When the health workers arrived at the Upendo Primary School on the edge of the Tanzanian capital, they ordered the girls who will turn 14 this year to line up to get abortions. Quinn Chengo made an urgent, whispered consultation with his friends. What exactly is the injection for? Could this be a Covid vaccine? (They had heard rumors about that.) Or was it meant to keep them from having children?
Ms. Chengo was restless, but he remembered that last year his sister got this shot, because of the human papilloma virus. So he entered the line. However, some girls hid, and hid behind the school buildings. When some of Ms.’s friends Chengo came home that night, they faced questions from their parents, who worried that it would make their children feel more comfortable with the idea of having sex – even if some didn’t want to come right out and say it. so.
The HPV vaccine, which offers 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 only now beginning to be widely introduced in low-income countries, where 90 percent of cervical cancer deaths occur.
The experience in Tanzania – with misinformation, with cultural and religious discomfort, and with supply and logistics barriers – highlights some of the challenges countries face in implementing what is seen as a critical intervention. in the health of the region.
Screening and treatment for cancer is limited in Tanzania; the shot can significantly reduce deaths from cervical cancer, the deadliest cancer among Tanzanian women.
HPV vaccination efforts have been stymied across Africa for years. Many countries are designing programs to start in 2018, working with Gavi, a global organization that supplies vaccines to low-income countries. But Gavi couldn’t buy shots for them.
In the United States, the HPV vaccine costs about $250; Gavi, which typically negotiates deep discounts from pharmaceutical companies, intends to pay $3 to $5 per shot for the large quantities of vaccine it seeks to obtain. But since high-income countries are also expanding their programs, vaccine makers – Merck and GlaxoSmithKline – are targeting markets, leaving little for developing countries.
“Even though we’ve been very vocal about the supply we need from manufacturers, that’s not coming,” said Aurélia Nguyen, Gavi’s chief strategy officer. “And so we had 22 million girls that countries were asking to vaccinate that we didn’t have at that time. It was a very painful situation.”
Low-income countries must make a decision on where to allocate the limited amount of vaccine they receive. Tanzania has chosen to first target 14-year-olds who, as the oldest eligible girls, are seen as most likely to initiate sexual activity. Girls start dropping out at that age, before transitioning to secondary school; the country plans to deliver vaccines mostly in schools.
But vaccinating a teenager for HPV is not like giving a child measles, says Dr. Florian Tinuga, program manager for the immunization and vaccine development unit of the Ministry of Health. Fourteen year olds need to be convinced. But since they are still immature, the parents have to be won over as well. That means having frank discussions about sex, a sensitive matter in the country.
And since 14-year-olds are seen as young women almost old enough for marriage, rumors spread wildly on social media and messaging apps about what was really going on. shot: Could this be a birth control campaign from the West?
The government did not expect such a problem, said Dr. Sad creature. Rumors are difficult to counter in a population with limited understanding of research or scientific evidence.
The Covid pandemic has further complicated the HPV campaign as it has disrupted health systems, forced school closures and created new levels of vaccine hesitancy.
“Parents take children out of school when they hear about vaccination,” said Khalila Mbowe, who runs the Tanzania office of Girl Effect, a non-governmental organization funded by Gavi to raise awareness. the need for the vaccine. “After Covid, the issues around vaccination have increased.”
The Girl Effect creates radio drama, slick posters, chatbots and social media campaigns that encourage girls to take the shot. But that effort and others in Tanzania have concentrated on encouraging girls to receive the vaccine, without giving sufficient leverage to other gatekeepers, including religious leaders and school officials, who have strong voice in the decision, said Ms.
Asia Shomari, 16, was terrified the day health workers came to her school on the outskirts of Dar es Salaam last year. The students were not notified and did not know what the shot was for. This is an Islamic school where no one talks about sex, said Ms. Shomari. He hid behind a toilet block with some friends until the nurses left.
“Most of us decided to run,” he said. When she came home and told what happened, her mother said she did the right thing: Any vaccine that involves the reproductive organs is suspect.
But now, his mother, Pili Abdallah, is starting to think again. “Women her age, they’re sexually active, and there’s a lot of cancer,” he said. “If he can be protected, it will be good.”
While the Girl Effect focuses some messages on mothers, the truth is that fathers have the final say in most families, Ms. Mbowe said. “The power of decision-making does not rest with women.”
Despite all the challenges, Tanzania managed to inoculate almost three-quarters of 14-year-old girls in 2021 with the first dose. (Tanzania reached that target for first-dose coverage twice as fast as the United States.) Persuading people to return for a second dose is harder: only 57 percent got the second shot six months later . A similar gap persists in most sub-Saharan countries that have started HPV vaccination.
Because Tanzania largely relies on school pop-up clinics to deliver the shots, some girls miss the second dose because they leave school by the time health workers return.
Rahma Said was vaccinated at school in 2019, when she was 14 years old. But before long, he failed to pass the exams to advance to secondary school and dropped out. Ms. tried. Said twice to get a second shot at public health clinics in his neighborhood, but no one had the vaccine, and last year, he said, he stopped.
Next year, Tanzania will probably switch to a single dose regimen, said Dr. Creature. There is growing evidence that a single shot of the HPV vaccine provides sufficient protection, and by 2022 the WHO recommends that countries move to a single-dose campaign, which would improve the cost and supply of the vaccine, and eliminate it which is a challenge in trying to inoculate women. the second time.
Another cost-saving measure, public health experts say, is to shift from school-based vaccination to making the HPV shot one of the routine vaccines offered at health centers. Making that shift will require a massive and sustained public education effort.
“We have to make sure that the demand is very strong because they don’t usually go to facilities for other interventions,” said Ms. Nguyen of Gavi.
Now, finally, the vaccine supply is established, 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.
Populous countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh plan to introduce or expand use of the vaccine this year, which could challenge even expanded supplies. But the hope is that soon there will be enough doses for countries to be able to vaccinate all girls between 9 and 14, said Ms. Nguyen. Once they are caught, the vaccine becomes routine for 9-year-old children.
“We have set a target of 86 million women by the end of 2025,” she said. “That would be 1.4 million preventable deaths.”
Ms. Chengo and her friends fainted with giggles at the mere mention of sex, but they said that in fact, many girls in their grade are already sexually active, and that it would be better if Tanzania could vaccinate girls. at the age of 9.
“Eleven is very late,” said Restuta Chunja, with a sad shake of her head.
Ms. Chengo, a bright-eyed 13-year-old who aspires to be a pilot when he finishes school, said his mother told him the vaccine would protect him from cancer, but he shouldn’t get any ideas.
“He said that I should not get married or be involved in any sexual activities, because that is not good and you can get something like HIV”
The HPV vaccine is offered to men as well as women in higher-income countries, but the WHO advises prioritizing women in developing countries with existing vaccine supplies because those Women get 90 percent of HPV-related cancers.
“From Gavi’s point of view, we are not there yet, to add men,” said Ms. Nguyen.
Mary Rose Giattas, the technical director of reproductive cancer in Tanzania for Jhpiego, a health care nonprofit affiliated with Johns Hopkins University, believes that any remaining doubts can be overcome. When he was educating the public about the shot, he was talking about Australia.
“I said, forget the rumours: Australia is about to eliminate cervical cancer. And why? Because they vaccinate. And if the vaccine causes fertility problems, we will know because they were one of the first countries to use it. “
Misconceptions can be resolved with “chewable pieces” of evidence, he said. “I say, our health ministry takes serious steps to test the drugs: They don’t come straight from Europe to your clinic. I say to the women, ‘Unfortunately, you and I missed it because of our age. , but I hope I get vaccinated now.’