Money, Sex and Rumors: Tanzania Faces Challenges to Protect Girls From HPV

When health workers arrived at Apendu Primary School on the outskirts of Dar es Salaam, Tanzania, they directed the girls, who will turn 14 this year, to line up for the shot. Qin Chengu held a quick, whispered consultation with his friends. What was the injection really for? Could it be the covid vaccine? (They had heard rumors about this.) Or was it meant to prevent them from having children?

Ms Chengu was anxious, but remembered that her sister had received the shot for human papillomavirus last year. So she got in line. However, some girls sneaked away and hid behind school buildings. When some of Ms Chingo’s friends arrived home that evening, she faced questions from her parents, who worried it might make their children more comfortable with the idea of ​​sex – even if some would come out straight away. And did not want to say. So

The HPV vaccine, which provides complete protection against the sexually transmitted virus that causes cervical cancer, has been given to teenagers in the United States and other industrialized countries for about 20 years. But it is now starting to be widely introduced in low-income countries, where 90 percent of cervical cancer deaths occur.

Tanzania’s experience—with misinformation, cultural and religious discomfort, and logistical and logistical barriers—highlights some of the challenges countries face in implementing a major health intervention in the region.

Cancer screening and treatment is limited in Tanzania. The pill can dramatically reduce deaths from cervical cancer, the deadliest cancer for Tanzanian women.

HPV vaccination efforts have been stalled across Africa for years. Many countries had plans to launch in 2018, working with Gavi, a global organization that provides vaccines to low-income countries. But Gavi failed to get shots for them.

In the United States, the HPV vaccine costs about $250. Gavi, which typically negotiates big discounts from drug companies, aimed to pay $3 to $5 per shot for bulk doses of the vaccine. But as high-income countries were also ramping up their programs, the vaccine companies — Merck and GlaxoSmithKline — targeted those markets, leaving little for developing countries.

“Although we were very vocal about the supply needed by manufacturers, it was not being met,” said Aurelia Nguyen, chief strategy officer at Givi. “And so we had 22 million girls who were asked by countries to vaccinate for whom we had no supply at the time. It was a very painful situation.”

Low-income countries have had to decide where to allocate limited amounts of vaccine. Tanzania first chose to target 14-year-olds, who, as the oldest eligible girls, were considered the most likely to initiate sexual activity. Girls start leaving school at this age, before transitioning to secondary school. The country planned to provide the vaccine in most schools.

But vaccinating a teenager for HPV is like giving a child a measles shot, said Dr. Florian Tenoga, program manager of the Immunization and Vaccine Development Unit at the Ministry of Health. Fourteen year olds have to be convinced. Yet since they are not adults yet, parents have to win as well. It means openly discussing sex, a sensitive issue in the country.

And since girls as young as 14 were seen as young women almost too old for marriage, rumors abounded on social media and messaging apps about what was really in the shot: whether it was from the West. Could there be an upcoming birth control campaign?

The government had no idea of ​​the problem, lamented Dr. Tinuga. Rumors were difficult to combat 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 school closures and created new levels of vaccine reluctance.

“Parents pull kids out of school when they hear vaccinations are coming,” said Khalila Mboye, who directs Tanzania’s GirlEffect office, which directs Gavi to boost vaccine demand. is a non-governmental organization funded by “Post-Covid, Vaccination Issues Are Supercharged.”

The Girl Effect produced a radio play, clever posters, chatbots and more. Social media campaigns Encouraging girls to shoot. But this effort and others in Tanzania have focused on encouraging girls to accept the vaccine, without the power of other gatekeepers, including religious leaders and school officials, who have a strong voice in the decision.

Asia Shomari, 16, was terrified the day health workers came to her school in the suburbs of Dar es Salaam last year. The students were not briefed and did not know what the shot was for. Ms Shomari said it was an Islamic school where no one ever talked about sex. She hid behind a toilet block with some friends until the nurses left.

