Human papillomavirus vaccine coverage in Rwanda: A population-level analysis by birth cohort

HPV vaccination in Africa in the COVID-19 era: a cross-sectional survey of healthcare providers' knowledge, training, and recommendation practices

Introduction

Although the burden of cervical cancer in Africa is highest, HPV vaccination coverage remains alarmingly low in this region. Providers' knowledge and recommendation are key drivers of HPV vaccination uptake. Yet, evidence about providers' knowledge and recommendation practices about the HPV vaccine against a backdrop of emerging vaccine hesitancy fueled by the COVID-19 pandemic is lacking in Africa.

Methods

A cross-sectional study was conducted in 2021-2022 among healthcare providers involved in cervical cancer prevention activities in Africa. They were invited to report prior training, the availability of the HPV vaccine in their practice, whether they recommended the HPV vaccine, and, if not, the reasons for not recommending it. Their knowledge about the HPV vaccine was assessed through self-reporting (perceived knowledge) and with three pre-tested knowledge questions (measured knowledge).

Results

Of the 153 providers from 23 African countries who responded to the survey (mean age: 38.5 years, SD: 10.1), 75 (54.0%) were female and 97 (63.4%) were based In countries with national HPV immunization programs. Overall, 57 (43.8%) reported having received prior training on HPV vaccine education/counseling, and 40 (37.4%) indicated that the HPV vaccine was available at the facility where they work. Most respondents (109, 83.2%) reported recommending the HPV vaccine in their practice. Vaccine unavailability (57.1%), lack of effective communication tools and informational material (28.6%), and need for adequate training (28.6%) were the most commonly reported reasons for not recommending the HPV vaccine. While 63 providers (52.9%) reported that their knowledge about HPV vaccination was adequate for their practice, only 9.9% responded correctly to the 3 knowledge questions.

Conclusion

To increase HPV vaccination coverage and counter misinformation about this vaccine in Africa, adequate training of providers and culturally appropriate educational materials are needed to improve their knowledge of the HPV vaccine and to facilitate effective communication with their patients and the community.

Understanding HPV Vaccination Policymaking in Rwanda: A Case of Health Prioritization and Public-Private-Partnership in a Low-Resource Setting

Rwanda is the first African country to implement a national HPV vaccination program in 2011. This study sought to clarify the HPV vaccination policymaking process in Rwanda through the lens of Kingdon's multiple stream framework and Foucault's concept of governmentality. Perspectives of policymakers engaged in HPV vaccination policy were gathered from published sources, along with key informant interviews. Rwanda's track record of successful vaccination programs enabled by a culture of local accountability created public and private sector incentives. Effective stakeholder engagement, health priority setting, and resource mobilization garnered locally and through international development aid, reflect indicators of policy success. The national HPV policymaking process in Rwanda unfolded in a relatively cohesive and stable policy network. Although peripheral stakeholder resistance and a constrained national budget can present a threat to policy survival, the study shows that such factors as the engagement of policy entrepreneurs within a policy network, private sector incentives, and international aid were effective in ensuring policy resolution.

Malawian caregivers' experiences with HPV vaccination for preadolescent girls: A qualitative study

Introduction

Many low- and middle-income countries have introduced the human papillomavirus (HPV) vaccine, but uptake remains extremely low. Malawi has the second-highest incidence of cervical cancer globally, and launched a national HPV vaccination program in 2019. We sought to understand attitudes about, and experiences with, the HPV vaccine among caregivers of eligible girls in Malawi.

Methods

We conducted qualitative interviews with 40 caregivers (parents or guardians) of preadolescent girls in Malawi to understand their experiences with HPV vaccination. We coded the data informed by the Behavioural and Social Drivers of vaccine uptake model and recommendations from WHO's Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy.

Results

In this sample, 37% of age-eligible daughters had not received any HPV vaccine doses, 35% had received 1 dose, 19% had received 2 doses, and 10% had an unknown vaccination status. Caregivers were aware of the dangers of cervical cancer, and understood that HPV vaccine is an effective prevention tool. However, many caregivers had heard rumors about the vaccine, particularly its alleged harmful effect on girls' future fertility. Many caregivers, especially mothers, felt that school-based vaccination was efficient; but some caregivers expressed disappointment that they had not been more engaged in the school-based delivery of HPV vaccine. Caregivers also reported that the COVID-19 pandemic has been disruptive to vaccination.

