. Simultaneously, the government promoted the benefits and strong safety profile of the HPV vaccine through multilingual newspapers, broadcast news, and social media channels. Prior to project implementation, HPB also engaged in thorough discussions with the Islamic Religious Council of Singapore, confirming that there were no religious contraindications to HPV vaccination.
On the day of on-campus vaccination, the vaccination team nurses explained HPV infection and its link to cervical cancer to students, outlined the indications for the HPV vaccine, and discussed potential side effects and relief measures. Subsequently, licensed physicians assessed students to confirm the absence of contraindications. On-site verification of both paper and electronic versions of the informed consent form was conducted. If parents had not yet signed either version, on-site nurses contacted them by phone to obtain consent. This process also allowed for real-time clarification of parental concerns and resolution of misunderstandings. Upon parental agreement, consent could be provided via the CCP or by visiting the school to sign the paper document. Vaccination was then administered by the vaccination team. After vaccination, students remained seated in the observation area under direct supervision of the nursing team for 15 minutes to monitor for adverse reactions or side effects. Only if no abnormal reactions were observed could students return to class, along with guidance on when to seek medical attention.
The Effectiveness of HPV Program Implementation
Data review indicates that from 2018 to 2024, vaccination coverage among female Singaporean residents aged 15 (including citizens and permanent residents) rose significantly from under 30% to approximately 88%-89%.
Another study published in 2023 revealed that prior to implementing the school-based HPV immunization program, vaccination rates among women aged 18 to 26 stood at only 13.6%. Among first-year secondary school students, just 3.0% had completed the vaccination series, while vaccination rates for fourth- and fifth-grade students reached 6.2%. Following the school-based program implementation, overall vaccine coverage—including off-campus vaccination pathways—reached 90.3%–93.4%. The explicit refusal rate was only 1.5%–1.9%, indicating high societal acceptance.
During the study period, 50,695 doses of HPV vaccine administered in schools (including initial routine doses and catch-up first/second doses) were reviewed, with an adverse reaction reporting rate of 0.1% (51 cases). Reported symptoms primarily consisted of known mild reactions such as dizziness and fatigue. Only 3 students experienced syncope, all of whom underwent further medical evaluation: one case was attributed to extreme needle phobia, while the other two were determined to be unrelated to the vaccine. Among these, 37 students (including the 2 who experienced syncope) successfully completed their second-dose vaccination.
Insights and Lessons Learned
The implementation experience of Singapore’s HPV vaccine school-based immunization program demonstrates that the success of high-coverage immunization initiatives depends on the effective integration of top-level institutional design, financial safeguards, inter-agency collaboration, and a meticulous implementation system. The success of the school-based approach can be attributed to the following factors:
Insights into the needs of target vaccination populations and parents. Surveys were conducted early in the project implementation phase to assess parents’; and children’s knowledge, attitudes, and practices regarding vaccines and health-related information. Preference for vaccination site selection was also investigated. Based on the findings, multiple solutions were implemented, including launching a media campaign to boost vaccine awareness, conducting extensive outreach, producing informational brochures, and providing parents with FAQ handbooks.
Engagement of key stakeholders and establishment of robust partnerships. Collaboration with the Ministry of Education ensured the vaccination program seamlessly integrated with the school curriculum while fully accommodating national examination schedules and critical assessment timelines. Partnerships with the Singapore Cancer Society reinforced unified messaging on the vaccine’s importance, while coordination with religious groups ensured the immunization plan did not conflict with religious requirements. At the implementation level, collaboration with schools and their service operations managers ensured smooth on-site arrangements and immunization processes. Partnerships with healthcare providers enabled timely reminders and catch-up follow-ups, allowing students who missed school-based vaccinations to conveniently receive doses at community clinics nationwide.
Continuous monitoring, evaluation, and improvement of the on-campus vaccination service system. The Health Promotion Board maintains vaccine storage standards through continuous field visits, evaluations, and cold chain management oversight. It facilitates ongoing assessment and improvement of existing systems by conducting daily Activity After-Action Reviews (AARs), including: 1) Enhancing vaccine delivery timeliness to avoid prolonging students’; school hours; 2) Analyzing success factors of schools achieving 95%-100% vaccination rates for replication across other institutions. Regarding implementation, details and services are meticulously executed, including: 1) Sending reminder letters to parents one week prior to vaccination to reduce incomplete form submission rates; 2) Systematically following up with absentees by phone to invite them for alternate vaccination dates; 3) Collaborating with school parent support groups; 4) Pre-sorting consent forms before vaccination days and contacting parents with incomplete forms on-site to optimize time efficiency.
The Singapore Model provides a comprehensive implementation framework encompassing evidence-based decision-making, needs assessment, multisectoral coordination, and continuous quality improvement. For countries and regions with well-established education systems and robust primary healthcare networks, this model offers high transferability in terms of institutional embedding pathways, collaborative governance structures, and digital support systems. It provides valuable policy and practical references for accelerating HPV vaccination programs and achieving the goal of eliminating cervical cancer.
Acknowledgments
We extend our gratitude to Mr. Lim Soon Kok, Director of the Immunization Policy and Strategy Division, Policy and Systems Department, National Infectious Disease Agency, Ministry of Health, Singapore, for his presentation at the VaxLab online technical workshop. We also thank Gao Zhenghong, a student from the School of Public Health at Kunming Medical University, for compiling and translating the seminar minutes.
Content Editor: Zhourong Li
Proofreader: Zhangyang Pan
Page Editor : Ruitong Li
Reference:
[1] Vijayalakshmi K, Goei AHY. Improved population coverage of the human papillomavirus vaccine after implementation of a school-based vaccination programme: the Singapore experience. Singapore Med J. 2023 May;64(5):294-301. doi: 10.11622/smedj.2022053. PMID: 35546141; PMCID: PMC10219123.
