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Battling for HPV Vaccine Uptake in sub-Saharan Africa

Authored by Robin Hall

Art by Constance Newell


As a thirteen-year-old preparing for my first year of high school, I made a list of everything I needed for the first day of class: pencils, pens, notebooks, a backpack, and my first dose of the human papillomavirus (HPV) vaccine at my annual physical. I knew what to expect: I’d walk into my doctor’s office, talk about my health, exercise habits, and plans for the school year. I’d walk out with a mermaid band-aid on my arm and updated paperwork to give to the school nurse. However, though the HPV vaccine is commonly given to teenagers throughout the United States, this is not the norm in many places around the world: in sub-Saharan Africa, for example, HPV vaccine uptake can be as low as 20% [1].


HPV is the world’s most common STI with 80-90% of people globally contracting it within their lifetime and a worldwide prevalence of 11-12% [2]. Two specific strains, HPV-16 and HPV-18, account for 70% of precancerous lesions and cervical cancer cases [2]. The creation and approval of the HPV vaccine resulted in a 65% decline in HPV cases between 2012-2019, and has made cervical cancer more preventable and treatable [3]. However, low HPV vaccine uptake and lack of resources for early detection are major problems facing developing countries, especially in sub-Saharan Africa.


In 2018, 19 of 20 countries with the highest cervical cancer burden were in sub-Saharan Africa [2]. Even though the HPV vaccine has been available for 15 years, the uptake rate in sub-Saharan Africa is extremely low, with some countries hovering around 20% [3]. Interventions focused on increasing HPV vaccination rates will be needed to drive down the cervical cancer burden in these countries. Proof of the vaccination success can be seen in the United Kingdom, where cervical cancer has been almost eliminated after implementing an HPV vaccination program among adolescent girls [4].


The struggle for HPV vaccination acceptance and lack of screening for cervical cancer have been further exacerbated by the COVID-19 pandemic [5]. One country that has been particularly affected is Zimbabwe, which has the fourth highest cervical cancer rate. In Zimbabwe, there are just two gynecological oncologists who serve the entire population [6]. At the beginning of the COVID-19 pandemic, all non-essential services were discontinued, including gynecological screenings designed to detect cervical cancer at early stages. While these services have come back as the pandemic has subsided, there has been a decreased number of patients seeking screening and treatment for fear of contracting COVID-19 [7]. 


Zimbabwe faces a challenging vaccine landscape with a high prevalence of vaccine hesitancy and inadequate financial resources. This low COVID-19 vaccine uptake has been paired with a sharp decline in HPV vaccinations throughout the country. The onset of the pandemic has resulted in HPV vaccines going to waste as many countries were solely focused on rolling out COVID-19 vaccinations, while suspending HPV vaccination programs [7]. Additionally, the closure of schools has shut down a very common venue for girls to receive HPV vaccinations. As a result, the COVID-19 pandemic has had a lasting negative impact on the health of young girls in Zimbabwe, leaving them more vulnerable to HPV and higher cancer risk due to early marriage and sexual exposure [7]. 


A major part of the issue of low uptake of vaccines is overall hesitancy and negative views of the HPV vaccine in many African countries. There has been a movement towards offering HPV vaccines in schools throughout sub-Saharan Africa, however these programs have not been very effective, as evidenced by an average vaccination rate of only around 60% [8]. Parents, when asked about why they rejected the vaccine, cited many different reasons. Among the most common ones is inadequate education about the program due to poor or complete lack of communication [7]. Additional motives for vaccine hesitancy include misconceptions about the risk of HPV, belief that the vaccine would cause sterility, and that it is ineffective [9]. 