Conclusions

There are complex and intersecting factors that affect caregivers' motivation to vaccinate their daughters against HPV, and the practical challenges that caregivers may encounter. We identify areas for future research and intervention that could contribute to cervical cancer elimination: better communicating about vaccine safety (particularly to address concerns about loss of fertility), leveraging the unique advantages of school-based vaccination while ensuring parental engagement, and understanding the complex effects of the COVID-19 pandemic (and vaccination program).

Human papillomavirus vaccine effect against human papillomavirus infection in Rwanda: evidence from repeated cross-sectional cervical-cell-based surveys

BACKGROUND

Rwanda was the first African country to implement national human papillomavirus (HPV) vaccination (against types HPV6, 11, 16, and 18). In 2011, a school-based catch-up programme was initiated to vaccinate girls aged younger than 15 years but it also reached older girls in schools. We aimed to estimate the population-level effect of HPV vaccination on HPV prevalence.

METHODS

Cross-sectional surveys were done between July, 2013, and April, 2014 (baseline), and between March, 2019, and December, 2020 (repeat), in sexually active women aged 17-29 years at health centres in the Nyarugenge District of Kigali, Rwanda. HPV prevalence was assessed in cervical cell samples collected by a health-care worker in PreservCyt solution (Cytyc, Boxbourough, MA, USA) and tested using a general primer (GP5+ or GP6+)-mediated PCR. Adjusted overall, total, and indirect (herd immunity) vaccine effectiveness was computed as the percentage of HPV detection among all women and among unvaccinated women.

FINDINGS

1501 participants completed the baseline survey and 1639 completed the repeat survey. HPV vaccine-type prevalence in participants aged 17-29 years decreased from 12% (173 of 1501) in the baseline survey to 5% (89 of 1639) in the repeat survey, with an adjusted overall vaccine effectiveness of 47% (95% CI 31 to 60) and an adjusted indirect vaccine effectiveness of 32% (9 to 49). Among participants aged 17-23 years, who were eligible for catch-up vaccination, the adjusted overall vaccine effectiveness was 52% (35 to 65) and the adjusted indirect vaccine effectiveness was 36% (8 to 55), with important heterogeneity according to education (overall vaccine effectiveness was 68% [51 to 79] in participants with ≥6 years of school completed and 16% [-34 to 47] in those with <6 years) and HIV status (overall vaccine effectiveness was 55% [36 to 69] for HIV-negative participants and 24% [-62 to 64] for HIV-positive participants).

INTERPRETATION

In Rwanda, the prevalence of vaccine-targeted HPV types has been significantly decreased by the HPV vaccine programme, most notably in women who were attending school during the catch-up programme in 2011. HPV vaccine coverage and population-level impact is expected to increase in future cohorts who are eligible for routine HPV vaccination at age 12 years.

FUNDING

Bill & Melinda Gates Foundation.

Human papillomavirus vaccination in low- and middle-income countries: progression, barriers, and future prospective

Human papillomavirus (HPV) is a viral infection that, if does not go away, can cause health problems like genital warts and cancer. The national immunization schedules for individuals before sexual debut, significantly decreased HPV-associated mortality and it will be affordable. However, immunization programs remain vulnerable to macroeconomic factors such as inflation, fiscal policy, employment levels, and national income. This review aims to investigate the association between national income in lower-middle-income countries to explore recent advances and potential issues, as well as how to deal with challenges.

Human papillomavirus vaccination and cervical cancer risk

Persistent human papillomavirus infection is the central cause of cervical cancer, the leading cause of cancer death among women worldwide. Clear evidence from both randomized trials and population based studies shows that vaccination against human papillomavirus reduces the incidence of cervical pre-cancer. These data suggest that the vaccine reduces the incidence of cervical cancer. However, human papillomavirus vaccine coverage is inadequate in all countries, especially in low and middle income countries where disease burden is highest. Supply side strategies to improve coverage include increasing the availability of low cost vaccines, school located delivery, single dose vaccine schedules, and development of vaccines that do not need refrigeration. Demand side strategies include enhancing provider recommendations, correcting misinformation, and public awareness campaigns. The near elimination of cervical cancer is achievable through increased uptake of human papillomavirus vaccination and efforts to increase screening for cervical cancer, especially when enacted to reduce disparities in across the world.

