African country faces challenges to protect girls from HPV

When health workers arrived at Upendo Primary School, on the outskirts of the Tanzanian capital, they asked girls who would turn 14 this year to line up to get vaccinated. Quinn Chengo held an urgent, whispered consultation with her friends. What was the injection for, really? Could it be a Covid vaccine? (They had heard rumors about it.) Or was it supposed to keep them from having babies?

Ms. Chengo was uncomfortable, but remembered that last year her sister had been vaccinated against the human papillomavirus. So she come in the line. However, some girls escaped and hid behind the school buildings. When some of Ms. Chengo’s friends arrived home that evening, they were faced with questions from their parents, who feared that this would make their children more comfortable with the idea of ​​having sex. – even if some didn’t want to come out right away and say so.

The HPV vaccine, which provides near-total protection against the sexually transmitted virus that causes cervical cancer, has been given to adolescents in the United States and other industrialized countries for nearly 20 years. But it is only now beginning to be widely introduced in low-income countries, where 90% of cervical cancer deaths occur.

Tanzania’s experience – with misinformation, with cultural and religious unease, and with supply and logistical obstacles – highlights some of the challenges countries face in implementing what is seen as an essential health intervention in the region.

Cancer screening and treatment is limited in Tanzania; the vaccine could significantly reduce deaths from cervical cancer, the deadliest cancer for Tanzanian women.

HPV vaccination efforts have been hampered across Africa for years. Many countries had designed programs to start in 2018, working with Gavi, a global organization that provides vaccines to low-income countries. But Gavi was unable to provide them with injections.

In the United States, the HPV vaccine costs about $250; Gavi, which typically negotiates deep discounts with pharmaceutical companies, aimed to pay $3-5 per injection for the large volumes of vaccines it sought to procure. But as high-income countries also expanded their programs, vaccine makers – Merck and GlaxoSmithKline – targeted those markets, leaving little to developing countries.

“Even though we had talked a lot about the supply we needed from manufacturers, it wasn’t happening,” said Aurélia Nguyen, Gavi’s chief strategy officer. “And so we had 22 million girls that countries had requested to be vaccinated and that we had no stock for at that time. It was a very painful situation.

Low-income countries have had to decide where to allocate the limited quantities of vaccines they have received. Tanzania chose to first target 14-year-olds who, as the oldest eligible girls, were considered most likely to initiate sexual activity. Girls begin to drop out at this age, before going to secondary school; the country had planned to deliver the vaccines mainly to schools.

But vaccinating a teenager against HPV is not like giving a measles vaccine to a baby, said Dr. Florian Tinuga, program manager for the immunization and vaccine development unit at the Ministry of Health. Fourteen year olds need to be convinced. But because they are not yet adults, the parents also have to be convinced. It means having candid discussions about sex, a sensitive topic in the country.

And because 14-year-olds were considered young women nearing marriageable age, rumors quickly spread on social media and messaging apps about what was really in the plan: could- is this a stealthy birth control campaign from the West?

The government had not anticipated this problem, Dr Tinuga said sadly. Rumors were difficult to counter in a population with limited understanding of research or scientific evidence.

The Covid pandemic has further complicated the campaign against HPV by disrupting healthcare systems, forcing school closures and creating new levels of vaccine hesitancy.

“Parents pull their children out of school when they hear the vaccination is coming,” said Khalila Mbowe, who heads the Tanzanian office of Girl Effect, a nongovernmental organization funded by Gavi to stimulate demand for the vaccine. “After Covid, vaccination issues are supercharged.”

Girl Effect produced a radio soap opera, nifty posters, chatbots and social media campaigns urging girls to have their pictures taken. But this effort and others in Tanzania have focused on motivating girls to accept the vaccine, without sufficiently considering the power of other gatekeepers, including religious leaders and school officials, who have a strong voice in the decision, Ms Mbowe said.

Asia Shomari, 16, was scared the day health workers came to her school on the outskirts of Dar es Salaam last year. The students had not been informed and did not know what the shooting was for. It was an Islamic school where no one ever talked about sex, Ms Shomari said. She hid behind a toilet block with friends until the nurses left.

