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When health workers arrived at Upendo Primary School on the outskirts of the Tanzanian capital, they instructed the girls, who will be 14 years old, to line up to get their shots. Quinn Chengo held a whispering consultation with his friends. What is the injection for, really? Could it be a Covid vaccine? (She had heard rumors about it.) Or was it meant to keep her from having babies?
Ms. Chengo was not happy, but she remembered that last year her sister got this injection, because of the human papillomavirus. So he got in line. Some girls sneaked in, and hid behind the school building. When some of Jeng Chengo’s friends come home in the evening, they face questions from their parents, who are worried that their children might feel the pleasure of having sex – even if some of them don’t want to come right out and say it. become.
The HPV vaccine, which provides almost 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 now becoming widely known in low-income countries, where 90 percent of cervical cancer deaths occur.
Tanzania’s experience – with misinformation, cultural and religious discomfort, and supply and logistical barriers – highlights some of the challenges the country faces in implementing what appears to be a critical health intervention in the region.
Screening and treatment for cancer is limited in Tanzania; taken can greatly reduce the death of cervical cancer, the deadliest cancer for Tanzanian women.
HPV vaccination efforts have been stymied in Africa for years. Many countries have planned programs to start in 2018, working with Gavi, a global organization that provides vaccines to low-income countries. But Gavi couldn’t take a picture for him.
In the United States, the HPV vaccine costs about $250; Gavi, which usually negotiates big discounts from pharmaceutical companies, aims to pay $3 to $5 per shot for the volume of vaccine it wants. But as high-income countries also develop programs, vaccine manufacturers – Merck and GlaxoSmithKline – target that market, leaving little for developing countries.
“Although we have been very vocal about the supply we need from the manufacturer, we have not been able to do it,” said Aurélia Nguyen, Gavi’s chief strategy officer. “Therefore, we have 22 million girls who are asked by the country to be vaccinated for which there is no supply at that time. It is a very painful situation.
Low-income countries must make decisions about where to give limited vaccines. Tanzania chose to first target 14-year-olds who, as the oldest eligible girls, seem most likely to initiate sexual activity. Girls start to stop at that age, before transitioning to high school; The country has planned to deliver the vaccine usually in schools.
But vaccinating teenagers with HPV is not like giving a baby a measles shot, 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 due to immaturity, parents also have to win. That means having a frank discussion about sex, a sensitive matter in the country.
And because 14-year-olds were seen as young women almost old enough for marriage, rumors have spread quickly on social media and messaging apps about what is really in the shot: Is it a stealth birth control campaign coming from the West?
The government did not anticipate the problem, said Dr. Tinuga sadly. These rumors are difficult to combat in a population that is not aware of research or scientific evidence.
The Covid pandemic has further complicated the HPV campaign by disrupting the health system, forcing schools to close and creating a level of skepticism about new vaccines.
“Parents pull their children out of school when they hear vaccinations are coming,” said Khalila Mbowe, who directs the Tanzanian office of Girl Effect, a non-governmental organization funded by Gavi to address the demand for the vaccine. “After Covid, the problem with vaccinations increased.”
Girl Effect produces radio plays, beautiful posters, chatbots and social media campaigns that invite girls to take pictures. But these efforts and others in Tanzania have concentrated on motivating girls to receive the vaccine, without sufficiently leveraging the power of other gatekeepers, including religious leaders and school officials, who have a powerful voice in the decision, he said. Mbowe.
Asia Shomari, 16, was shocked when health workers came to her school on the outskirts of Dar es Salaam last year. The students had not been briefed and did not know what they were taking. This is an Islamic school where no one talks about sex, Ms. Shomari said. He hid behind a toilet block with some friends until the nurse left.
“Most of us decided to run,” he said. When he got home and told her what happened, her mother said she did the right thing: Any vaccine that involves reproductive organs is suspect.
But now, his mother, Pili Abdallah, has started to think again. “Women age, they’re sexually active, and they get a lot of cancer,” he said. “If they can be protected, that would be great.”
While Girl Effect directs some of its messages at mothers, the truth is that fathers have the final say in most families, Mbowe said. “The power to make decisions does not rest with girls.”
Despite all the challenges, Tanzania managed to inoculate almost three quarters of 14-year-old girls by 2021 with the first dose. (Tanzania reached that target for first-dose coverage twice as fast as the United States.) It’s harder to persuade people to return for a second dose: Only 57 percent got a second shot six months later. A similar gap still exists in most sub-Saharan countries that have started HPV vaccination.
Since Tanzania mostly relies on school pop-up clinics to deliver images, 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. But it wasn’t long before she failed her exams until she entered high school and dropped out. Said tried twice to get a second shot at a public health clinic in his neighborhood, but no one had the vaccine, and last year, he said, he gave up.
Next year, Tanzania will likely switch to a single dose regimen, Dr Tinuga said. There is growing evidence that one shot of the HPV vaccine will provide sufficient protection, and by 2022 the WHO recommends that countries move to a single-dose campaign, which will increase the cost and supply of the vaccine, and eliminate this challenge in trying to inoculate children – girls. the second time.
Another cost-saving measure, public health experts say, is to move from school-based vaccinations to making HPV taken as one of the routine vaccines offered at health centers. Making these changes will require a large and sustained public education effort.
“We have to make sure that the demand is very, very strong because they don’t usually want to come to the facility for other interventions,” Ms. Nguyen from Gavi said.
Now, finally, the supply of the vaccine has increased, Ms. Nguyen said, and new versions of the shot have arrived on the market from companies in China, India and Indonesia. Supply is expected to triple by 2025.
Largely populated countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh plan to introduce or expand the use of the vaccine this year, which may challenge expanded supplies. But the hope is that there will be enough doses for the country to vaccinate all girls between 9 and 14, Ms. Nguyen said. Once caught, the vaccine will become routine for 9-year-olds.
“We have set a target of 86 million girls by the end of 2025,” he said. “That would be 1.4 million people dead.”
Mrs. Chengo and her colleagues cringe at the mere mention of sex, but she says many of the girls in the class are already sexually active, and it would be good if Tanzania could vaccinate girls as young as 9. .
“Eleven is late,” said Restuta Chunja, shaking her head.
Ms. Chengo, a twinkly-eyed 13-year-old who plans to become a pilot when she finishes school, said her mother told her the vaccine would protect her from cancer, but she didn’t get the idea.
“They told me not to get married or engage in sexual activity, because that would be bad and you might get HIV”
The HPV vaccine is offered to boys as well as girls in higher-income countries, but the WHO recommends prioritizing girls in developing countries with existing vaccine supplies because women get 90 percent of HPV-related cancers.
“From Gavi’s perspective, we’re not there yet, to add boys,” Ms. Nguyen said.
Dr. Mary Rose Giattas, a cervical cancer expert who is the medical director in Tanzania for Jhpiego, a non-profit health care organization affiliated with Johns Hopkins University, believes the remaining doubts can be overcome. When he educated the public about the shooting, he talked about Australia.
“I say, forget the rumors: Australia has almost eliminated cervical cancer. And why? Because they vaccinate. And if the vaccine causes fertility problems, we will know about it because they were one of the first countries to use it.
Misconceptions can be resolved with “chewable pieces” of evidence, he said. “I said, our health ministry is taking serious steps to test the drugs: They don’t come directly from Europe to your clinic. I said to the woman, ‘Honey, you and I missed it because of our age, but I want to be vaccinated now .’
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