When health workers arrived at Upendo Primary School on the outskirts of the Tanzanian capital, they instructed girls who would turn 14 this year to stand up for a chance. Quinn Chengo held an urgent, whispering consultation with his friends. What was the injection for, anyway? Could it be a covid vaccine? (They had heard rumors about it.) Or were they not meant to have children?
Chengo was worried, but she remembered that last year her sister received this shot, for the human papilloma virus. So she got in line. Some girls, however, sneaked away and hid behind the school buildings. When some of Chengo’s friends got home that night, they faced questions from their parents, who worried it might make their kids more comfortable with the idea of having sex—though some didn’t want to come right out and say so.
The HPV vaccine, which offers almost 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 being widely introduced in low-income countries, where 90 percent of cervical cancer deaths occur.
Tanzania’s experience—with misinformation, with cultural and religious discomfort, and with supply and logistical barriers—highlights some of the challenges countries face in implementing what is considered a critical health response in the region.
Screening and treatment for cancer is limited in Tanzania; the shot could greatly reduce deaths from cervical cancer, the deadliest cancer for Tanzanian women.
HPV vaccination efforts have been hampered throughout Africa for years. Many countries had designed programs to begin in 2018, in partnership with Gavi, a global organization that supplies vaccines to low-income countries. But Gavi could not procure shots for them.
In the United States, the HPV vaccine costs about $250; Gavi, which typically negotiates deep discounts from drug companies, aimed to pay $3 to $5 per syringe for the large volumes of vaccine it was trying to acquire. But as high-income countries also expanded their programs, the vaccine makers – Merck and GlaxoSmithKline – targeted those markets, leaving little for the developing world.
“Although we had been very vocal about the supply we needed from the manufacturers, it didn’t come through,” says Aurélia Nguyen, Gavi’s chief strategy officer. “And so we had 22 million girls that countries had asked to be vaccinated that we didn’t have access to at the time. It was a very painful situation.”
Lower-income countries have had to make decisions about where to distribute the limited amounts of vaccine they have received. Tanzania chose to first target 14-year-olds who, as the oldest eligible girls, were seen as most likely to begin sexual activity. Girls start dropping out at that age, before the transition to high school; the country had planned to deliver the vaccines mostly in schools.
But vaccinating a teenager against HPV is not like giving a measles shot to a baby, said Dr. Florian Tinuga, program manager of the Department of Health’s Immunization and Vaccine Development Unit. Fourteen year olds need to be convinced. But since they are not yet adults, parents also have to be won over. It means having frank discussions about sex, a sensitive issue in the country.
And since the 14-year-olds were seen as young women almost old enough to marry, rumors have spread quickly on social media and messaging apps about what’s really in the shot: Could it be a stealth prevention campaign coming from the West?
The government did not foresee that problem, Dr Tinuga said ruefully. Rumors were difficult to respond to in a population with limited understanding of research or scientific evidence.
The Covid pandemic further complicated the HPV campaign as it disrupted health systems, forced out schools and created new levels of vaccination hesitancy.
“Parents pull the kids out of school when they hear the vaccination is coming,” said Khalila Mbowe, who heads the Tanzania office of Girl Effect, an NGO funded by Gavi to boost demand for the vaccine. “After Covid, questions about vaccination are supercharged.”
Girl Effect produced a radio drama, stylish posters, chatbots and social media campaigns urges girls to shoot. But that effort and others in Tanzania have concentrated 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, Mbowe said.
Asia Shomari, 16, was terrified the day medical staff arrived at her school on the outskirts of Dar es Salaam last year. The students had not been 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 her what happened, her mother said she had done the right thing: Any vaccine that involved reproductive organs was suspect.
But now her mother, Pili Abdallah, has begun to reconsider. “Girls her age, they’re sexually active and there’s a lot of cancer,” she said. “If she could be protected, that would be good.”
While Girl Effect aimed some messages at mothers, the truth is that fathers have the final say in most families, Mbowe said. “The decision-making power does not lie with the girl.”
Despite all the challenges, Tanzania managed to inoculate almost three-quarters of its 14-year-old girls in 2021 with a first dose. (Tanzania reached that first-dose coverage goal twice as fast as the United States.) Persuading people to return for a second dose has been harder: Only 57 percent received the second shot six months later. A similar gap has persisted in most sub-Saharan countries that have started HPV vaccination.
Because Tanzania has largely relied on pop-up clinics in schools to deliver the shots, 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. But not long after, she failed the exams to go up to high school and dropped out. Said tried a couple of times to get a second shot at public health clinics in her neighborhood, but no one had the vaccine, and last year, she said, she gave up.
Next year, Tanzania will most likely switch to a single-dose regimen, said Dr. Tinuga. There is growing evidence that a single shot of the HPV vaccine will produce adequate protection, and by 2022 WHO recommended countries switch to a single-dose campaign, which would improve costs and vaccine supply, and remove this challenge of trying to inoculate girls a second time.
Another cost-saving step, public health experts say, would be to move from school-based vaccination to making the HPV injection one of the routine vaccines offered at health centers. Making that change will require a huge and sustained public education effort.
“We have to make sure the demand is very, very strong because they usually won’t come to facilities for other efforts,” said Nguyen of Gavi.
Now, finally, supply of the vaccine has built up, Nguyen said, and new versions of the injection have come to market from companies in China, India and Indonesia. The supply is expected to triple by 2025.
Popular countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh plan to introduce or expand use of the vaccine this year, which could challenge even the expanded supply. But the hope is that soon enough doses will be available for countries to vaccinate all girls between the ages of 9 and 14, Nguyen said. Once they catch 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.”
Chengo and her friends 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 that it would be better if Tanzania could vaccinate girls at age 9. .
“Eleven is too late,” Restuta Chunja said with a grim shake of her head.
Chengo, a sparkling 13-year-old who plans to become a pilot when she leaves school, said her mother told her the vaccine would protect her from cancer, but she shouldn’t get any ideas.
“She said I shouldn’t get married or be involved in any sexual activities because that would be bad and you could get something like HIV”
The HPV vaccine is offered to boys as well as girls in high-income countries, but the WHO recommends that girls in developing countries be prioritized with the existing vaccine offering because women get 90 percent of HPV-related cancers.
“From a Gavi perspective, we’re not there yet, to add boys,” Nguyen said.
Dr. Mary Rose Giattas, a cervical cancer expert who is the Tanzanian medical director of Jhpiego, a non-profit healthcare organization affiliated with Johns Hopkins University, believes any remaining hesitation can be overcome. When she educates the public about the shooting, 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 problems with fertility, we would know about it because they were one of the first countries to use it.”
Misconceptions can be resolved with “chewable” evidence, she said. “I say, our Ministry of Health takes serious steps to test medicines: They do not come directly from Europe to your clinic. I say to women: “Unfortunately, you and I missed it because of our age, but I wish I could be vaccinated now .”