Vaccinating against Human Papillomavirus from a Global Perspective: Challenges and Future Direction

January 27th, 2022 | Viewpoint

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As Cervical Cancer Awareness Month draws to a close, Molly Ferguson asked Lora Shimp to reflect on the progress in the fight against cervical cancer.

An estimated 311,000 women die annually from cervical cancer, with nearly 90% of those deaths occurring in low- and middle-income countries. In November 2020, WHO launched a global strategy for worldwide elimination of cervical cancer as a public health issue within the next 100 years. One of the three goals outlined in this strategy is that 90% of girls will be vaccinated against HPV by the age of 15. JSI supported the planning, introduction, and implementation of HPV vaccination in eight countries and continues to share a wealth of knowledge and lessons learned from these country experiences.

In just the last two years, JSI has provided technical assistance to Malawi, Mozambique, Kenya, and Cameroon as they integrate HPV vaccines into their immunization systems. HPV vaccination has brought a variety of unique challenges to light. For example, the target cohort for HPV vaccination—adolescent girls —is different from the usual infant population for most routine vaccinations. Also, while coordination with the Ministry of Education and outreach through schools can be leveraged to access the majority of girls in this  age group, in many countries, some of these girls may already have dropped out of school.

Additionally, as with any new vaccine, there is risk of misinformation and rumors. Because of the age group and the association of HPV with sexual transmission, there is potential for hesitancy and misperception rather than a focus on the benefits of a cancer-preventing vaccine. Communication, messaging, and collaboration with religious and community groups are imperative. Structured inter-generational communication approaches can promote positive messaging and common understanding of the HPV vaccination benefits while also increasing awareness and linkages with sexual and reproductive health care.

The COVID-19 pandemic and vaccine introduction have exacerbated the challenges that countries face in vaccinating girls against HPV. School closures and lockdowns interrupted the delivery of the HPV vaccine; and the introduction of the COVID-19 vaccine, which initially focused on adults, contributed to an environment of misinformation. (In Malawi, for example, there was confusion that adolescents were receiving the COVID-19 vaccine during HPV vaccination services.) Countries need to prioritize delivery strategies, supply distribution, and availability, and analysis of missed populations to track and catch up girls who have not received the full course of their HPV vaccines over the last two years during the pandemic.

Global supply and availability of HPV vaccines were an issue even before COVID-19, due to limited manufacturers. In countries that introduced nationwide HPV vaccination in the last 1-2 years, the pandemic also affected supply due to canceled flights, interruptions in vaccine delivery to subnational levels, and an overburdened health workforce. Positive news in 2021 is that another HPV vaccine, Cecolin®  manufactured by Innovax, has received prequalification by the WHO and can potentially be accessed by countries that have been waiting for additional supply to begin or increase nationwide HPV vaccination.

Our experience over the last two years has also shed light on opportunities to shape the future direction of HPV vaccination. Now that youth are eligible to receive the COVID-19 vaccine, the possibility of co-administering vaccines is worth exploring, given the need to reach high-risk populations for COVID-19 and high-risk adolescent girls for HPV. This requires careful service delivery planning and a strong and well-implemented communication strategy to ensure confidence and trust. Life-course vaccination (e.g. with measles, HPV) can also be emphasized as a preventive health benefit for this age group. Communicating and adapting lessons learned from local experts for HPV vaccine introduction (before and during the COVID-19 pandemic) is a critical opportunity to advance adaptive and innovative strategies for HPV and life-course vaccination. At JSI, we have produced podcasts to share country experiences with HPV vaccine introduction in Malawi, Cameroon, Kenya, Tanzania, and Zimbabwe.

The future resilience and sustainability of HPV vaccination requires country immunization programs to incorporate innovative ways of thinking and communicating. To overcome current and future challenges, countries need to address the gaps – and be supported by donors and partners – in strengthening their HPV vaccination delivery systems, including ensuring annual operations for each new cohort. This also requires active communications and engagement with the education sector, cancer prevention and adolescent health groups, and with reliable private-sector immunization service delivery partners (such as pharmacists and local health clinics), promoting HPV vaccination as part of life-course immunization and as an adolescent health priority.

Written by Molly Ferguson

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