Potential benefit of extended dose schedules of human papillomavirus vaccination in the context of scarce resources and COVID-19 disruptions in low-income and middle-income countries: a mathematical modelling analysis

BACKGROUND

The WHO Strategic Advisory Group of Experts recommended that an extended interval of 3-5 years between the two doses of the human papillomavirus (HPV) vaccine could be considered to alleviate vaccine supply shortages. However, three concerns have limited the introduction of extended schedules: girls could be infected between the two doses, the vaccination coverage for the second dose could be lower at ages 13-14 years than at ages 9-10 years, and identifying girls vaccinated with a first dose to give them the second dose could be difficult. Using mathematical modelling, we examined the potential effect of these concerns on the population-level impact and efficiency of extended dose HPV vaccination schedules.

METHODS

We used HPV-ADVISE, an individual-based, transmission-dynamic model of multitype HPV infection and disease, calibrated to country-specific data for four low-income and middle-income countries (India, Viet Nam, Uganda, and Nigeria). For the extended dose scenarios, we varied the vaccination coverage of the second dose among girls previously vaccinated, the one-dose vaccine efficacy, and the one-dose vaccine duration of protection. We also examined a strategy in which girls aged 14 years were vaccinated irrespective of their previous vaccination status. We used a scenario of girls-only two-dose vaccination at age 9 years (vaccine=9 valent, vaccine-type efficacy=100%, duration of protection=lifetime, and coverage=80%) as our comparator. We estimated two outcomes: the relative reduction in the age-standardised cervical cancer incidence (population-level impact) and the number of cervical cancers averted per 100 000 doses (efficiency).

FINDINGS

Our model projected substantial reductions in cervical cancer incidence over 100 years with the two-dose schedule (79-86% depending on the country), compared with no vaccination. Projections for the 5-year extended schedule, in which the second dose is given only to girls previously vaccinated at age 9 years, were similar to the current two-dose schedule, unless vaccination coverage of the second dose is very low (reductions in cervical cancer incidence of 71-78% assuming 30% coverage at age 14 years among girls vaccinated at age 9 years). However, when the dose at age 14 years is given to girls irrespective of vaccination status and assuming high vaccination coverage, the model projected a substantially greater reduction in cervical cancer incidence compared with the current two-dose schedule (reductions in cervical cancer incidence of 86-93% assuming 70% coverage at age 14 years, irrespective of vaccination status). Efficiency of the extended schedule was greater than the two-dose schedule, even with a drop in vaccination coverage.

INTERPRETATION

The three concerns are unlikely to have a substantial effect on the population-level impact of extended dose schedules. Hence, extended dose schedules will likely provide similar cervical cancer reductions as two-dose schedules, while reducing the number of doses required in the short-term, providing a more efficient use of scarce resources, and offering a 5-year time window to reassess the necessity of the second dose.

FUNDING

WHO, Canadian Institute of Health Research Foundation, Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, and Bill & Melinda Gates Foundation.

Cancer service delivery and the impact of the COVID-19 pandemic in sub-Saharan Africa: a scoping review

Background

The impact of the Coronavirus Disease 2019 (COVID-19) pandemic on health systems is widely reported worldwide. However, what remains unclear is the relative extent of the pandemic's effects on cancer management in sub-Saharan Africa (SSA). This review provides an up-to-date synthesis of the literature to inform post-pandemic policy and practice efforts in the region.

Methods

Sources searched for published research include MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, African Index Medicus, African Wide Information and Web of Science. Using predefined criteria, the retrieved citations were screened for primary research describing the direct and indirect impacts of the COVID-19 pandemic on the cancer care and service delivery landscape in SSA since March 2020. Evidence was summarised using narrative synthesis.

