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August 7th, 2024
Introduction
This white paper summarizes discussions from the online post-symposium engagement meeting held on August 7, 2024, which followed the December 2023 HPV symposium in Abidjan, Côte d’Ivoire. Building on the significant increase in HPV1 coverage reported in the 2023 WHO and UNICEF Estimates of National Immunization Coverage1, where the AFRO region saw a rise from 28% in 2022 to 40% in 2023, this online engagement session aimed to highlight the best practices and advances made by African countries. The goal was to provide a platform to share best practices and evolving strategies among the CHIC community of practice, to foster collective learning and collaboration. The discussions focused on strategies to maintain this momentum, address barriers, and optimize delivery models for increasing coverage. This document provides insights from country representatives and highlights some of the critical questions raised during the meeting.
Country Updates
Burkina Faso
Since transitioning to a single-dose HPV vaccination schedule in early 2023, Burkina Faso has made significant progress. After conducting a pilot from 2015 to 2017 in two districts, the country moved to a two-dose schedule in 2022. In December 2022, following recommendations from the NITAG, the Ministry of Health revised the schedule to a single dose. This shift was fully implemented in February 2023, resulting in the vaccination of 144,000 girls during a week-long intensification campaign in 2023. During 2024 the number of girls vaccinated during the intensification period dropped to 71,076, nevertheless, more girls were vaccinated during the routine campaign period during 2024.
This raised the question of how to maintain high coverage rates, especially during intensification campaigns, and what strategies could be employed to compensate for the reduction in numbers during routine periods. It was suggested that more targeted outreach to rural areas and an enhanced communication strategy could help address this challenge.
Cameroon
In 2023, Cameroon strengthened its HPV vaccination program by adopting a single-dose, gender-neutral approach, along with periodic intensification of routine immunization efforts. These strategic changes resulted in significant improvements in vaccination coverage for both girls and boys. The transition to a single-dose protocol further accelerated progress, with effective communication between partners playing a key role in these achievements.
However, in 2024, coverage dropped due to the absence of an intensification period, and the routine immunization system faced challenges in maintaining high coverage.
The conversation centered around how Cameroon could better sustain its vaccination efforts year-round. Cameroon is planning campaign to vaccinate adolescents aged 9-15 with HIV. The potential for further improvements through the integration of HPV vaccination into the “Big Catchup” campaign and other immunization initiatives was also discussed.
Côte d’Ivoire
Côte d’Ivoire has made progress in maintaining the momentum for HPV vaccination, highlighted by the drafting of a national cervical cancer elimination plan in June 2024 and the Abidjan Declaration on sustainable vaccine financing in July 2024. The country has focused on strengthening community dialogues and training health workers in schools and universities to increase coverage. Despite these efforts, Côte d’Ivoire has faced significant challenges due to vaccine shortages. In 2023, the country experienced 189 days of stockouts, and in 2024, there were 115 days without available vaccines.
Questions arouse around how can the country ensure continuous vaccine availability and maintain coverage momentum despite these supply challenges? Additionally, it was asked how Côte d’Ivoire could better coordinate with local actors, such as community health workers, to mitigate the impact of stockouts and continue outreach in insecure border areas.
Nigeria
Nigeria’s phased introduction of the HPV vaccine has achieved remarkable success, with over 12 million girls vaccinated by mid-2024. The program, which began with a 16-state campaign delivering vaccine in public health facilities in 2023, reached 96% coverage in the second phase in 2024. This progress was driven by strong political commitment, including the support of the First Lady, and by integrating the HPV vaccine into existing health outreach activities. The country aims to integrate the HPV vaccine into routine immunization by 2025 targetting 9 year old girls.
However, the challenge of lower coverage in regions such as Lagos, where a targeted campaign is planned, prompted discussions on how Nigeria could replicate the success seen in other states. The need for sustained coordination between health facilities and schools was emphasized, as well as the importance of community outreach, particularly for out-of-school girls. A key lesson learned was the effectiveness of integrating HPV vaccination with other public health initiatives, but questions remain about how to address regional disparities in coverage and how to ensure equitable access for all eligible girls.
Zimbabwe
Zimbabwe’s HPV vaccination program has seen fluctuating coverage rates since its introduction in 2018. High peaks were recorded during school-based campaigns in 2018, 2019, and 2021. However, after the GAVI grant ended, the country shifted to a health facility-based approach in 2023, which led to lower coverage. Zimbabwe also faces challenges related to staff shortages, religious objections, and the integration of HPV vaccination with other health programs.
The situational analysis conducted in 2023 revealed that while school-based campaigns were key to accessing girls, especially in urban areas, more effort was needed to reach out-of-school girls, particularly in rural settings. The discussion raised the question of how Zimbabwe could reintroduce or strengthen school-based programs while addressing the logistical challenges of health facility-based delivery. The NITAG has recommended the government the adoption of a single-dose schedule, which could simplify delivery and improve coverage rates, particularly in hard-to-reach areas.
Breakout Group Discussion
Participants in the post-symposium engagement were split into three groups: one Francophone group (Burkina Faso, Senegal, Niger, Mali, Côte d’Ivoire, Cameroon) and two Anglophone groups ( 1:The Gambia, Uganda, Zambia, Zimbabwe, 2: Nigeria, Ghana, Kenya). Each group discussed strategies to improve HPV vaccination programs, highlighting both common challenges and unique approaches.
Service delivery was a major focus, with school-based vaccination identified as a key strategy for reaching girls. Countries like Zimbabwe and Uganda saw success using schools, but they also acknowledged challenges in reaching out-of-school girls and maintaining coverage through health facilities. Community outreach was noted as a valuable supplement, though difficult to sustain. Consent issues in schools and the need for better strategies to reach immunocompromised and marginalized populations were also discussed.
Coordination between health, education, and community leaders was seen as essential. Strong partnerships, including public-private collaborations in Uganda, helped improve vaccination coverage. However, misinformation—particularly concerns about infertility—remains a significant barrier, underlining the importance of engaging religious and community leaders in vaccination campaigns.
Finally, the groups discussed sustainability, emphasizing the need to integrate HPV vaccination into routine health services. Intensification periods and campaigns like Senegal’s “Pink October” boost coverage but are not sustainable long-term. The importance of securing national-level financing post-GAVI support was highlighted, with calls for continuous engagement of stakeholders to sustain vaccination momentum.
Conclusion and Next Steps
The post-symposium engagement highlighted both successes and ongoing challenges in scaling HPV vaccination efforts across countries. Countries such as Burkina Faso and Nigeria have made significant strides, while others, like Côte d’Ivoire and Zimbabwe, continue to face challenges related to vaccine availability, logistical barriers, and community acceptance.
A key takeaway from the discussions was the need for countries to sustain momentum through a combination of school-based campaigns, targeted outreach to out-of-school girls, and better integration of HPV vaccination with other health programs. The move toward single-dose schedules in many countries offers new opportunities for intensification efforts, but questions remain about how best to sustain coverage throughout the year, especially in regions where routine immunization systems face constraints.
Moving forward, countries will need to continue leveraging global partnerships, such as with GAVI, to address funding gaps and vaccine supply issues. Additionally, continued community engagement and tailored communication strategies will be crucial to overcoming cultural barriers and misinformation.
This white paper provides a detailed account of the post-symposium engagement discussions and presents the key updates, challenges, and questions raised. It serves as a resource for countries to reflect on their progress and consider new strategies for overcoming barriers to HPV vaccination.
- Who, Unicef. WHO/UNICEF Estimates of National Immunization Coverage, 2023 Revision. 2024. ↩︎