When health workers arrived at the Upendo Primary School on the outskirts of Dar es Salaam in Tanzania, they instructed the girls, who will turn 14 this year, to line up to be vaccinated. Quinn Chango urgently, in a whisper, conferred with her friends. What was the injection really for? Could it be the Covid vaccine? (They heard rumors about it.) Or was it to prevent them from having children?

Ms. Chango was uneasy, but she remembered that her sister had been vaccinated against the human papillomavirus last year. So she got in line. However, some girls slipped away and hid behind school buildings. When some of Ms. Chango’s friends returned home that evening, they faced questions from their parents, who were worried that it might make their children feel more comfortable with the thought of sex, even if some of them didn’t want to go out right away. say so.

The HPV vaccine, which provides almost complete protection against the sexually transmitted virus that causes cervical cancer, has been administered to adolescents in the United States and other industrialized countries for nearly 20 years. But it is only now beginning to be widely adopted in low-income countries, where 90 percent of cervical cancer deaths occur.

Tanzania’s experience — with misinformation, cultural and religious discomfort, and supply and logistical obstacles — highlights some of the challenges countries face in implementing what is considered a critical health intervention in the region.

Cancer screening and treatment in Tanzania is limited; the shot could drastically reduce mortality from cervical cancer, the deadliest cancer for Tanzanian women.

HPV vaccination efforts have been stalled across Africa for years. Many countries have developed programs due to begin in 2018 by working with Gavi, a global organization that supplies vaccines to low-income countries. But Gavi couldn’t get the shots for them.

In the United States, the HPV vaccine costs about $250; Gavi, which usually negotiates big discounts with pharmaceutical companies, was aiming to pay $3 to $5 per shot for the large volumes of vaccine it sought to purchase. But as high-income countries have also expanded their programs, vaccine makers Merck and GlaxoSmithKline have targeted those markets, leaving little to developing countries.

“Despite the fact that we were very vocal about the supplies we needed from manufacturers, they were not there,” said Aurelia Nguyen, director of strategy at Gavi. “So we had 22 million girls who were being asked by countries to get immunizations for which we didn’t have supplies at the time. It was a very painful situation.”

Low-income countries had to decide where to distribute the limited amount of vaccine they received. Tanzania decided to target 14-year-old girls first, who, as the oldest eligible girls, were considered the most sexually inclined. Girls start dropping out at this age, before moving on to high school; the country planned to supply vaccines mainly to schools.

But vaccinating a teenager against HPV is not like vaccinating a child against measles. Florian Tinuga, Program Manager, Department of Immunization and Vaccine Development, Ministry of Health. Fourteen year olds need to be convinced. However, since they are not yet adults, parents also need to be won over. This means talking frankly about sex, a sensitive issue in the country.

And because 14-year-old girls were considered young women almost of marriageable age, rumors quickly spread on social media and messaging apps about what’s really in the frame: could it be a covert birth control campaign? coming from the West?

The government did not foresee this problem, dr. Tinuga said sadly. Rumors have been difficult to counter among a population with limited understanding of research or scientific evidence.

The Covid pandemic has further complicated the HPV campaign as it disrupted health systems, forced school closures and created a new level of vaccine hesitancy.

“Parents take their kids out of school when they hear about the imminent vaccination,” said Khalila Mbow, who runs the Tanzanian office of Girl Effect, an NGO funded by Gavi to boost demand for the vaccine. “Vaccination issues have escalated since Covid.”

Girl Effect released a radio show, beautiful posters, chatbots and social media campaigns urging the girls to take a picture. But these and other efforts in Tanzania have been focused on encouraging girls to take the vaccine, without giving sufficient consideration to the influence of other gatekeepers, including religious leaders and school officials, who have a strong say in the decision, Ms Mbowe said.

Asia Shomari, 16, was terrified the day health workers came to her school on the outskirts of Dar es Salaam last year. The students were not instructed and did not know what the shot was for. According to Ms Shomari, it was in an Islamic school where no one ever talked about sex. She hid behind a toilet block with her friends until the nurses left.