“Most of us decided to run,” she said. When she returned home and told what had happened, her mother said she had done the right thing: any vaccine related to reproductive organs was suspect.

But now her mother, Pili Abdallah, has started to change her mind. “Girls her age are sexually active and there are a lot of cancers,” she said. “If she could be protected, that would be good.”

While Girl Effect has some messages for mothers, the truth is that fathers have the final say in most families, Ms Mbowe said. “The power of decision does not belong to the girl.”

Despite all the challenges, Tanzania managed to vaccinate almost three-quarters of its 14-year-old girls in 2021 with a first dose. (Tanzania reached this first dose coverage target twice as fast as the United States.) Persuading people to return for a second dose was more difficult: only 57% received the second injection six months later. A similar gap persists in most sub-Saharan countries that have started HPV vaccination.

Since Tanzania has relied heavily on pop-up clinics in schools to administer vaccines, some girls miss the second dose because they have left school by the time health workers return.

Rahma Said was vaccinated at school in 2019 when she was 14 years old. But soon after, she failed the exams to go to high school and dropped out. Ms Said made several attempts to get a second shot at public health clinics in her neighborhood, but none had the vaccine, and last year, she said, she gave up.

Next year, Tanzania will most likely switch to a single-dose regimen, Dr Tinuga said. There is growing evidence that a single injection of the HPV vaccine will produce adequate protection, and in 2022 the WHO recommended that countries move to a single-dose campaign, which would improve costs and vaccine supply, and remove that challenge of trying to vaccinate girls. a second time.

Another cost-effective step, according to public health experts, would be to switch from school-based vaccination to HPV vaccination as one of the routine vaccines offered in health centers. This change will require a huge and sustained public education effort.

“We need to make sure the demand is very, very high because they usually won’t be going to facilities for other procedures,” said Ms Nguyen of Gavi.

Now, at last, the vaccine supply has piled up, Ms Nguyen said, and new versions of the vaccine have come to market from companies in China, India and Indonesia. Supply is expected to triple by 2025.

Populous countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh plan to introduce or expand use of the vaccine this year, which could even challenge the expanded supply . But the hope is that there will soon be enough doses for countries to vaccinate all girls between the ages of 9 and 14, Ms Nguyen said. Once caught up, the vaccine will become routine for 9-year-olds.

“We have set the target of 86 million girls by the end of 2025,” she said. “That will be 1.4 million deaths averted.”

Ms. Chengo and her friends were convulsed with giggles at the mere mention of sex, but they said that in fact many girls in their class were already sexually active, and it would be better when Tanzania could vaccinate the girls at 9 years old. .

“Eleven is too late,” Restuta Chunja said, with a grim nod.

Ms Chengo, a 13-year-old with sparkling eyes who intends to become a pilot when she graduates, said her mother told her the vaccine would protect her from cancer, but she shouldn’t have ideas.

“She said I shouldn’t get married or be involved in sexual activities because it would be bad and you might get something like HIV”

The HPV vaccine is offered to both boys and girls in high-income countries, but WHO advises prioritizing girls in developing countries with existing vaccine supplies, as women contract 90% of HPV vaccines. HPV-related cancers.

“From Gavi’s perspective, we are not there yet to add boys,” Ms Nguyen said.

Dr. Mary Rose Giattas, cervical cancer expert and Tanzania medical director of Jhpiego, a non-profit health care organization affiliated with Johns Hopkins University, thinks any remaining hesitation can be overcome. When educating the public on the spot, she talks about Australia.

“I say, forget the rumours: Australia has almost eliminated cervical cancer. And why? Because they vaccinate. And if the vaccine caused a fertility problem, we would know because they were one of the first countries to use it.

Misconceptions can be resolved with “chewing evidence,” she said. “I say that our Ministry of Health takes serious measures to test the drugs: they do not come directly from Europe to your clinic. I tell women, “Unfortunately, you and I missed it because of our age, but I wish I could get vaccinated now.”