“Most of us decided to run,” he said. When he went home to explain what had happened, his mother said he had done the right thing: any vaccine that involved reproductive organs was suspect.

But now, his mother, Peli Abdallah, is beginning to reconsider. “Girls are his age, they’re sexually active, and there’s a lot of cancer,” she said. “It would be nice if it could be protected.”

While The Girl Effect is intended to have some messages for mothers, the truth is that in most families fathers make the final decision, Ms Mbowe said. “The power to decide does not rest with the girl.”

Despite all the challenges, Tanzania was able to vaccinate nearly three-quarters of its 14-year-old girls through the first dose in 2021. (Tanzania reached its first-dose coverage goal twice as fast as the United States.) Convincing people to return for a second dose has been difficult: only 57 percent received a second dose after six months. A similar gap persists in most sub-Saharan countries that have introduced HPV vaccination.

Because Tanzania has relied heavily on pop-up school clinics to deliver the shots, some girls miss out on the second dose because they have left school until health workers return.

Rahma Saeed was vaccinated at school in 2019, when she was 14 years old. But shortly after, she failed to pass the exams to get to secondary school and dropped out. Ms. Saeed tried twice to get a second shot at a public health clinic in her neighborhood, but no one had the vaccine, and last year, she said, she gave up.

Next year, Tanzania will likely switch to a single food system, Dr Tinuga said. Is Growing evidence that a single shot of the HPV vaccine will provide adequate protection, and in 2022 the WHO recommended that countries go on a dose campaign, which would improve costs and supply of vaccines, and overcome the challenge of trying to vaccinate girls a second time. will be done

Another cost-saving step, public health experts say, is to shift from school-based vaccination to HPV being one of the routine vaccines offered at health centers. This change will require a massive and sustained public education effort.

“We have to make sure the demand is very, very strong because they wouldn’t normally come into facilities for other interventions,” said Ms Nguyen of Gavi.

Now, finally, vaccine supplies have increased, Ms. Nguyen said, and new versions of the shot from companies in China, India and Indonesia have hit the market. 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 also challenge expanded supplies. But the hope is that soon enough doses will be available for countries to be able to vaccinate all girls between the ages of 9 and 14, Ms. Nguyen said. Once they catch up, the vaccine will become routine for 9-year-olds.

He said that we have set a target of 86 million girls by the end of 2025. “It would avoid 1.4 million deaths.”

Ms. Chengu and her friends laughed at the mere mention of sex, but she said that, in fact, many girls in her grade were already sexually active, and it would be better if Tanzania 9 Be able to vaccinate girls at the age of .

“Eleven is too late,” said Resuta Chunja, shaking her head.

Bright-eyed 13-year-old Ms Chengu, who plans to become a pilot after finishing school, said her mother told her the vaccine would protect her from cancer, but she shouldn’t worry.

“He said I shouldn’t get married or engage in any sexual activities, because it would be bad and you might get a disease like HIV.”

The HPV vaccine is offered to boys as well as girls in high-income countries, but the WHO recommends giving priority to girls in developing countries with current vaccine supplies because women are more vulnerable to HPV. About 90 percent of them develop cancer.

“From Gavi’s point of view, we’re not there yet to add boys,” Ms Nguyen said.

Dr. Mary Rose Gitas, technical director of reproductive cancer in Tanzania for the Johns Hopkins University-affiliated healthcare nonprofit Zhipgo, believes any reluctance can be overcome. When she informs the public about the shot, she talks about Australia.

“I say, forget the rumours: Australia has almost eliminated cervical cancer. And why? Because they vaccinate. And if the vaccine causes fertility problems, we know about it. It would be known because they were one of the first countries to use it.”

Misconceptions can be resolved with “chewable morsels” of evidence, he said. “I say, our Ministry of Health takes serious measures to test drugs: they don’t come from Europe to your clinic. I tell women, ‘Unfortunately, you and I missed it because of our age. , but I wish I could be vaccinated now.’