When health workers arrived at Upendo Primary School, on the outskirts of Dar es Salaam, Tanzania, they instructed girls who would turn 14 this year to line up to receive the vaccine. Quinn Chengo held an urgent, whispered consultation with her friends. What is the injection really for? Could it be a Covid vaccine? (They had heard rumors about it.) Or was it to keep them from having children?
Mrs. Chengo was worried, but remembered that last year her sister had this vaccine, for the human papilloma virus. So she got in line. Some girls escaped and hid behind school buildings. When some of Mrs. Chengo got home that night, they faced questions from their parents, who feared it might make their kids feel more comfortable with the idea of having sex — even if some didn’t want to come out and say so.
The HPV vaccine, which offers near-total protection against the sexually transmitted virus that causes cervical cancer, has been given to teenagers 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, cultural and religious discomfort, and logistical and supply bottlenecks – highlights some of the challenges countries face in implementing what is seen as a critical health intervention in the region.
Cancer screening and treatment is limited in Tanzania; the injection could dramatically reduce deaths from cervical cancer, the deadliest cancer for women in Tanzania.
HPV vaccination efforts have been hampered across Africa for years. Many countries have created programs to start in 2018, working with Gavi, a global organization that provides vaccines to low-income countries. But Gavi couldn’t get them any shots.
In the US, the HPV vaccine costs about $250; Gavi, which typically negotiates steep discounts with pharmaceutical companies, was looking to pay $3 to $5 per injection for the large volumes of vaccine it was seeking to acquire. But as high-income countries were also expanding their programs, vaccine makers – Merck and GlaxoSmithKline – targeted these markets, leaving little for developing countries.
“While we talked a lot about the supply we needed from manufacturers, it just wasn’t happening,” said Aurélia Nguyen, chief strategy officer at Gavi. “And then we had 22 million girls that countries asked to be vaccinated and that we didn’t have supplies for at the time. It was a very painful situation.”
Low-income countries had to make a decision about where to allocate the limited amounts of vaccine they received. Tanzania chose to target 14-year-old girls first who, like older eligible girls, were seen as more likely to initiate sexual activity. Girls start to drop out of school at this age, before the transition to high school; the country planned to deliver the vaccines primarily to schools.
But vaccinating a teenager against HPV is not like giving a baby a measles vaccine, said Dr. Florian Tinuga, program manager at the Ministry of Health’s immunization and vaccine development unit. Fourteen-year-olds must be convinced. However, since they are not yet adults, parents also need to be won over. That means having frank discussions about sex, a touchy subject in the country.
And with the 14-year-olds seen as almost marriageable, rumors quickly spread on social media and messaging apps about what’s really at stake: it could be a sneaky birth control campaign coming from the West. ?
The government did not anticipate this problem, said Dr. Tinuga with regret. Rumors were difficult to combat in a population with a limited understanding of research or scientific evidence.
The Covid pandemic has further complicated the HPV campaign as it has disrupted healthcare systems, forced school closures and created new levels of vaccine hesitancy.
“Parents take children out of school when they hear that vaccinations are coming,” said Khalila Mbowe, who runs the Tanzania office of Girl Effect, a nongovernmental organization funded by Gavi to increase demand for the vaccine. “After Covid, questions about vaccination are overwhelming.”
Girl Effect produced a radio drama, stylish posters, chatbots and social media campaigns urging girls to get their picture taken. But that 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 say in the decision, 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 were not informed and did not know what the shot was for. It was an Islamic school where no one ever talked about sex, Shomari said. She hid behind a toilet block with some friends until the nurses left.
“Most of us decided to run,” she said. When she went home and told what happened, her mother said that she had done the right thing: any vaccine that had to do with reproductive organs was suspect.
But now, her mother, Pili Abdallah, has begun to have second thoughts. “Girls her age are sexually active and there is a lot of cancer,” she said. “If she could be protected, that would be good.”
While the Girl Effect has sent some messages to mothers, the truth is that fathers have the final say in most families, Mbowe said. “The power of decision is not in the hands of the girl.”
Despite all the challenges, Tanzania managed to vaccinate nearly three-quarters of its 14-year-old girls in 2021 with a first dose. (Tanzania reached this goal of first-dose coverage twice as fast as the United States.) It has been more difficult to persuade people to return for a second dose: only 57% received the second dose six months later. A similar gap persisted in most sub-Saharan countries that initiated HPV vaccination.
As Tanzania relies heavily on temporary school clinics to administer vaccines, some girls miss the second dose because they have already left school when health workers return.
Rahma Said was vaccinated at school in 2019 when she was 14 years old. But shortly after, she failed her high school entrance exams and dropped out. Mrs. Said tried a few times to get a second chance at public health clinics in her neighborhood, but none had the vaccine, and last year, she said, she gave up.
Within the next year, Tanzania will likely switch to a single-dose regimen, said Dr. Tinuga. There is growing evidence that a single injection of the HPV vaccine will provide adequate protection, and by 2022, WHO recommended that countries move to a single-dose campaign, which would improve vaccine costs and supply, eliminating this vaccine challenge. try vaccinating girls a second time.
Another cost-saving step, public health experts say, would be to move from vaccinating in schools to making the HPV vaccine one of the routine vaccines offered at health centers. Making this shift will require an enormous and sustained public education effort.
“We have to make sure the demand is really, really strong because they don’t normally go to the facility for other interventions,” said Gavi’s Nguyen.
Now, finally, supply of the vaccine has increased, Nguyen said, and new versions of the vaccine have reached the market from companies in China, India and Indonesia. Supply is expected to triple by 2025.
Populous countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh are planning to introduce or expand use of the vaccine this year, which could challenge even expanding supply. But the hope is that there will soon be enough doses for countries to be able to vaccinate all girls between the ages of 9 and 14, Nguyen said. Once they are up to date, the vaccine will become routine for 9-year-olds.
“We’ve set a target of 86 million girls by the end of 2025,” she said. “That will represent 1.4 million deaths averted.”
Mrs. Chengo and her friends burst out laughing at the mere mention of sex, but said that, in fact, many girls in their grade were already sexually active and that it would be better when Tanzania could vaccinate girls as young as 9 years old. .
“Eleven is too late,” said Restuta Chunja, with a grim shake of his head.
Mrs. Chengo, a bright-eyed 13-year-old who plans to be a pilot when she finishes school, said her mother told her the vaccine would protect her from cancer, but that she shouldn’t have any ideas.
“She said I shouldn’t get married or engage in sexual activities because that would be bad and you could 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 the existing vaccine supply because women get 90% of HPV-related cancers.
“From a Gavi perspective, we’re not quite there yet to add boys,” Nguyen said.
Dr. Mary Rose Giattas, technical director of reproductive cancer in Tanzania at Jhpiego, a non-profit health institution affiliated with Johns Hopkins University, believes that any remaining hesitation can be overcome. When she educates the public about the injection, she talks about Australia.
“I say, forget the rumours: Australia has almost eliminated cervical cancer. It’s because? 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 “chewable pieces” of evidence, she said. “I mean, our health ministry takes serious measures to test drugs: they don’t come straight from Europe to your clinic. I say to women, ‘Unfortunately, you and I missed out because of our age, but I wish I could get vaccinated now.’”