This paper highlights the low levels of vaccine coverage and high levels of reported vaccination hesitancy in Yerevan, Armenia, that present profound challenges to the control of disease through routine vaccination programmes. We draw on investigations of hesitancy towards the introduction of new vaccines, using the Human Papillomavirus (HPV) vaccine Gardasil as a case study, to interrogate underlying challenges to vaccine acceptance. We analyse primary data from the introduction of Gardasil, first used in Armenia in 2017, to investigate how levels of medical knowledge amongst physicians in 20 health facilities in Yerevan, Armenia, regarding vaccine science influence attitudes towards the introduction of a newly developed vaccine. A questionnaire-based cross-sectional study was completed by 348 physicians between December 2017 and September 2018. The responding physicians displayed a respectable level of knowledge and awareness regarding vaccination with respect to some characteristics (e.g., more than 81% knew that HPV infection was commonly asymptomatic, 73% knew that HPV infection was implicated in most cervical cancers, and 87% knew that cervical cancer is the most prevalent cancer amongst women) but low knowledge and poor understanding of other key issues such as the age at which women were most likely to develop cervical cancer (only 15% answered correctly), whether or not the vaccine should be administered to people who had already been infected (27% answered correctly) and whether sexually active young people should be treated for infection before vaccination (26% answered correctly). The study suggests that the drivers of vaccine hesitancy are complex and may not be consistent from vaccine to vaccine. The Armenian healthcare sector may need to provide additional training, awareness-raising and educational activities alongside the introduction of new vaccines to improve understanding of and trust in vaccination programmes.

Background This primary-data analysis investigates the current level of awareness and medical knowledge of physicians in 20 health facilities in Yerevan, Armenia regarding vaccination – specifically with regard to HPV infection and the recently-introduced Gardasil vaccine used against HPV infection – that may have implications for successful roll-outs of national programmes for new vaccines, including those for COVID-19. Methods A questionnaire-based cross-sectional study was completed by 348 physicians who met the study inclusion criteria, from 20 out of 36 randomly selected healthcare facilities in Yerevan, Armenia, between Dec 2017 to Sep 2018. The aim of the questionnaire was to identify physicians’ awareness of and attitudes to HPV-related cervical cancer and the Gardasil vaccine. Responses were analysed using SPSS software (Version 16). Results The responding physicians displayed a respectable level of knowledge and awareness regarding vaccination with regard to some characteristics (e.g. more than 81% knew that HPV infection was commonly asymptomatic, 87% were knew that HPV infection was implicated in most cervical cancers and 87% knew that cervical cancer is the most prevalent cancer amongst women) but low knowledge in others and poor understanding of key issues such as the age at which women were most likely to develop cervical cancer (only 15% answered correctly); whether or not the vaccine should be administered to people who had already been affected (27% answered correctly) and whether sexually active young people should be treated for infection before vaccination (26%). Lack of confidence within the surveyed groups regarding the value of vaccination and, in particular concerns over the reasons for administering it to certain age cohorts, was driven by misconceptions. Conclusions Armenian physicians’ awareness of vaccine characteristics, the reasons for their inclusion in the national vaccination programme and the characteristics of the diseases they treat can be poor. The study further suggests that drivers of vaccine hesitancy are complex, may not be consistent from vaccine to vaccine, and may vary from generation to generation. The Armenian healthcare sector may need to provide additional training, awareness-raising and educational activities to improve understanding of and trust in vaccination programmes. Further studies are warranted to better understand knowledge, attitudes and practices (KAP) regarding immunization and vaccination programmes amongst Armenian healthcare workers.