Results

Fourteen studies reporting findings from 19 SSA countries were included in this review. Studies were conducted mostly in the first wave of the pandemic (between March and July 2020) (10/14). The most commonly reported impact on cancer treatment (including surgery) were cancellations, delays and modifications (11/14). Half (7/14) of the studies reported on the impact of the pandemic on cancer care resource availability and service restructuring. Other notable impacts included temporary suspension, total cancellations or alterations in cancer screening (3/14) and diagnostic (3/14) services or programmes. Disruptions in cancer research and outreach activities were also reported (3/14). The availability and maintenance of cancer healthcare depended on multiple factors like availability of clinical supplies, existing oncology workforce, adequate supply of personal protective equipment and local pandemic mitigation measures. Notably, no studies reported on the impact of the pandemic on psychosocial support programmes, physiotherapy and other rehabilitation care for cancer patients.

Conclusion

Changes in cancer care and service delivery due to the COVID-19 pandemic varied considerably across countries in SSA. This review underscores the need for urgent actions to mitigate current setbacks while recommending evidence-based and contextualised approaches to revitalising cancer care in the post-pandemic era.

Cervical cancer in sub-Saharan Africa: an urgent call for improving accessibility and use of preventive services

Sub-Saharan Africa has the highest rates of cervical cancer in the world, largely attributed to low cervical cancer screening coverage. Cervical cancer is the most common cause of death among women in 21 of the 48 countries in sub-Saharan Africa. Close to 100% of all cases of cervical cancer are attributable to Human papillomavirus (HPV). HPV types 16 and 18 cause at least 70% of all cervical cancers globally, while types 31, 33, 45, 52, and 58 cause a further 20% of the cases. Women living with HIV are six times more likely to develop cervical cancer than those without HIV. Considering that sub-Saharan Africa carries the greatest burden of cervical cancer, ways to increase accessibility and use of preventive services are urgently required. With this review, we discuss the preventive measures required to reduce the burden of cervical cancer in sub-Saharan Africa, the challenges to improving accessibility and use of the preventive services, and the recommendations to address these challenges.

Impact of Parental Knowledge and Beliefs on HPV Vaccine Hesitancy in Kenya-Findings and Implications

Cervical cancer can be prevented by human papillomavirus (HPV) vaccination. However, parents can have concerns about vaccinating their daughters. Consequently, there is a need to identify prevalence and risk factors for HPV vaccine hesitancy among parents in Kenya. A descriptive cross-sectional study was conducted among parents with children aged 9−14 years attending a leading referral hospital in Kenya. Data on sociodemographic traits, HPV knowledge, beliefs and vaccine hesitancy were collected. Out of 195 participants, 183 (93.5%) were aged >30 years. Thirty-four (46.4%) of males and 39 (35.1%) of females did not know that the vaccine is given to prevent HPV infection. Encouragingly, levels of vaccine acceptance were high (90%) although one-third (37.9%) had a negative perception about the effectiveness of the vaccine, with vaccine hesitancy attributed to safety concerns (76%) and feelings that the child was too young (48%). Positive beliefs and knowledge of the vaccine were positively associated with parental willingness to vaccinate their children. Low levels of parenteral education and a younger age among mothers were negatively associated with willingness to vaccinate. Most parents (59%) would consult their daughters before vaccination, and 77% (n = 150) recommended early sex education. Despite low knowledge levels, there was high parental willingness to have their children vaccinated.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Human Papillomavirus Vaccination in South Africa: Programmatic Challenges and Opportunities for Integration With Other Adolescent Health Services?

