Reaching teenagers with three-times jab is a first for most countries

Abstract

In May 2010, tiny mountain kingdom of Bhutan made very big news. By partnering with pharmaceutical company Merck & Co. and Australian Cervical Cancer Foundation, Bhutan became first developing country to roll out national vaccination programme against human papillomavirus (HPV), main cause of cervical cancer. In two and half years since then, others have followed suit. In 2011, Rwanda became first country in sub-Saharan Africa to roll out HPV vaccination. A year later, Uganda launched first phase of its national HPV vaccination introduction in September, aiming to reach girls in primary grade four--most between ages of nine and 12 years--in 14 of country's 112 districts in 2012, further 40 districts in 2013 and full national rollout in 2014. A 2008-2009 pilot points way ahead, says Dr Emmanuel Mugisha, country manager for non-profit health organization PATH that is partnering with Ugandan government in pilot and, now, national rollout in east African country of 34.5 million. We found that we reached more girls by selecting them by grade rather than age, that it's feasible and cheaper to deliver vaccine alongside other packages targeting schools, Mugisha says, referring to packages such as vitamin A and deworming medications distributed by health workers during twice-yearly Child Days Plus programme. Delivering it at same time each year aids planning of health worker time and space in cold chain while reducing disruption in schools. Uganda has high school attendance rates, but some girls do not go to school and among those who do, there is fair amount of absenteeism, so mop-up campaigns are also needed. These girls may fall between cracks or be lost to follow up, so we are developing plan to urge them to go for HPV vaccination at nearest health facility, Mugisha says. Another worry for Ugandans is that full nationwide rollout beyond initial 14 districts could be jeopardized by lack of funds. You need timely planning and implementation to ensure that vaccines are on hand when they are needed Mugisha says. But Ministry of Health and local government districts have in past faced delays in funding which can, in turn, delay delivery of subsequent HPV vaccine doses. Uganda and Bhutan are just two of some 40 countries that have included HPV vaccine in their national vaccination schedules. Most are in developed world, but with last year's announcement that GAVI Alliance would subsidize HPV vaccine, more low-income countries will be able to afford to immunize girls against HPV and join their ranks. Dr Andreas Ullrich, cancer expert at World Health Organization (WHO), calls GAVI's decision a major step for implementing WHO guidance. WHO recommends comprehensive approach to cervical cancer prevention and control, of which vaccination is but one part. HPV vaccination should not divert resources from cervical cancer screening programmes. The GAVI decision, Ullrich says, moves forward the spirit of United Nations (UN) High-level Meeting on Non-Communicable Diseases in September of last year, which aimed to generate greater awareness of global burden of NCDs, shine spotlight on new initiatives to combat them and shape global health agenda for future generations. The second most common cancer in women worldwide, cervical cancer affects close to half million women ever year, killing an estimated 275 000 of them. About 77% of new cases and 85% of deaths occur in developing world, where cancer screening and treatment services are scarce. The majority of cervical cancer cases are linked to infection with HPV and, while most sexually-active people become infected with HPV without realizing it and most such infections resolve without consequences, persistent infection of high-risk HPV types for more than year increases likelihood that woman will develop cancerous lesions. …