“Most of us chose to run,” she said. When she returned home and spoke about what had happened, her mother said that she had done the right thing: any vaccine related to the reproductive organs was suspicious.

But now her mother, Pili Abdallah, has begun to reconsider. “Girls her age are sexually active and have a lot of cancers,” she said. “If she could be protected, that would be good.”

While Girl Effect is aimed at mothers, the truth is that fathers have the final say in most families, Ms Mbow said. “The decision-making power does not belong to the girl.”

Against all odds, Tanzania managed to vaccinate nearly three-quarters of its 14-year-old girls in 2021 with the first dose. (Tanzania achieved this goal of first-dose coverage twice as fast as the United States.) It was harder to convince people to come back for a second dose: only 57 percent received a second dose six months later. A similar gap persists in most sub-Saharan countries that have started HPV vaccination.

Because Tanzania has largely relied on school makeshift clinics to administer immunizations, some girls miss their second dose because they leave school by the time health workers return.

Rahma Saeed was vaccinated at school in 2019 when she was 14 years old. But soon after, she failed her exams to move on to high school and dropped out. Ms Said tried a couple of times to get a second shot at government clinics in her neighborhood, but no one had the vaccine, and last year she said she gave up.

Tanzania is likely to switch to a single dose regimen next year. Tinuga said. There is growing evidence that a single HPV vaccine will provide adequate protection, and in 2022 WHO recommended that countries switch to a single shot campaign, which would improve vaccine costs and supply, and eliminate this problem of trying to vaccinate girls. second time.

Switching from school vaccinations to HPV vaccinations as one of the regular vaccines offered at health centers could be another step towards cost savings, public health experts say. To bring about this shift will require a huge and sustained effort in public education.

“We have to make sure that the demand is very, very high, because usually they are not going to come to institutions for other interventions,” said Ms Nguyen from Gavi.

Ms Nguyen said that now, finally, stocks of the vaccine have increased, and new versions of the vaccine have entered the market from companies in China, India and Indonesia. Supply is expected to triple by 2025.

Populated countries, including Indonesia, Nigeria, India, Ethiopia and Bangladesh, are planning to introduce or expand the use of the vaccine this year, which could jeopardize even expanding supplies. But there is hope that enough doses will soon be available to enable countries to vaccinate all girls aged 9 to 14, Ms Nguyen said. Once they are caught, the vaccine will become routine for 9-year-olds.

“By the end of 2025, we have set a goal of having 86 million girls,” she said. “That would be 1.4 million deaths averted.”

Ms. Chango and her friends giggled at the mere mention of sex, but they said that in fact, many girls in their class were already sexually active and that it would be better if Tanzania could vaccinate girls as young as 9 years old. .

“Eleven is too late,” said Restuta Chunja, shaking her head grimly.

Ms. Chengo, a sparkling-eyed 13-year-old who plans to become a pilot when she finishes school, said her mother told her that the vaccine would protect her from cancer, but that she shouldn’t think about it.

“She said I shouldn’t get married or have any kind of sexual relationship because that would be bad and you could get something like HIV.”

The HPV vaccine is offered to both boys and girls in higher-income countries, but WHO recommends giving priority to girls in developing countries with existing vaccine supplies, as women get 90% of HPV-related cancers.

“From Gavi’s point of view, we are not yet ready to add boys,” Ms Nguyen said.

Dr. Mary Rose Giattas, technical director of reproductive cancer in Tanzania for Jhpiego, a non-profit health organization affiliated with Johns Hopkins University, believes any remaining doubt can be overcome. When she tells the audience about the picture, she is talking about Australia.

“I say forget the rumors: Australia has virtually eliminated cervical cancer. And why? Because they get vaccinated. And if the vaccine had caused fertility problems, we would have known about it because they were one of the first countries to use it.”

According to her, misconceptions can be dispelled with the help of “chewed pieces” of evidence. “I say that our Ministry of Health is taking serious steps to test drugs: they do not come directly from Europe to your clinic. I tell women, “Unfortunately, you and I missed this due to our age, but I’d like to get vaccinated now.”