HPV vaccine introduction in Africa: Early lessons learned

Regional Conference on New Opportunities and Innovations in Cervical Pre-Cancer Screening and Treatment, Lusaka, Zambia

Chilunga Puta, PhD D. Scott LaMontagne, PhD Vivien Tsu, PhD 19 June 2014

Background

• Two vaccines (2 or 3 doses) – bivalent (GSK) and quadrivalent (Merck); both prequalified by WHO for 3 doses

• National introductions in Africa: Lesotho, Rwanda, South Africa, Uganda

• Demonstration and pilot projects in Africa: Botswana, Cameroon, Ghana, Kenya, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, Zambia

• Worldwide, more than 50 countries have national HPV vaccine programs

• GAVI Alliance provides subsidized vaccine for low-income countries (countries pay US$0.20-$0.30/dose; GAVI pays rest of price)

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Evaluation sources

• Formal and informal evaluations • Literature review – several published papers • PATH experience – 4 rigorously evaluated demonstration

projects • Reports at national and regional meetings • Key aspects evaluated: coverage, feasibility, cost, acceptability

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Lessons can be grouped in 3 categories: • Operational • Community education and mobilization • GAVI-specific issues

Operational: Micro-planning and coordination

• Micro-planning • Should be done at local level and involve all key stakeholders

• Coordination • Strong coordination between health and education sectors is

essential, especially for school-based programs • Immunization program (EPI) usually takes lead, but other sectors

within MOH can be valuable partners (adolescent health, school health, reproductive health, non-communicable diseases)

• Good communication and cooperation between central and district levels are critical

• Nurse immunizers and community mobilizers are key personnel

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Operational: Service delivery design

• Venue • Several different delivery strategies have been successful • Schools effective, especially primary level when girls still attend • Schools and other outreaches require transport and, in some

places, allowances for staff • Health facilities – puts travel burden on families • Other community settings – good for education and simple

clinical interventions • Target population

• Can be defined by age, year of birth, or grade (class) in school • Easy to identify based on grade in school, but wide range of ages

in each grade • Variable feasibility when targeting age or year of birth

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Operational: Vaccination schedule

• Previous 3-dose schedule • Completion best if done within one school year • For school-based programs, must coordinate with holiday and

exam schedules • New 2-dose schedule – limited experience in Africa

• WHO recently determined there is sufficient evidence to switch from 3-dose to 2-dose, with minimum interval of 6 months and limited to girls less than 15 years at the time of the first dose

• Can also be annual schedule with dose 2 given 12 months after dose 1

• Timing • Pulsed services less disruptive than continuous • Short “mop-up” period useful for girls who missed dose

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Community: HPV vaccine acceptability high

6/24/2014

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Factor Girls Parents

Protection against cancer/vaccines good for health. √ √

Information received and understood. √ √

Direct communication by health workers, teachers, and community leaders. √ √

Messages reinforced by multiple, trusted sources. √ √

Endorsed by government, teachers, and community leaders. √

Absenteeism, insufficient information, lack of awareness. √

Concerns about new vaccines, vaccine safety, and side effects. √ √

References: LaMontagne 2011; Cover 2012; Bartolini 2012; Katahoire 2013; Paul 2011 (unpublished); Wamai 2012; Watson-Jones 2012.

Community: Tailored communication strategies

• Needs of different audiences: girls, parents, health workers, community leaders • Different questions • Different channels

• For parents in Uganda, talking with informed people in the community was more important than print materials or mass media messages (Galagan, 2013)

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Will it hurt?

Is it safe?

Why do girls need it?

Community: Tailored communication strategies

• Government endorsement is critical to success (national, district health officials, teachers)

• Timing varies by group:

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Community: Rumors and misinformation

• Create a strong communications team and develop a crisis response plan well in advance

• Train key spokespersons and assemble evidence in advance so response can be swift and persuasive

• Keep religious and community leaders and school officials involved from early on and continuously throughout—including those who represent ethnic, religious and political minorities

• Identify advocates who are knowledgeable and trusted by the community

• Don’t repeat the rumors and don’t criticize or stigmatize the rumor group or individual

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GAVI-specific lessons from demonstration projects

Achievements • Many more countries than

expected have applied and launched demonstration projects

• “Learn by doing” goal has been well accomplished

• Initial coverage data shows good acceptance

Challenges ? • District selection criteria and

constraints not well understood • Data on population and schools

not readily available • Insufficient time between years

1 and 2 to make adjustments • Confusion about program

guidelines • Budget rules not well

understood

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Many resources from WHO

• HPV Vaccine Introduction Clearing House

http://www.who.int/immunization/hpv/en/

• HPV vaccine introduction guide http://www.who.int/entity/immunization/hpv/plan/hpv_vaccine_intro_guide_c4gep_who_2013.pdf?ua=1

• Population estimates, 9-13 girls http://www.who.int/entity/immunization/monitoring_surveillance/Pop_year_age.zip?ua=1

• HPV vaccine communication http://apps.who.int/iris/bitstream/10665/94549/1/WHO_IVB_13.12_eng.pdf?ua=1

• Cervical cancer prevention and control costing tool (C4P)

http://www.who.int/entity/immunization/diseases/hpv/cervical_cancer_costing_tool/en/index.html

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Resources from PATH and others

• Practical experience guides for implementation and evaluation

http://www.rho.org/HPV-practical-experience.htm

• Lessons learned summaries http://www.rho.org/lessons-learned-

reports.htm

• Cervical cancer and HPV vaccine resource library, and Action Planner

www.rho.org

• Cervical Cancer Action Report Card http://cervicalcanceraction.org/pubs/pubs.php#reportcard

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Conclusions

• High uptake of HPV vaccine is achievable • Many delivery strategies are feasible; all need good planning,

coordination and evaluation • Vaccine is acceptable to communities, IF there are

• Tailored communication strategies that address information needs

• Visible government endorsement and support • Prompt attention to rumors and misinformation

• GAVI support is providing valuable opportunity to learn

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HPV vaccine represents incredible opportunity to protect future generations of women

from the scourge of cervical cancer

Thank you

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Chilunga Puta, PhD cputa@path.org http://www.path.org/our-work/cervical-

cancer.php www.rho.org