When health workers arrived at Upendo Primary School on the outskirts of Tanzania’s capital, they instructed girls approaching the age of 14 to line up for a shot. Among them was Quinn Chengo, who sought advice from her friends about the purpose of the injection. Speculations arose, ranging from rumors of a COVID-19 vaccine to contraception. However, recalling her sister receiving a shot for the human papillomavirus (HPV) last year, Ms. Chengo decided to join the line. Some girls, though, sneaked away, fearing the potential implications of the vaccine.
While HPV vaccination has been administered to adolescents in industrialized nations for nearly two decades, its introduction in lower-income countries, where 90% of cervical cancer deaths occur, has been more recent and challenging. Tanzania’s experience highlights the hurdles faced by countries in implementing this critical health intervention.
Limited cancer screening and treatment options in Tanzania make the HPV vaccine a potentially lifesaving measure against cervical cancer, the deadliest form of cancer for Tanzanian women.
HPV vaccination efforts across Africa have long been hindered. Many countries, working with the global organization Gavi, had planned to initiate programs in 2018. However, Gavi struggled to procure the required vaccine doses. Pharmaceutical companies focused on high-income nations that were expanding their HPV vaccination programs, leaving developing countries with limited supplies.
Lower-income countries, like Tanzania, had to allocate their scarce vaccine quantities strategically. Tanzania chose to prioritize 14-year-old girls, considering them the most likely to engage in sexual activity. However, convincing teenagers and their parents, who hold decision-making power, proved challenging due to cultural sensitivities surrounding discussions about sex. Rumors spread through social media and messaging apps, raising suspicions about the vaccine’s true intentions and generating concerns about Western birth control campaigns.
The government did not anticipate this problem, as the population had limited understanding of research and scientific evidence. The COVID-19 pandemic further complicated the HPV vaccination campaign, disrupting health systems, causing school closures, and amplifying vaccine hesitancy.
Girl Effect, an organization funded by Gavi to stimulate demand for the vaccine, launched various campaigns, including radio dramas, posters, chatbots, and social media initiatives targeting girls. However, these efforts did not adequately address the influence of other gatekeepers, such as religious leaders and school officials, who play a significant role in the decision-making process.
Spooked by the arrival of health workers at her Islamic school, Asia Shomari, 16, and her friends hid until the nurses departed. In a school where discussions about sex were taboo, the girls were unaware of the purpose of the shot. Ms. Shomari’s initial skepticism mirrored her mother’s concerns about reproductive organ-related vaccines. However, as her mother gradually reconsiders, acknowledging the prevalence of cancer and sexual activity among girls her age, she sees the potential benefits of the vaccine.
Despite the challenges, Tanzania managed to administer the first dose of the HPV vaccine to nearly three-quarters of its 14-year-old girls in 2021, surpassing the United States’ achievement. Encouraging return visits for the second dose proved more difficult, with only 57% of girls receiving it within the recommended timeframe. Similar gaps persisted in most sub-Saharan countries implementing HPV vaccination due to the reliance on school-based clinics, which caused some girls to miss the second dose after leaving school.
To overcome these challenges, Tanzania is considering transitioning to a single-dose regimen, aligning with the World Health Organization’s recommendation for a one-dose campaign. This change would enhance cost-effectiveness, vaccine availability, and eliminate the need to vaccinate girls a second time. Additionally, shifting from school-based vaccination to routine delivery at health centers could further increase accessibility, although it requires a significant and sustained public education effort.
Fortunately, the vaccine supply has improved, with new versions introduced by companies in China, India, and Indonesia. The supply is expected to triple by 2025. Populous countries like Indonesia, Nigeria, India, Ethiopia, and Bangladesh plan to introduce or expand HPV vaccination this year. However, it is crucial to ensure sufficient doses for vaccinating all girls aged 9 to 14 before transitioning to routine vaccination at age 9.
Public health experts believe that addressing remaining hesitancy requires dispelling misconceptions with evidence-based information. Comparing the success of cervical cancer prevention in Australia, where HPV vaccination has significantly reduced incidence rates, can help combat rumors. Highlighting rigorous testing procedures for medicines and expressing a personal desire for vaccination can further build trust.
While challenges persist, the progress made in HPV vaccination in Tanzania offers hope for reducing cervical cancer deaths. Through continued efforts, improved supply, and comprehensive education campaigns, it is possible to achieve widespread vaccination coverage and save countless lives.
