HPV Vaccine Introduction: Learning and adapting in the time of COVID-19

Cervical cancer is one of the most common cancers in women, with a higher burden in low- and middle-income countries. Almost all cervical cancer cases are linked to infection with high-risk human papillomaviruses (HPV). Through a combined approach of vaccination against HPV and cervical cancer screening, most cases can be prevented.

JSI has supported the preparation, introduction, and routinization of the HPV vaccine in eight countries: Niger, Tanzania, Zimbabwe, Madagascar, Malawi, Mozambique, Cameroon, and Kenya. Through our technical assistance, we have learned unique and valuable lessons from each country’s experience launching the vaccine.

COVID-19, however, has interrupted countries’ preparations to integrate the HPV vaccine into their routine immunization programs. In Kenya, Malawi, and Cameroon, plans for the routinization of HPV vaccine before the start of the pandemic then required a shift in resources, focus, and strategy for both HPV and COVID-19 vaccinations. Mozambique moved forward with its HPV vaccination launch but had to do so at  the height of the pandemic.

Each of these country experiences provide useful insight and lessons learned for introducing new vaccines, routinization of new vaccines with different priority populations, and shifting priorities for pandemic response.

As we learned in Zimbabwe, adequate time and planning for HPV vaccination is crucial to its success. Coordination between institutions and stakeholders not typically involved in health services (e.g. schools and educators to reach adolescent populations), training, dissemination of communications materials, and scheduling of vaccine administration often require additional time and attention for HPV vaccines, given that these are separate from infant vaccines.

In Kenya, Malawi, and Cameroon, flexibility and pivoting of resources and strategy were crucial, given COVID-19 interruptions and, later, a shifting focus on COVID-19 vaccination. In Kenya, microplanning and mapping for the HPV vaccine launch required more specific interventions —in particular reaching a new target population (girls aged 9 to 15). Kenya’s initial school-based approach required significant consensus and coordination across multiple partners and stakeholders, as well as the development of new advocacy and communications materials that target that age cohort.

In Mozambique, introducing multiple vaccines at the same time requires earlier and more coordinated planning at both the national and sub-national levels than introducing a single vaccine. Delays in internal review processes across multiple stakeholders, and therefore delays with the disbursement of funds, led to various HPV and COVID-19 vaccination activities and training sessions being held simultaneously, potentially compromising the quality of the training for both vaccines. While disruptions due to the need to prioritize COVID-19 could not have been avoided, the launch of both HPV and COVID-19 vaccines simultaneously reinforced the need for advocacy for national prioritization, conducting activities such as the national readiness assessment, communication for demand, and the preparation and submission of the budget for implementation strategy well in advance of planned introduction. Similarly, Cameroon launched an HPV vaccination campaign in September 2020, while also implementing polio supplementary immunization activities. Although this enabled leveraging of resources for combined delivery, the EPI faced challenges with readiness given the multiple antigens and difficulty prioritizing different immunization activities and age groups.

In Malawi, the initial HPV vaccine introduction plan included a multi-age cohort of girls aged 9-14. Due to global supply shortages, however, the strategy shifted to focus on only 9-year-old girls through HPV vaccine integration into the routine vaccination delivery system, rather than a school-based campaign approach. With this shift in strategy, plans needed to be readjusted and, combined with inadequate funding for training, resulted in implementation delays in some districts. Delays were then further complicated by school closures due to the pandemic, and again the need to change plans and shift focus amidst other priorities, including COVID-19 vaccine roll-out. Ultimately, such obstacles and delays can lead to confusion and increased hesitancy, which negatively impacts demand. A key takeaway from Malawi’s introduction and routinization is that preparation and continuous contingency planning are of the highest importance: country EPIs should build in buffers to resource planning and timelines to prepare for and mitigate unexpected delays.

Given the different age cohorts for HPV vaccination, expanding stakeholder collaboration and advocacy beyond those typically engaged for infant immunization is integral to successful implementation. In each of the countries JSI has supported in HPV vaccine introduction, this process has involved identifying new key stakeholders, mobilizing new partners, solidifying messaging, and building knowledge and capacity of implementing partners such as health workers, teachers, and community health volunteers. The pandemic prompted school closures, which meant challenges accessing eligible girls and reduced opportunity for vaccination. While Kenya had already shifted HPV vaccination to a facility-based strategy after its initial school-based approach, coordination remained critical for delivering messages and advocacy with the Ministry of Education, schools, and teachers, which was almost impossible during school closures. In Tanzania, which began nationwide HPV vaccination in 2018, the increased engagement with communities and refocused social mobilization were vital for catching-up girls that have been missed during the pandemic.

As with any new vaccine, continuous communication and messaging are critical beyond the initial HPV vaccine introduction to ensure long-term implementation. Misperceptions are common with the HPV vaccine, given the age group and focus on HPV transmission rather than cancer prevention. We have learned that addressing the concerns and potential hesitancy of religious institutions (e.g. church hierarchy) and community leaders early on would have been better for the overall success of Kenya’s HPV vaccination roll-out. With this pre-adolescent/adolescent age group, more innovative approaches to inform and engage them can also help to mobilize their parents, peers and communities. It’s important to involve the girls and boys themselves in communication and advocacy, as well as community networks, religious leaders, and families. As with any health communication campaign, engaging participants and social listening to determine adequate messaging are best practices with new vaccines and new cohorts.

Social mobilization was a particularly notable challenge for Cameroon, given the political context and existing issues to health care and vaccination access, exacerbated by the pressures of the pandemic. Building confidence and trust through communication across sectors was a major challenge. In Malawi involving Health surveillance assistants (HSAs) with risk communication was a vital role in increasing communications, acceptance and coverage.  This included engaging parents one-on-one and sharing messages on the vaccination’s role in preventing cervical cancer. Tailoring messaging would be similarly useful for COVID-19 vaccination.

The COVID-19 pandemic has demonstrated the need for resilience and adaptability of immunization service delivery. HPV vaccination challenges related to supply, access, and messaging – and the need for collaboration with a broader range of stakeholders – were applicable to the launch of the COVID-19 vaccination. With overlapping target populations, there is a potential opportunity for linking  COVID-19 vaccination with HPV vaccination. Kenya’s 2021 adapted strategy, for example, includes the integration of service delivery of both HPV and COVID-19 vaccines for teachers and their eligible students.

These findings can also be applied to future life-course vaccination, encouraging MOHs, EPIs, and stakeholders to continuously learn, adapt, resource, and implement new strategies to improve routine immunization systems.

Written by Molly Ferguson