"Investment in an engagement and communication strategy, including effective consent processes, is essential to success. Countries must plan for crises and be flexible and tackle them rapidly when they occur."
This report distills and shares information gathered and presented by the World Health Organization (WHO) and partners at a Global Learning Meeting on HPV Vaccine Introduction in November 2015. It offers experiences - many directly reported by country health managers - and implications for action in the main areas of human papillomavirus (HPV) vaccine introduction: decision-making, planning and coordination, delivery strategies, communication, crises management, monitoring and evaluation, and costing and sustainability. It also offers insights into reaching hard-to-reach populations and on integration of HPV vaccine in both a comprehensive cervical cancer prevention and control plan and into adolescent health programming.
In brief, the report's country experiences, both positive and challenging, show that it is feasible to introduce and attain high coverage of HPV vaccine in different country settings. Communication and advocacy play a key role here, as decision-making requires high-level political commitment, and coordination and sustainability demand a partnership spanning immunisation, adolescent health, cancer programming, the Ministry of Education (MoE), and communities. More work and time are required to integrate HPV vaccine with other adolescent health services and to document that work.
The WHO recommends HPV vaccination for 9–14 year-old girls as the most cost-effective public health measure against cervical cancer, and a core strategy for primary prevention. As detailed here, as of December 2015, more than 65 countries had introduced national HPV vaccine programmes, and a number of others had introduced or planned to introduce pilot or demonstration programmes. The pace of introduction in low-income countries eligible for Gavi, the Vaccine Alliance support is increasing and Gavi aims to support vaccination of more than 30 million girls in 40 countries by 2020. However, despite the progress, WHO estimates that in 2015 less than 5% of the age cohort of girls who could benefit from HPV vaccine worldwide were fully immunised with HPV vaccine. In 2012, an estimated 530,000 women developed cervical cancer, and 270,000 women died from the disease. More than 85% of these women lived in low and middle-income countries where access to screening and treatment can be limited. "The public health impact of HPV vaccination is continuing to be demonstrated as an effective preventer of HPV infection and disease..."
Specifically, selected communication lessons from each of the stages in the process include:
- With regard to the decision to introduce, some countries reported a confluence of factors - for example: the Ministry of Health (MoH) and/or non-governmental organisations (NGOs) had collected disease burden information and were proposing to strengthen cervical cancer programming; the First Lady advocated for stronger cervical cancer programming upon her return from a meeting; and a donation or Gavi funding presented the opportunity to introduce the vaccine.
- Like the decision-making process, coordination and planning for implementation will involve many partners. To increase the chance of successful HPV vaccine delivery, Expanded Programme on Immunization (EPI) managers may need to adjust their ways of working to forge a successful, productive partnership with new stakeholders in cancer control, women's and reproductive health, adolescent health, the education sector, and others. Countries cited insufficient training time as a common problem. One country representative said, "The more health workers know, the more they can advocate for the vaccine." Training was considered successful when standardised guides and sufficient information, education, and communication (IEC) materials were available. Ensure all trainees have a thorough understanding of cervical cancer, the links to HPV, the protective benefits and side effects of the vaccine, and their role in crisis communication and rumour management.
- Choosing a cost-effective delivery strategy (school- versus health-facility-based) involves considerations such as the fact that insufficient coordination, mobilisation, engagement, and awareness, particularly at private and religious schools, can lead to resistance such as school authorities withholding authorisation to vaccinate or parents not providing consent. Routine delivery through the health facility will likely require additional resources for communication and social mobilisation so that girls and their caregivers know when and where the vaccine is available, especially in countries where health facilities may not offer services during weekends and outside of school hours.
- Reaching the hard-to-reach is a matter of equity and a guiding principle of the Global Vaccine Action Plan (GVAP). The most common strategy is for community health workers to connect with local leaders to enumerate and mobilise out-of-school girls wherever they are - at home, on the farm, at the market, or at transit points. Countries generally translate materials into local languages for minority communities. When caregivers are vaccine-hesitant, countries work with trusted influencers such as religious and traditional leaders or school headmasters to speak with the caregivers. Ideas for investing in strengthening ties between communities and health facilities include: increasing community mobilisation to increase demand; investing in women peer leaders from the community; investing in champions at the health facility; and strengthening links with local community and faith-based organisations. Several suggestions are offered for improving coverage of hard-to-reach girls, such as: Use lessons and data from the polio eradication programme, and conduct anthropological and other socio-behavioural studies to understand hard-to-reach girls and how to reach them better.
- Demonstration programmes and phased introductions give countries the opportunity to learn by doing and can provide experience in, for example, handling communication for a vaccine that is known to present challenges with rumours and misunderstandings. There have been challenges reported, however; for example, some countries said the word "demo" triggered fears of "vaccine trials" in the population. Some demo countries discussed what they might do differently in hindsight - e.g., encouraging partners to conduct more orientation meetings with potential demonstration countries to share lessons learned.
