National Introduction of HPV Vaccination in Senegal - Successes, Challenges, and Lessons Learned

"To build sustainability of the HPV vaccination program in the future, it is important to improve the understanding and engagement among all stakeholders...and to strengthen and innovate communication and crisis management strategies."

Following school-based demonstration programmes in 2014-2016, Senegal introduced the human papillomavirus (HPV) vaccine nationwide for 9-year-old girls in 2018. This study reviews successes, challenges, and lessons learned. The below summary focuses on communication elements of the process.

Focusing on three key domains (programme decision-making, planning, and implementation), the researchers conducted ten semi-structured interviews during 2019-2020 with purposively selected national-level stakeholders (government, expert advisory committee, key technical and implementation partners) and desk reviews of country documents on HPV vaccine introduction.

Key results:

With regard to programme decision-making: Per key informants, primary drivers for the nationwide introduction of the HPV vaccine were World Health Organization (WHO) recommendations, funding support from Gavi, high demand for the HPV vaccine, the high burden of cervical cancer in Senegal, and equity (the HPV vaccine was already available in the private sector). All key informants reported that the HPV vaccine introduction was regarded as a political priority in Senegal; civil society organisations and women's organisations advocated for the HPV vaccine introduction, especially given a lack of cervical cancer screening and treatment. Key informants noted the scarcity of local data (the HPV burden, vaccine effectiveness, and the perception of key stakeholders) as a challenge to effective decision-making.

Upon the government's decision for a nationwide introduction, the Ministry of Health and Social Action (MoHSA), along with various partners and stakeholders, held a 5-day residential retreat to make decisions on the implementation strategy. Senegal used the same process for consensual decision-making among partners when planning for other vaccine introductions, and key informants generally regarded it as a strength of the country's approach.

Due to the global HPV vaccine shortage, the introduction was limited to a single-age cohort; therefore, 9-year-old girls were chosen. This strategy enabled Senegal to potentially reach more girls in primary education because school enrolment rates decline thereafter. However, the change from multi-age to single-age cohort delivery reportedly caused confusion among healthcare workers (HCWs) and community members during the nationwide introduction.

With regard to planning: Key informants reported that cascaded training was conducted nationwide at the regional and district levels. Trainees included district-level health officers, at least one HCW per facility, and at least one focal person from each school. All HPV training materials were developed in Senegal, and some were created specifically for use in the education sector, including a guide on the HPV vaccine introduction for teachers and a module on primary prevention of cervical cancer for the school curriculum.

An HPV vaccine communication plan was developed that included a gap analysis of the existing infrastructure, as well as an analysis of strengths, weaknesses, opportunities, and threats (SWOTs). The MoHSA led a general public information and advocacy campaign. Reported strengths of the country's approach included regular early planning meetings and the timely preparation of communication tools. Information on the national introduction of the HPV vaccination was disseminated through the press, radio, and television, and the immunisation programme developed leaflets, banners, posters, and flyers for nationwide distribution. Well-known technical experts in Senegal publicly demonstrated their support for the HPV vaccine. The responsible persons at the district and health facility levels coordinated advocacy meetings with the local stakeholders, including community and religious leaders.

Among the challenges associated with the communication plan: Decision-makers acknowledged even before the pilots that immunising girls against HPV, a sexually transmitted infection, would be a delicate issue in certain Senegalese cultures. Other issues: There was insufficient local data available on attitudes towards the HPV vaccination among key stakeholders (HCWs, teachers, and community members) before the national introduction; the country did not finalise a crisis communication plan; and social media communication routes were not fully leveraged.

With regard to implementation: Vaccination took place through routine delivery platforms (i.e., health facility, school-based, and community outreach - featuring CHWs sensitising the community and identifying out-of-school girls for vaccination), as opposed to a campaign approach.

The national launch ceremony was held on October 31 2018 in Diamniado with the President of Senegal, 15 African First Ladies, and 20 African Ministers of Health in attendance. This high-level initiative was regarded by key informants as a strength of the programme launch.

However, there were significant challenges with unanticipated issues of vaccine hesitancy and vaccine refusals across Senegal after the launch. An ongoing HCW strike resulted in a boycott of providing immunisations, including the HPV vaccine. HCWs reportedly participated in the propagation of misinformation regarding the HPV vaccination (e.g., false information regarding the adverse events following HPV vaccination and rumors regarding vaccine-related infertility) through interpersonal communications and across social media platforms, such as WhatsApp.

Key informants reported a strong response to remedy vaccine hesitancy at the national level, including implementing a revised communication plan, involvement of community and religious leaders, revival meetings in poorly performing regions, and increased communication efforts through various channels (social media, written press, radio, and television). Yet, there were ongoing difficulties with vaccine hesitancy in Senegal for many months post-introduction. An "opt-out" approach to consent was adopted at most schools, whereby parents and guardians or the girls themselves had the option to refuse the vaccination. These refusals were documented; however, none of the key informants were aware of any efforts to use refusal data to improve coverage.

Despite challenges associated with hesitancy and other issues highlighted by the informants, by July 2019, more than 100,000 HPV vaccine doses had been administered, and almost three-quarters of districts were reported to have achieved 80% coverage of the intended population with the first dose of HPV vaccine. However, uncertainties were acknowledged regarding these data. The reporting system for HPV vaccination utilised the existing health information system, with no special tracking for the HPV vaccine. Key informants noted that achieving a high 2-dose coverage for all girls could be a challenge without having a clear strategy to ensure the receipt of the second dose.

In reflecting on the findings, the researchers note that the vaccine hesitancy challenges experienced in this HPV vaccination introduction "were unprecedented in Senegal and largely unanticipated, thus highlighting the need for more engagement with key stakeholders (HCWs, teachers, and community members) before scaling up to the national level to gain a better understanding of the attitudes towards HPV and the HPV vaccination. Adequate information should be provided to HCWs to enable them to support appropriate messaging and answer caregiver questions; efforts should be increased to build population resilience against vaccine rumors through ongoing vaccination advocacy activities....A properly funded communication strategy, including a social media plan, as well as a crisis management plan, are essential prerequisites for any new vaccine introduction."