A few weeks ago, I attended a talk by the CDC’s Anne Schuchat, MD, on US HPV vaccination that she subtitled “How Not to Introduce a Vaccine.” In spite of the promise of HPV vaccines to reduce the burden of cervical and other cancers in this country, uptake of the complete three-dose series has lagged far behind the other vaccines on the adolescent immunization platform. On Friday, I heard a more optimistic talk about HPV vaccination in South Africa by Helen Rees, MD, MA, Executive Director, Wits Reproductive Health and HIV Initiative, University of Witswatersrand. Dr. Rees is a member of the WHO immunization policy committee and has a background in pediatrics, HIV care, and obstetrics and gynecology. She spoke as a guest of the Johns Hopkins Vaccine Initiative as part of their annual Vaccine Day events.
Globally, 90% of HPV-related cancers are cervical cancers, and sub-Saharan Africa is, as Rees said, the epicenter for cervical cancer. The high prevalence of HIV infection, which is a risk factor for oncogenic HPV infection, and the lack of access to HPV screening contribute to the high HPV disease burden. And apart from HPV-related cancers, Rees also noted that genital warts are not a trivial condition in an HIV-prevalent setting: they can be debilitating in those with compromised immune systems. The quadrivalent HPV vaccine offers protection from the two most common types of oncogenic HPVs and two types that cause genital warts; the bivalent vaccine covers only the two most common types of oncogenic HPVs.
But HPV vaccines are expensive: in the US, one dose costs about $130, and three doses are recommended here. The WHO policy committee has recently recommended a two-dose vaccination series for girls under age 15 that many countries are beginning to adopt. The GAVI price is about $4.50/dose. GAVI-eligible countries can apply for cofunding for HPV vaccine introduction, but in Africa only Rwanda has done so. It is the first low-income country to introduce the vaccine as part of the Expanded Programme on Immunization (March 2014).
Several other African countries, Rees’s South Africa included, have conducted HPV vaccination pilot programs. In South Africa, they used the bivalent vaccine, because it alone was approved to be given there as a two-dose, rather than three-dose, series. Rees noted that using the bivalent vaccine would not address the problem of HPV-related genital warts on those co-infected with HIV. But the savings involved in using a two-dose regimen drove the decision to forego the quadrivalent vaccine. South Africa is not a GAVI-eligible country, but was able to negotiate with manufacturer GSK a cost of one-fifth the normal price of the vaccine.
Rees discussed the complex decisions that went in to designing the HPV vaccination program in South African. Officials had to decide which ages to focus on, in what setting they would give the vaccine, how to ensure that the cold chain remained intact, how to secure consent, how to deliver both doses of vaccine, and more.
Research showed that school delivery of the vaccine was acceptable to learners, parents, schools, and healthcare workers. In terms of messaging about the benefits of the vaccine, the cancer prevention message was more acceptable than messages about preventing a sexually transmitted infection (though the latter message did not generate particularly negative reactions).
The pilot achieved 91% school coverage and 87% learner coverage, in total vaccinating 340,000+ girls in March-April 2014. No major adverse events were reported, though Rees noted that ensuring access to emergency supplies in case of outcomes such as anaphylaxis was problematic.
Rees said that while most media coverage of the pilot was positive or neutral, some coverage was negative, and she thought that this had an effect on uptake. Additionally, an active social media campaign against the vaccine urged South African mothers not to allow their girls to get the vaccine. Here Rees showed what looked like a Facebook posting directed to South African mothers, which claimed that 32 girls had died in the US as a result of HPV vaccination. (Those of us who pay attention to the antivaccination network recognize this claim. The figure 32 comes from reports to VAERS that have been studied and have been found to be unrelated to HPV vaccination).
In Africa, 17 countries are approved by GAVI to seek support of HPV vaccination pilot programs. And other than Rwanda, Uganda is the only other African country that is eligible for GAVI support for a national HPV immunization program. (See GAVI: Countries Approved for Support for the complete list.)