Compared to other regions of the world, sub-Saharan Africa has made limited progress in the implementation and performance of nationwide human papillomavirus (HPV) vaccination programmes. Without urgent intervention, this will serve to undermine cervical cancer elimination efforts in this region. The primary intent of this narrative review is to highlight the programmatic successes and challenges of the school-based HPV vaccination programme in South Africa since its inception in 2014, with the aim of contributing to the evidence base needed to accelerate implementation and improve programme performance in other sub-Saharan African countries. As of 2020, the proportion of adolescent girls aged 15 years who had received at least one dose of the HPV vaccine at any time between ages 9–14 years was 75%, while 61% had completed the full recommended two-dose schedule. This gives some indication of the reach of the South African HPV vaccination programme over the past 6 years. Despite this, vaccine coverage and dose completion rates have persistently followed a downward trend, slowing progress toward attaining global elimination targets. There is evidence suggesting that declining public demand for the HPV vaccine may be a result of weakening social mobilization over time, inadequate reminder and tracking systems, and vaccine hesitancy. Another concern is the disproportionate burden of HPV and HIV co-infections among adolescent girls and young women in South Africa, which predisposes them to early development of invasive cervical cancer. Moving forward, national policy makers and implementers will have to explore reforms to current age eligibility criteria and vaccine dose schedules, as well as implement strategies to support vaccine uptake among populations like out-of-school girls, girls attending private schools, and HIV positive young women. Additional opportunities to strengthen the South African HPV vaccination programme can be achieved by scaling up the co-delivery of other adolescent health services such as comprehensive sexual and reproductive health and rights education, deworming, and health screening. This calls for reinforcing implementation of the integrated school health policy and leveraging existing adolescent health programmes and initiatives in South Africa. Ultimately, establishing tailored, adolescent-centered, integrated health programmes will require guidance from further operational research.

The impact of HPV vaccination beyond cancer prevention: effect on pregnancy outcomes

While the benefits of human papillomavirus (HPV) vaccination relating to cervical cancer prevention have been widely documented, recent published evidence is suggestive of an impact on adverse pregnancy outcomes (APOs) in vaccinated mothers and their infants, including a reduction in rates of preterm births and small for gestational age infants. In this review, we examine this evidence and the possible mechanisms by which HPV vaccination may prevent these APOs. Large-scale studies linking HPV vaccination status with birth registries are needed to confirm these results. Potential confounding factors to consider in future analyses include other risk factors for APOs, and historical changes in both the management of cervical precancerous lesions and prevention of APOs. If confirmed, these additional benefits of HPV vaccination in reducing APO rates will be of global significance, due to the substantial health, social and economic costs associated with APOs, strengthening the case for worldwide HPV immunization.

Single-Dose Human Papillomavirus Vaccination in Low- and Middle-Income Countries-Time for Implementation?

Although cervical cancer is becoming a rare disease in high income regions, it is still a major health issue in low- and middle-income countries (LMICs). Cervical cancer develops after infection with a high-risk human papilloma virus (hrHPV), an infection against which vaccination has been possible since 2006. Large population immunization programs have been organized in many higher income countries, and yet they have not been implemented in most of the lower and middle-income nations. The cost of the vaccine, as well as the need for two doses impedes coverage in the most vulnerable groups. Studies are suggesting the efficacy of single dose vaccination, but so far only observational data are available while large, randomized, double-blind studies are still ongoing. In order to prevent and combat this disease, it is essential to inform the population of vaccination benefits and offer accessible programs in higher as well as low-and middle-income countries. In this commentary, we wish to focus our attention on the case for implementing single dose vaccination in lower- and middle-income nations.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

State of Cancer Control in Rwanda: Past, Present, and Future Opportunities

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country’s 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.

Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda

Our objective was to assess the health facility related factors that cause delays in cervical cancer diagnosis at a primary healthcare level in Rwanda. Healthcare providers in outpatient clinics at 10 health centers in Kigali city and the Eastern province of Rwanda were surveyed. Eighty-five healthcare providers participated; 83.5% were nurses and the remainder were midwives. Only 15 (17.6%) reported prior training on visual inspection with acetic acid (VIA) cervical cancer screening, and they were distributed among 6 of the 10 health centers surveyed. However, 76.5% of respondents reported that at least one person was trained in VIA at their health center. The basic equipment necessary for cervical cancer evaluation was reported to be generally available. Overall, only 31.8% of participants had good basic knowledge level on cervical cancer screening. No association was found between respondents' knowledge about cervical cancer screening and profession, education level, work experience or reported prior training on VIA. There is a gap in the number of primary healthcare providers with the skills to perform pelvic exam and VIA cervical cancer screening at health centers in Rwanda. As health centers are the first point of contact for patients with the healthcare system, there is a need to improve their knowledge and skills in performing cervical cancer screening and detection.

