When the health workers arrived at Apendo Primary School on the outskirts of the Tanzanian capital, they instructed the girls, who turned 14 this year, to line up for shots. Qin Chengo held an urgent whispering consultation with her friends. What was the injection really for? Could it be a covid vaccine? (Did they hear rumors about this) or was it intended that they should not have children?
Ms. Chengo is not bothered, but she remembers that her sister got this vaccine for human papillomavirus last year. And she got in line. But some girls sneaked out and hid behind the school buildings. When some of Ms. Chengo’s friends got home that night, they were faced with questions from their parents, worried that it might make their children more uncomfortable about sex — even if some didn’t want to actually come out and say it. in order to.
The HPV vaccine, which provides general protection against sexually transmitted viruses that cause cervical cancer, has been offered to teenagers in the United States and other industrialized countries for about 20 years. But it is now becoming more common in low-income countries, where 90 percent of cervical cancer deaths occur.
Tanzania’s experience—along with misinformation, cultural and religious discomfort, and supply and logistical barriers—highlights some of the challenges countries face in implementing critical health interventions in the region.
Cancer screening and treatment is limited in Tanzania; The vaccine could significantly reduce deaths from cervical cancer, the deadliest cancer among Tanzanian women.
HPV vaccination efforts across Africa have been hampered for years. Many countries have designed programs to start in 2018, partnering with Gavi, an international organization that provides vaccines to low-income countries. But Gavi couldn’t buy a shot for them.
In the United States, the HPV vaccine costs about $250. Gavi, who typically negotiates big deals from pharmaceutical companies, planned to pay $3 to $5 per shot for the bulk vaccine he wanted to buy. But as high-income countries expanded their programs, the vaccine makers — Merck and GlaxoSmithKline — targeted those markets, leaving little room for developing countries.
Aurelia Nguyen, Gavi’s chief strategy officer, said: “Although we talked a lot about the supply we wanted from the manufacturers, it was not forthcoming.” “And then we had 22 million girls who asked to be vaccinated in countries where we had no access. That was a very painful situation,” he said.
Low-income countries had to make decisions about where to allocate the limited amount of vaccine they were given. Tanzania chose to target 14-year-olds first; They are also more likely to become sexually active as middle-aged girls. Girls begin to drop out at that age before transitioning to high school; The country planned to deliver the vaccine mostly in schools.
But Dr. Florian Tinuga, program manager of the Department of Immunization and Vaccine Development at the Ministry of Health, said vaccinating a teenager against HPV is not like giving a child the measles vaccine. Fourteen year olds need to be convinced. But since they are not adults yet, parents have to win. This means having an open discussion about sex in the country.
And since 14-year-olds were seen as young women of marriageable age, rumors spread quickly on social media and messaging apps about whether it was really a covert contraceptive campaign coming from the West?
Dr. Tinuga lamented that the government had not considered that problem. In a population with limited understanding of research or scientific evidence, the rumor was hard to counter.
The Covid-19 pandemic has further complicated the HPV campaign by disrupting health systems, forcing school closures, and creating new vaccine uncertainties.
Kalila Mbowe, who heads the Tanzania office of a Gavi-funded NGO, said parents would pull their children out of school when they heard the vaccine was coming. “Vaccine Cases Overwhelmed After Vivid.”
Girl Effect Radio Drama, Slideshows, Chatbots and more Social media campaigns urging the girls to take the shot. But that effort and others in Tanzania focused on motivating girls to get the vaccine, without enough support from other gatekeepers, including religious leaders and school officials, who have strong voices in the decision, Ms. Mbow said.
Asia Shomari, 16, was told the day they arrived at her school on the outskirts of Dar es Salaam last year. The students were not given an explanation and did not know why the shooting happened. It was an Islamic school where no one talked about sex, Ms Shomari said. She hid behind the toilet with her friends until the nurses left.
“Many of us decided to run,” she said. When she got home and told what had happened, her mother said she did the right thing: any vaccine involving the reproductive organs is suspect.
But now her mother, Pili Abdellah, is starting to reconsider. “Girls her age, they have sex and there’s a lot of cancer,” she said. “It would be nice if she was protected.”
While Girl Effect targets some of its messages at mothers, the truth is that fathers have the final say in most families, Ms Mbowe said. “The power of decision does not rest with the girl.”
Despite challenges, Tanzania managed to vaccinate nearly three-quarters of its 14-year-old girls with the first dose by 2021. (Tanzania covered the first dose twice as fast as the United States.) Convincing people to return for a second dose was difficult: only 57 percent had received the second vaccine six months later. A similar gap persists in sub-Saharan countries that have introduced HPV vaccination.
Because Tanzania relies on school-based pop-up clinics to deliver the vaccine, some girls miss the second dose because they leave school when health workers return.
Rahma Syed Ms Saeed said she had tried twice to get a second vaccination at local public health clinics, but had never received a single vaccination and had given up last year.
Next year, Tanzania will be able to switch to a mostly single-dose rate, Dr. Tinuga said. Evidence is mounting that a single shot of the HPV vaccine provides sufficient protection, and by 2022 the World Health Organization has proposed that countries switch to a single-dose campaign, which would improve cost and vaccine availability and eliminate the temptation to vaccinate girls. for the second time.
Another cost-effective step, public health experts say, is to switch from the school vaccination to the HPV shot as one of the routine vaccinations offered at health centers. Making that change will require a major and sustained public education effort.
“We have to make sure that demand is very, very strong because typically they don’t come to facilities for other interventions,” said Ms. Nguyen of Gaviw.
Now that the supply of the vaccine has finally been built up, Ms. Nguyen said, new versions of the shot have come to market from companies in China, India and Indonesia. The supply is expected to triple by 2025.
Prominent countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh plan to introduce or use the vaccine this year, which could challenge even expanded availability. But the hope is that countries will soon have enough to vaccinate all girls between the ages of 9 and 14, Ms. Nguyen said. Once caught, the vaccine will be standard for 9-year-old children.
“In the year We have set a target of 86 million girls by the end of 2025,” she said. “That would avoid 1.4 million deaths.”
Ms Chengo and her friends were shocked to laugh about sex, but in reality many girls had sex in their classrooms, and said Tanzania would be better off vaccinating girls at age 9. .
“Eleven is too late,” Rustuta Chunja said, shaking her head.
Ms Chengo, a 13-year-old with twinkling eyes who plans to become a pilot when she finishes school, said her mother had told her the vaccine would protect her from cancer, but she should get no idea.
“She said I shouldn’t get married or engage in any sexual activity because it’s bad and I can get something like HIV.”
The HPV vaccine is offered to both boys and girls in high-income countries, but since women account for 90 percent of HPV-related cancers, he recommends prioritizing girls in developing countries.
“From Gavi’s point of view, we’re not there yet, to add boys,” Ms Nguyen said.
Dr. Mary Rose Giatas, technical director of Tanzania Reproductive Cancer, a health care nonprofit affiliated with Johns Hopkins University, believes any remaining hesitation can be overcome. She talks about Australia when she educates the public about the shooting.
“I say, forget the hype: Australia is going to eradicate cervical cancer. And why? Because they give a vaccine. And if the vaccine causes fertility problems, we know about it because they were one of the first countries to use it.
Misconceptions, she said, can be resolved with “chewable” evidence. “I say, our Ministry of Health takes serious measures to check drugs: they don’t come straight to your clinic from Europe. I say to women, ‘Unfortunately, you and I missed it because of our age, but I wish I had the vaccine now.’