When the health workers arrived at Upendo Primary School on the edge of Dar es Salaam, Tanzania, they instructed girls who would turn 14 this year to line up to get a shot. Quinn Chengo held an urgent, whispered consultation with her friends. What was the injection for, really? Could it be a Covid vaccine? (They had heard rumors about that.) Or was it meant to keep them from having babies?
Ms. Chengo was uneasy, but she remembered that last year her sister got this shot, for the human papillomavirus. So she got in the line. Some girls sneaked away, though, and hid behind the school buildings. When some of Ms. Chengo’s friends arrived home that evening, they faced questions from their parents, who worried that it might make their children feel more comfortable with the idea of having sex — even if some didn’t want to come right out and say so.
The HPV vaccine, which offers near-total protection against the sexually transmitted virus that causes cervical cancer, has been given to adolescents in the United States and other industrialized countries for almost 20 years. But it is only now starting to be widely introduced in lower-income countries, where 90 percent of cervical cancer deaths occur.
Tanzania’s experience — with misinformation, with cultural and religious discomfort, and with supply and logistical obstacles — highlights some of the challenges countries face in implementing what is seen a critical health intervention in the region.
Screening and treatment for cancer are limited in Tanzania; the shot could sharply reduce deaths from cervical cancer, the deadliest cancer for Tanzanian women.
HPV vaccination efforts have been hampered across Africa for years. Many countries had designed programs to begin in 2018, working with Gavi, a global organization that supplies vaccines to low-income nations. But Gavi was unable to procure shots for them.
In the United States, the HPV vaccine costs about $250; Gavi, which typically negotiates big discounts from pharmaceutical companies, was aiming to pay $3 to $5 per shot for the large volumes of vaccine it sought to procure. But because high-income nations were also expanding their programs, the vaccine makers — Merck and GlaxoSmithKline — targeted those markets, leaving little for developing countries.
“Even though we had been very vocal about the supply we needed from manufacturers, that wasn’t coming through,” said Aurélia Nguyen, Gavi’s chief strategy officer. “And so we had 22 million girls that countries had asked to be vaccinated for whom we had no supply at that time. That was a very painful situation.”
Lower-income countries have had to make a decision about where to allot the limited quantities of vaccine they have received. Tanzania chose to first target 14-year-olds who, as the oldest eligible girls, were seen as most likely to start sexual activity. Girls begin to drop out at that age, before the transition to secondary school; the country had planned to deliver the vaccines mostly in schools.
But vaccinating a teenager for HPV is not like delivering a measles shot to a baby, said Dr. Florian Tinuga, program manager for the immunization and vaccine development unit at the Ministry of Health. Fourteen-year-olds must be convinced. Yet because they’re not yet adults, parents have to be won over, too. That means having frank discussions about sex, a sensitive matter in the country.
And because the 14-year-olds were seen as young women almost old enough for marriage, rumors have spread fast on social media and messaging apps about what is really in the shot: Could it be a stealth birth control campaign coming from the West?
The government didn’t anticipate that problem, Dr. Tinuga said ruefully. The rumors were tough to counter in a population with a limited understanding of research or scientific evidence.
The Covid pandemic further complicated the HPV campaign as it disrupted health systems, forced school closures and created new levels of vaccine hesitancy.
“Parents pull kids out of school when they hear the vaccination is coming,” said Khalila Mbowe, who directs the Tanzania office of Girl Effect, a nongovernmental organization funded by Gavi to drum up demand for the vaccine. “After Covid, issues about vaccination are supercharged.”
Girl Effect produced a radio drama, slick posters, chatbots and social media campaigns urging girls to get the shot. But that effort and others in Tanzania have concentrated on motivating girls to accept the vaccine, without sufficiently factoring in the power other gatekeepers, including religious leaders and school officials, who have a strong voice in the decision, Ms. Mbowe said.
Asia Shomari, 16, was spooked the day the health workers came to her school on the outskirts of Dar es Salaam last year. The students hadn’t been briefed and didn’t know what the shot was for. It was an Islamic school where no one ever talked about sex, Ms. Shomari said. She hid behind a toilet block with some friends until the nurses left.