Reflection: burden of cervical cancer in Sub-Saharan Africa and progress with HPV vaccination

In Sub-Saharan (SSA) cervical cancer is the leading cause of cancer deaths amongst women. The region carries the greatest burden, with 24.55% of the global mortality from cervical cancer. Reports indicate an increasing challenge of cervical cancer in SSA. HPV vaccination with its well-established effectiveness provides hope for cancer control in SSA. Following an initial delay in HPV vaccine uptake in SSA, 18 countries mostly in Eastern and Southern Africa, had a national programme by 2020. Vaccination coverage data show that high populated countries have lower coverage figures. Furthermore, high coverage of demonstration projects may not be achieved in the national rollout. In conclusion, whilst there is significant progress with the rollout of HPV vaccination programme in SSA, some countries in West Africa should be prioritised. Experiences of early adopters should be reviewed to guide other countries to achieve and sustain high coverage.

Human papillomavirus vaccination uptake in low-and middle-income countries: a meta-analysis

BACKGROUND

The proportion of incident cases of HPV-attributable cancers is highest in the low- and middle-income countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges.

METHODS

A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429.

FINDINGS

During 2008-2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015-2020 compared to 2006-2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015-2020 compared to 2006-2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%).

INTERPRETATION

The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.

National implementation of HPV vaccination programs in low-resource countries: Lessons, challenges, and future prospects

More than 90% of cervical cancer deaths occur in low- and middle-income countries (LMICs), which have limited capacity to mount the comprehensive national screening and precancer treatment programs that could prevent most of these deaths. The development of vaccines against the human papillomavirus (HPV) has dramatically altered the landscape of cervical cancer prevention. As of mid-2020, 56 LMICs (41% of all LMICs) have initiated national HPV vaccination programs. This paper reviews the experience of LMICs that have introduced HPV vaccine into their national programs, key lessons learned, HPV vaccination sustainability and scale-up challenges, and future mitigation measures. As international guidance evolved and countries accumulated experience, strategies for national introduction shifted with regard to target groups, delivery site and timing, preparation and planning, communications and social mobilization, and ultimately monitoring, supervision and evaluation. Despite the successes that LMICs have been able to achieve in reaching large proportions of eligible girls, there are still considerable challenges countries encounter in overcoming rumors, reaching out-of-school girls, completing the vaccine series, estimating target populations, monitoring program performance, and assuring vaccination sustainability. New opportunities, such as the entry of additional vaccine manufacturers and ongoing studies to evaluate one-dose delivery, could help overcome the outstanding barriers to higher coverage and financial sustainability. Effective use of the experience to date and advances on the horizon could enable all LMICs to move towards the coverage levels that are needed to achieve eventual elimination.

HPV vaccination introduction worldwide and WHO and UNICEF estimates of national HPV immunization coverage 2010-2019

WHO/UNICEF estimates for HPV vaccination coverage from 2010 to 2019 are analyzed against the backdrop of the 90% coverage target for HPV vaccination by 2030 set in the recently approved global strategy for cervical cancer elimination as a public health problem. As of June 2020, 107 (55%) of the 194 WHO Member States have introduced HPV vaccination. The Americas and Europe are by far the WHO regions with the most introductions, 85% and 77% of their countries having already introduced respectively. A record number of introductions was observed in 2019, most of which in low- and middle- income countries (LMIC) where access has been limited. Programs had an average performance coverage of around 67% for the first dose and 53% for the final dose of HPV. LMICs performed on average better than high- income countries for the first dose, but worse for the last dose due to higher dropout. Only 5 (6%) countries achieved coverages with the final dose of more than 90%, 22 countries (21%) achieved coverages of 75% or higher while 35 (40%) had a final dose coverage of 50% or less. When expressed as world population coverage (i.e., weighted by population size), global coverage of the final HPV dose for 2019 is estimated at 15%. There is a long way to go to meet the 2030 elimination target of 90%. In the post-COVID era attention should be paid to maintain the pace of introductions, specially ensuring the most populous countries introduce, and further improving program performance globally.