- The section of the report on communication advises countries to start early and build on existing platforms and communication lessons acquired in polio eradication, tetanus, measles, and routine immunisation programming. Several countries and partners suggested gathering data before, during, and after to measure the impact of communication. This includes Knowledge, Attitudes and Practice (KAP) studies, smaller surveys, monitoring during implementation (including for rumours), and evaluating for impact. Several countries reported problems if they didn't work with the right stakeholders early enough. Countries are advised to prepare for and respond rapidly to common types of rumours and questions about HPV vaccine. Consent was an issue for some countries, especially if they introduced unfamiliar processes. Different audiences, including the media, out-of-school girls, and decision-makers need different packages of information, ranging from simple to the sophisticated. They will also respond to different influencers. Countries find that language consistency really matters. Social media makes a difference to the intended audience - in communicating messages and in spreading and managing rumours. It is suggested that countries invest in a long-term communication strategy that offers updated information for stakeholders every year, including about the HPV vaccine's impact on infection and disease.
- Countries reported a variety of types of crises, including communication crises, which occur when there is a gap in stakeholder involvement, poor choice of messaging, rumours in a community (including those spread by anti-vaccination groups), slow response to an adverse event following immunisation (AEFI), or other problem. Being aware of common pitfalls with HPV vaccine, countries can plan to avoid crises as much as possible: by early, thorough planning that anticipates risks and potential problems, engagement of the right stakeholders, work plan oversight and accountability, an investment in communication, and training.
- With regard to recording, monitoring, and evaluation, WHO notes that the challenges in defining accurate denominators pose a challenge for monitoring. Countries did not report on any communication indicators, but some reported "rumours monitoring" mechanisms, picking up rumours and concerns in communities and media so they could respond quickly. A handful of countries had conducted KAP surveys to get a baseline on cervical cancer, HPV, and HPV vaccine. As a precautionary measure to maintain trust in the HPV vaccine programme, Malaysia has a unique system of active AEFI surveillance. They send minor AEFI reporting forms home with girls and ask parents to fill them and return them to school. This way, they can record the proportion of minor AEFIs, ranging from pain at the injection site, to body aches and weakness. Compared with other vaccines, they record more HPV vaccine-related AEFIs as a result of the active surveillance, but the country also has ample data to show the types and normal frequency of AEFIs, which helps allay any concerns. One suggestion: Conduct more baseline communication-related surveys, including communication indicators for hesitancy and for determining the impact of communication activities.
- The next section focuses on integration with comprehensive cervical cancer prevention and control and adolescent health. One case study examines South Africa's "Me, My Body, My Life" adolescent health workbook, introduced as part of HPV vaccine delivery, which was integrated nationwide into its public school health programme in March 2014. In the school health programme, health teams travel to each school to provide a package for students in designated age groups (ages 5-8, 9-12, 13-15, 16-18). At the HPV vaccine session, the health team distributes a copy of a the workbook to every Year 4 girl and boy and explains how to use it. The workbook presents colourful, hand-drawn child and adult characters in typical surroundings, discussing everything from puberty, to nutrition, healthy friendships and bullying, vaccines including HPV vaccine, tuberculosis, and unhealthy behaviours such as alcohol use. Students can answer quizzes, draw pictures, write journal entries, and complete puzzles as they work through each page while waiting to be called in for their HPV vaccine.
- Experiences and challenges in the area of costing, financing, and sustainability are explored, revealing implications for action such as: Continue to strengthen the coalition of champions for HPV vaccine from EPI, cancer, women's health, gynaecology, adolescent health, education, and other areas who can help to advocate for budgeting HPV vaccine as part of a comprehensive cervical cancer prevention and control strategy.
The experiences and lessons in this document underscore the amount of learning countries and partners have collected on HPV vaccine while also pointing to the areas where WHO believes we need to gather more evidence. For instance, there are outstanding questions that research can address: How best to reach hard-to-reach girls, including those who are immunocompromised (e.g., due to HIV)? What interventions can countries most successfully integrate with HPV vaccine to improve adolescent health and gain efficiencies? Can countries fully immunise girls by offering an HPV vaccine opportunity once per year? What is the most cost-effective way to deliver HPV vaccine, while achieving maximum coverage in different settings?
Before offering a chart-like list of summarised implications for action beginning on page 50, this report concludes that "the quest to prevent cervical cancer, which extracts an especially heavy toll on women in low-income countries, is more timely than ever as the health and wellbeing of women and girls are considered essential to ending extreme poverty, promoting development and resilience, and achieving the Sustainable Development Goals....The strengthened ties between immunization, cancer programmes and the education sector is a platform to further mobilize communities to not only accept, but expect HPV vaccine as a key intervention for adolescent girls and to understand and demand cervical cancer screening for women."
HPVflash: A news update from the PATH cervical cancer prevention team, February 1 2017; and WHO website, February 2 2017. Image credit: C. McNab