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A Tough Start to Liberia’s HPV Vaccine Program

Developing countries could count for more than 95 percent of cervical cancer deaths by 2035. In Liberia, a pilot HPV vaccination program aims to cut that number – but first has to overcome mistrust, misinformation and a dire lack of resources.

Written by Katherina Thomas Published on Read time Approx. 4 minutes
Liberia rape
Two young girls who were sexually abused for years sit in a neighborhood police station in Monrovia, Liberia, June 5, 2007. Liberia's high rate of gender-based violence makes it difficult to know when to give girls the HPV vaccine, which should be administered before a girl starts to be sexually active. AP/Rebecca Blackwell

Until a team of nurses came to her school carrying boxes of human papillomavirus (HPV) vaccine, 12-year-old Lovetta Chea – a student in the Liberian town of Ganta – had never heard of cervical cancer. Nor had she heard of HPV, now widely recognized by experts as the leading cause of cervical cancer worldwide.

“Nurses took us girls into a classroom and explained to us about this vaccine,” Chea said. “They told us it could protect us from cervical cancer. At the time, I didn’t know what cervical cancer was. I thought there was only one kind of cancer.”

Her classmate, Ruth Spencer, also 12, had the same limited knowledge of cervical cancer. “I knew about one old man who died from cancer at the hospital,” she said. “But I didn’t know about different kinds of cancer, or even cancers that us young girls could get.”

In April, Lovetta and Ruth were among the first Liberian girls ever to receive the HPV vaccine, after the Global Alliance for Vaccines and Immunizations (GAVI) funded a pilot vaccination drive in two Liberian counties: Nimba, where the girls live, and neighboring Bong County. The pilot program, which is targeting more than 14,000 girls over the age of 10, is designed to curb cervical cancers, 93 percent of which are preventable, according to the U.S. Centers for Disease Control and Prevention (CDC).

Liberia is among the 21 developing countries to receive the vaccine so far, including Burundi, Ivory Coast, Senegal and Togo. Before launching the vaccination program, GAVI had announced that without changes in prevention and control, deaths from cervical cancer could rise to 416,000 globally by 2035.Low-income countries are expected to bear the highest burden. More than 95 percent of the projected deaths are likely to be women in developing countries, which often have barely functioning healthcare systems that make it difficult to implement wide-reaching screening programs.

According to a 2016 report by the HPV Information Center in Spain, cervical cancer is the most common female cancer in Liberia, with some 366 cases diagnosed annually. The true figure could be even higher; in the wake of the Ebola outbreak, healthcare remains extremely limited in Liberia. There is no designated cancer hospital, no resident oncologists, and cervical cancer screening programs are only just starting to be implemented.

At the moment, Liberia’s screening programs are available at just a handful of locations, including Phebe Hospital in Bong County – one of the country’s largest hospitals – and the Chinese-built Tappita Hospital in Nimba County. And even in those catchment areas, limited access to health education and information means that few women turn up to be screened.

According to Adolphus Clarke, deputy program manager for the Expanded Program on Immunization (EPI) at Liberia’s Ministry of Health, immunization teams have encountered a number of issues in rolling out the HPV vaccine.

“There have been challenges, such as a low level of understanding about the reasons behind the vaccination,” he said. “Our teams have also encountered block resistance to the vaccine due to rumors that it could cause Ebola, as well as general community distrust in the health system.”

Liberia’s high rate of gender-based violence also makes it difficult to find the right timing for the vaccinations. “You must introduce the vaccine before the girl child starts to have an active sexual life,” said Clarke. “However, in the interim, especially in Liberia, you also have to consider that girl children sometimes get raped. So there will be some young girls who could contract HPV at a young age that way, before receiving the vaccine.”

Immunization teams are working closely with community leaders and health teams in an effort to ensure girls’ families understand why their daughters should get the jab. All over the world, parents have expressed concern about the vaccination, including in U.S. and other developed countries, where controversies have broken out surrounding side effects linked to the Gardasil type of HPV vaccine. But in Liberia, parents have different worries.

Ruth Spencer’s mother, Margaret Mulbah, said she had been told her daughter might suffer some mild side effects, but she was much more concerned that the vaccine could somehow encourage sexual promiscuity.

“My husband told me that the vaccine might encourage [our daughter] to spend time with boys,” Mulbah said. “He had heard that it had something to do with sex. I talked to the community health people, and they informed me that the vaccine is meant for her protection, so the people gave it to her.”

The campaign has so far undergone two vaccination rounds in Liberia and is expected to continue into 2017. It will also take in other parts of the country, and include some girls who are not currently enrolled in school. GAVI said it also hopes to expand the drive to more developing countries, working with its procurement partner UNICEF to ensure that the HPV vaccinations can be purchased at the relatively affordable price of $4.50 per dose.

HPV vaccine offers the best hope at protecting young girls from cervical cancer, one of the leading killers of women in low-income countries,” said Dr. Seth Berkley, GAVI’s CEO, in a statement. “Our goal is to ensure that the vaccine reaches girls, no matter where they live.”

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