HPV Vaccination in Africa: Lessons Learned From a Pilot Program in Uganda

This report summarises a human papillomavirus (HPV) vaccination programme implemented in Uganda where the HPV vaccine was made available to almost 10,000 girls in select parts of the country. The purpose of the study was to investigate operational issues related to HPV vaccination of young adolescent girls and identify effective strategies. The report interprets the results and summarises helpful lessons for policymakers and programme managers, especially those in sub-Saharan Africa, looking to shape their own HPV vaccination programmes. The study found that experience in Uganda demonstrates that high coverage for HPV vaccines can be achieved through various vaccine delivery strategies. Programme acceptability within communities can be achieved through a comprehensive understanding of information needs, targeted messaging, and effective communication strategies using multiple channels.

The report explains that two vaccines to prevent HPV infection, the primary cause of cervical cancer, are now approved for use in many countries. Low- and middle-income countries often face significant obstacles to integrating new vaccines into their national immunisation programmes, meaning that the people living in these countries must wait many years for access to life-saving interventions currently available in higher-income settings. In 2006, PATH initiated the HPV Vaccines: Evidence for Impact project in order to generate evidence to help policymakers and planners worldwide make informed decisions regarding regional and national vaccine introduction efforts and international financing for improved cervical cancer prevention. The Uganda project was implemented by the Uganda National Expanded Program on Immunization (UNEPI) of the Ministry of Health with technical support from PATH, and operations research was conducted by the Child Health and Development Centre (CHDC) and PATH. The data resulting from the project provide evidence to the government of Uganda about when and how best to introduce cervical cancer vaccine nationwide.

The report outlines the following lessons learned from the project, explained in greater detail in the publication:

"Target Groups and Venues for Vaccination

• Lesson 1: Schools can successfully be used as a venue for HPV vaccinations.
• Lesson 2: Identifying eligible girls based on their grade/class in school may be easier than identifying them by age in some contexts, but may also present challenges for age-focused reporting and evaluation systems.
• Lesson 3: Adding HPV vaccine to an existing health programme can reduce the incremental costs of including HPV vaccine in the national immunisation schedule.

Operational Issues

• Lesson 4: Adequate preparation of health and education systems, including human resources, facilitates success.
• Lesson 5: Close coordination by the health and education sectors leads to effective community mobilisation and vaccine delivery.
• Lesson 6: Monitoring and supportive supervision strengthen health worker capacity and improve performance.

Health Worker and Teacher Training

• Lesson 7: Separate training of teachers and health workers allows for focus on their specific roles, complemented with a joint session for both groups to solidify collective understanding.
• Lesson 8: Adequate time and consistent content for training sessions help ensure health worker and teacher motivation and capacities.

Community Outreach

• Lesson 9: Vaccine uptake can be improved by providing evidence-based education and outreach at least one month before immunisation begins.
• Lesson 10: Visible endorsement by national and district government leaders is critical to community acceptance.
• Lesson 11: Additional support is needed to ensure that remote areas are reached by educational outreach activities.
• Lesson 12: Teachers and health workers play complementary roles in raising awareness in communities.

Messaging

• Lesson 13: Information on preventing cervical cancer, HPV vaccination, and the three-dose schedule are key building blocks for community education messages.
• Lesson 14: Communities become reassured as they gain direct experience with HPV vaccine.
• Lesson 15: Making comprehensive educational materials with simple language and graphics widely available can help raise community awareness."

According to the report, parents' initial sceptical feelings about HPV vaccine were lessened by key messages about the severity of cervical cancer and the vaccine’s ability to prevent it. The belief by parents that vaccines are generally good for health facilitated acceptance of the HPV vaccine programme. Even parents who did not have detailed facts about cervical cancer understood that it had no cure and that it could be prevented through vaccination; this was sufficient to convince them that their daughters should be vaccinated. Information about the three-dose schedule was also crucial to ensuring that girls would be fully vaccinated.

Health workers and teachers noted that they found printed educational materials distributed for the project useful in explaining to others about the vaccine, its importance, and why girls need to complete all three doses. Health workers in particular noted that they referred back to educational booklets when answering questions during the vaccination process. Teachers expressed appreciation for the role played by posters and booklets in educating children and parents. In particular, respondents appreciated that the language in the materials was simple and the pictures were clear and understandable. Teachers and community leaders felt that they made it easier to explain to others about cervical cancer and the need for vaccination to prevent HPV infection.

The report concludes that programme acceptability can be achieved through understanding of information needs, targeted messaging, and effective communication strategies using multiple channels. HPV vaccine delivery is feasible to implement in schools; however, eligibility for vaccination based on grade/class in school, rather than age, was easier to implement and track in Uganda to ensure administration of all three doses. Health workers and teachers can be trained and systems strengthened to successfully implement HPV vaccinations, in conjunction with other work and priorities at the district, sub-county, and lower levels. Implementation costs may be less when combining HPV vaccine delivery with another programmes, provided adequate funding for that programme has already been secured.