Vaccine hesitancy is an ongoing battle in sub-Saharan Africa that will require a comprehensive approach in order to overcome it. There is a long and devastating history of medical experimentation in Africa. One example is Pfizer’s trial of meningitis drugs in 1996 that led to the death of 11 Nigerian children [10]. Because of this troubled past, many people, including government officials, have a negative view of vaccines coming from the West. The former Tanzanian president John Magufuli stated: “Vaccines are not good. If they were, then the white men would have brought vaccines for HIV/AIDS” [11]. Magufuli’s statement reflects the feelings of much of the African population: minimal trust in Western medicine.


It will take much effort for the Western world and big pharma to earn the trust of African communities. In the meantime, it is important that there are new and greater community and policy interventions within the African countries. For example, public health organizations could hang posters and flyers throughout the country written in local languages. Additionally, governments need to focus on collaborative efforts with communities to make sure these campaigns and education are reaching all parts of the country. Lastly, it will be imperative for governments and pharmaceutical companies to partner and facilitate the production of vaccines in Africa, which could help reduce the fear of Western influence [11]. 




References

  1. Amponsah-Dacosta, E., Blose, N., Nkwinika, V. V., & Chepkurui, V. (2022). Human Papillomavirus Vaccination in South Africa: Programmatic Challenges and Opportunities for Integration With Other Adolescent Health Services? Frontiers in Public Health, 10. https://www.frontiersin.org/articles/10.3389/fpubh.2022.799984

  2. 2023 Cancer Facts & Figures Cancer | Incidence Drops for Cervical Cancer But Rises for Prostate Cancer. (n.d.). Retrieved March 3, 2023, from https://www.cancer.org/latest-news/facts-and-figures-2023.html

  3. Cervical cancer. (2023, March 2). WHO | Regional Office for Africa. https://www.afro.who.int/health-topics/cervical-cancer

  4. Falcaro, M., Castañon, A., Ndlela, B., Checchi, M., Soldan, K., Lopez-Bernal, J., Elliss-Brookes, L., & Sasieni, P. (2021). The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: A register-based observational study. The Lancet, 398(10316), 2084–2092. https://doi.org/10.1016/S0140-6736(21)02178-4 

  5. Fortin, D. (2022, January 27). Vaccinating against Human Papillomavirus from a Global Perspective: Challenges and Future Direction. JSI. https://www.jsi.com/vaccinating-against-human-papillomavirus-from-a-global-perspective-challenges-and-future-direction/

  6. Murewanhema, G. (2021). The COVID-19 pandemic and its implications for cervical cancer treatment and prevention in Zimbabwe: Perspectives and recommendations. The Pan African Medical Journal, 39(149), Article 149. https://doi.org/10.11604/pamj.2021.39.149.26467

  7. HPV vaccine “lying around” unused in Africa due to pandemic disruption | Cancerworld Magazine. (2021, March 19). https://cancerworld.net/hpv-vaccine-lying-around-unused-in-africa-due-to-pandemic-disruption/

  8. Khosa, L. A., Meyer, J. C., Motshwane, F. M. M., Dochez, C., & Burnett, R. J. (2022). Vaccine Hesitancy Drives Low Human Papillomavirus Vaccination Coverage in Girls Attending Public Schools in South Africa. Frontiers in Public Health, 10, 860809. https://doi.org/10.3389/fpubh.2022.860809

  9. Kindzeka, M. E. (2020, October 3). Cameroon: Millions of Girls at Risk for Cervical Cancer as Parents Reject HPV Vaccination. VOA. https://www.voanews.com/a/africa_cameroon-millions-girls-risk-cervical-cancer-parents-reject-hpv-vaccination/6196703.html

  10. Wise J. (2001). Pfizer accused of testing new drug without ethical approval. BMJ (Clinical research ed.), 322(7280), 194. 

  11. Myths and models: What’s driving vaccine hesitancy in Africa and how can we overcome it? (n.d.). Africa Portal. Retrieved March 3, 2023, from https://www.africaportal.org/features/myths-and-models-whats-driving-vaccine-hesitancy-in-africa-and-how-can-we-overcome-it/

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