“Most of us decided to run,” she said. When she went home and recounted what happened, her mother said she had done the right thing: Any vaccine that had to do with reproductive organs was suspect.
But now, her mother, Pili Abdallah, has begun to reconsider. “Girls her age, they are sexually active, and there is a lot of cancer,” she said. “If she could be protected, it would be good.”
While Girl Effect aimed some messages at mothers, the truth is that fathers have the final say in most families, Ms. Mbowe said. “The decision-making power doesn’t rest with the girl.”
Despite all the challenges, Tanzania managed to inoculate nearly three-quarters of its 14-year-old girls in 2021 with a first dose. (Tanzania reached that target for first-dose coverage twice as fast as the United States.) It has been harder to persuade people to return for a second dose: Only 57 percent got the second shot six months later. A similar gap has persisted in most sub-Saharan countries that have started HPV vaccination.
Since Tanzania has largely relied on school pop-up clinics to deliver the shots, some girls miss the second dose because they have left school by the time the health workers come back.
Rahma Said was vaccinated at school in 2019, when she was 14. But not long after, she failed to pass the exams to move up to secondary school and dropped out. Ms. Said tried a couple of times to get a second shot at public health clinics in her neighborhood, but none had the vaccine, and last year, she said, she gave up.
Next year, Tanzania will most likely switch to a single-dose regimen, Dr. Tinuga said. There is growing evidence that a single shot of the HPV vaccine will produce adequate protection, and in 2022 the W.H.O. recommended that countries switch to a one-dose campaign, which would improve costs and vaccine supply, and remove this challenge of trying to inoculate girls a second time.
Another cost-saving step, public health experts say, would be to move from school-based vaccination to making the HPV shot one of the routine vaccines offered at health centers. Making that shift will take a huge and sustained public education effort.
“We have to make sure demand is very, very strong because they’re not typically going to come to facilities for other interventions,” Ms. Nguyen of Gavi said.
Now, at last, supply of the vaccine has built up, Ms. Nguyen said, and new versions of the shot have come to the market from companies in China, India and Indonesia. Supply is expected to triple by 2025.
Populous countries including Indonesia, Nigeria, India, Ethiopia and Bangladesh are planning to introduce or expand use of the vaccine this year, which may challenge even the expanded supply. But the hope is that there will soon be sufficient doses for countries to be able to vaccinate all girls between 9 and 14, Ms. Nguyen said. Once they are caught up, the vaccine will become routine for 9-year-olds.
“We’ve set the target of 86 million girls by the end of 2025,” she said. “That will be 1.4 million deaths averted.”
Ms. Chengo and her friends were convulsed by giggles at the mere mention of sex, but they said that in fact, many girls in their grade were already sexually active, and that it would be better when Tanzania was able to vaccinate girls at age 9.
“Eleven is too late,” said Restuta Chunja, with a somber shake of her head.
Ms. Chengo, a sparkly-eyed 13-year-old who intends to be a pilot when she finishes school, said that her mother told her the vaccine would protect her from cancer, but that she shouldn’t get any ideas.
“She said I shouldn’t get married or be involved in any sexual activities, because that would be bad and you might get something like H.I.V.”
The HPV vaccine is offered to boys as well as girls in higher-income countries, but the W.H.O. advises prioritizing girls in developing countries with the existing vaccine supply because women get 90 percent of HPV-related cancers.
“From a Gavi perspective, we’re not there yet, to add boys,” Ms. Nguyen said.
Dr. Mary Rose Giattas, the technical director for reproductive cancer in Tanzania for Jhpiego, a health care nonprofit affiliated with Johns Hopkins University, believes any remaining hesitancy can be overcome. When she educates the public about the shot, she talks about Australia.
“I say, forget the rumors: Australia has almost eliminated cervical cancer. And why? Because they vaccinate. And if the vaccine caused a problem with fertility, we would know about it because they were one of the first countries to use it.”
Misconceptions can be resolved with “chewable pieces” of evidence, she said. “I say, our health ministry takes serious steps to test medicines: They don’t come right from Europe to your clinic. I say to women, ‘Unfortunately, you and I missed it because of our age, but I wish I could be vaccinated now.’”