National Introduction of Human Papillomavirus (HPV) Vaccine in Tanzania: Programmatic Decision-making and Implementation

"[C]ontinuous and targeted social mobilization for HPV vaccine and engagement of community members is mandatory for the continued success of the program and demonstrates the value of a detailed communications and risk communications plan..."

Cervical cancer is the leading cause of cancer among women in Tanzania. In April 2018, the Government of Tanzania introduced 2 doses of human papillomavirus (HPV) vaccine nationally to adolescent girls to prevent cervical cancer, following a 2-year pilot introduction of the vaccine in the Kilimanjaro Region. This paper describes the process of decision-making, introduction, and implementation of HPV vaccine into the national immunisation programme in Tanzania. It was informed by interviews with ten key informants at the national level in Tanzania from February to November 2019, including members of the Expanded Programme on Immunization (EPI) Technical Working Group (TWG), as well as a desk review of HPV vaccine introduction materials and coverage data.

Tanzania introduced HPV vaccine to a single-age cohort of 14-year-old girls at health facilities and through outreach services at community sites, community mobile sites, and primary and secondary schools. To prepare, three main sub-committees within the EPI TWG guided activities: (i) logistics; (ii) advocacy, communications, and social mobilisation (ACSM); and (iii) data and monitoring and evaluation. A national 3-day HPV vaccine and inactivated polio vaccine (IPV) Orientation and Macroplanning Workshop was conducted in January 2018 with representatives from all regions of Tanzania. The HPV vaccine training was combined with IPV vaccine in an effort to share training costs and capitalise on having all health workers gathered together because both vaccines were being introduced simultaneously into the national immunisation schedule. Training for HPV vaccine included background information on HPV infection and cervical cancer, HPV vaccine administration and safety, ACSM, monitoring and evaluation, and microplanning. Over 6,000 health workers and 22,000 school personnel were trained nationwide.

The ACSM sub-committee of the TWG then developed a communication plan for HPV vaccine introduction that outlined guidelines for advocacy and sensitisation meetings, mass media involvement, launching ceremonies, and identification of audiences, as well as the activities and materials meant for each audience (e.g., printed products (posters, brochures, fliers, tire wheel covers, and banners), mass media TV and radio spots, and social media (WhatsApp) messaging). To create awareness of and support for the HPV vaccine introduction, the ACSM sub-committee held several national and subnational stakeholder meetings involving political and religious leaders, as well as journalists. For example, a national-level media seminar in Dar es Salaam was held one month prior to the launch to inform the media of the HPV vaccine introduction and allow them the opportunity to ask questions. In addition, one-day media seminars were held in each region with approximately 30 participants from various media outlets including TV, radio, and newspaper. The ACSM sub-committee also developed a crisis communication plan to address potential misinformation and resistance to HPV vaccination.

A national launching ceremony was held on April 10 2018 in an open playground of Temeke District of Dar es Salaam, officiated by her Excellence Vice President of The United Republic of Tanzania, the Minister of Health, and other high-level religious and community leaders. Sub-national launches were held by the Regional Commissioner or the District Commissioner and were important for showing political commitment to the HPV vaccination programme and creating awareness in the community.

Administrative coverage of the first dose of HPV vaccine at the end of 2019 was 78%, and second dose coverage was 49%. No adverse events following HPV vaccination were reported at the national level. However, one religious radio station aired programming stating HPV vaccine causes infertility, and similar misinformation regarding infertility spread in one region on Tanzania's southern border. Health communications specialists mitigated this misinformation by implementing their crisis communication plan and speaking to the public on the radio. Since then, misinformation has only circulated in small areas of Tanzania and has been addressed through the communication plan and community re-sensitisation efforts, including supplementary orientations to health workers, school personnel, and community leaders; redistribution of print materials; and media/social media advocacy.

In reflecting on the experience as a whole, interviewees reported that the involvement of various ministries, partners, and community-based, religious, and professional associations and organisations created widespread awareness and support for the vaccine. These strong partnerships and high-level political commitment were thought to be critical to introducing the vaccine, the success of the HPV vaccine introduction and the sustainability of the programme. Interviewees also reported successful coordination with the education sector to provide HPV vaccine to girls in school, as part of routine outreach. Continuing to partner with schools and the Ministry of Education will be essential to reaching eligible girls, they opined. Engaging community health workers and community leaders will be needed to identify potentially missed girls.

Communication-related lessons learned include: "Results indicate that Tanzania's HPV vaccine introduction required large-scale effort for training and social mobilization....Sensitizing stakeholders across various fields (religious and political organizations, media/journalists, community leaders) was also thought to be a necessary component of the social mobilization strategy....Health workers, school personnel, and community leaders need to be equipped with tools to address potential misinformation in their communities, not only at the beginning of HPV vaccine introduction but continuously....The adoption of other community engagement platforms using social media strategies, as well as health worker and caregiver engagement through SMS [text messaging] reminders or other new techniques may also help to raise awareness and ensure full coverage of girls."

As of this writing, Tanzania planned to switch their routine cohort to 9-year-old girls, after vaccinating a multiple-age cohort and when the vaccine supply is adequate. Going forward, to ensure equity in the older age group, the authors suggest that it will be important to develop approaches for reaching vulnerable populations, including out-of-school girls, ethnic minorities, and HIV-positive girls. "Continued multi-sectoral partner collaboration and political commitment to the HPV vaccination program are essential for its sustainability."