Multiple cohort HPV vaccination in Zimbabwe: 2018-2019 program feasibility, awareness, and acceptability among health, education, and community stakeholders

Trends in gastrointestinal cancer burden in Zimbabwe: 10-year retrospective study 2009-2018

Background

As one of the non-communicable diseases, cancer will overtake communicable, maternal, neonatal and nutritional diseases combined as the leading cause of mortality by 2040. Gastrointestinal (GI) cancers are predicted to increase by over 50% in the next 20 years, with a higher incidence in developing countries. In this study, we describe the national GI cancer trends in Zimbabwe using the annual reports from the Zimbabwe National Cancer Registry (ZNCR) from 2009 to 2018.

Methods

Demographic data and incidence of GI cancer subtypes were collected and analysed from the ZNCR annual reports from 2009 to 2018. Age standardised rates (ASRs) for each GI cancer subtype were calculated and simple trend analysis was performed over the 10-year study period.

Results

In total, 10,859 new GI cancer cases were reported during the study period, accounting for 17.2% of all cancers in Zimbabwe and 55% of these were males. The most prevalent GI cancers were oesophageal, liver, gastric, colon and rectal malignancies. In males, on average the incidence of ASR of oesophageal, liver and gastric cancer increased annually by 14.7%, 17% and 16%, respectively. In females, on average the ASR of oesophageal, liver and gastric cancer increased annually by 27.2%; 18% and 13%, respectively. Overall, one in ten new cases of oesophageal cancer were diagnosed in patients under 45 years of age and for liver cancer, one in four new male cases were diagnosed below the age of 45 years.

Conclusion

Zimbabwe faces an increasing trend in all GI cancer subtype incidence over the decade reviewed. The rate of increase in oesophageal and gastric cancers in females was particularly high and the male-to-female ratio observed requires further etiological studies. The increasing rate of young GI cancer patients requires both education regarding risk factors and national screening policies that are tailored to the Zimbabwean population's characteristics and context.

Exploring the complexity of the implementation determinants of human papillomavirus vaccination in Africa through a systems thinking lens: A rapid review

A rapid review was conducted to explore the implementation determinants of human papillomavirus (HPV) vaccination in the World Health Organization African Region and describe their dynamic relationship. PubMed and Google Scholar were searched in October 2023 to find relevant literature. A total of 64 published studies that reported factors affecting HPV vaccination were identified. Analysis of identified factors yielded 74 implementation determinants of HPV vaccination across the five domains of the Consolidated Framework for Implementation Research (CFIR): two (2.70%) were in the innovation domain, seven (9.46%) were in the outer setting domain, 14 (18.92%) were in the inner setting domain, 37 (50%) were in the individual domain and 14 (18.92%) were in the implementation process domain. A causal loop diagram of these implementation determinants revealed four balancing and seven reinforcing loops. Applying systems lens promoted a more holistic understanding of the implementation determinants of HPV vaccination, exposing leverage points for interventions.

Improving HPV Vaccination Uptake Among Adolescents in Low Resource Settings: Sociocultural and Socioeconomic Barriers and Facilitators

Background

Lower- and middle-income countries (LMICs) are disproportionately impacted by human papillomavirus (HPV) and would benefit from implementing the HPV vaccine. In the context of competing health priorities, utilizing scarce domestic infrastructure and human resources for HPV vaccination remains challenging for many LMICs. Given the high benefits of the HPV vaccine, the World Health Organization (WHO) is now encouraging for all countries, particularly LMICs, to introduce HPV vaccines into their routine immunization programs. Understanding the barriers and facilitators to HPV adolescent vaccine programs in LMICs may help strengthen how LMICs implement HPV vaccine programs, in turn, increasing HPV vaccine acceptance, uptake, and coverage.

Objective

To identify and assess barriers and facilitators to implementing adolescent HPV vaccination programs in LMICs.

Methods

This study comprised a review of literature assessing adolescent HPV vaccination in LMICs published after 2020 from a sociocultural perspective.

Results

Overall, the findings showed that LMICs should prioritize increasing HPV vaccine availability and HPV vaccine knowledge, particularly focusing on cancer prevention, as knowledge reduces misinformation and increases vaccine acceptance. Evidence suggests that factors promoting HPV vaccine uptake include fostering low vaccine hesitancy, integrating HPV vaccination as a primary school routine vaccination, and vaccinating both genders. A one-dose HPV vaccine may enable many LMICs to increase vaccine acceptance, uptake, and coverage while controlling financial, infrastructure, and human resource costs.

Conclusion

As HPV is one of the leading causes of death in many LMICs, implementing the HPV vaccine may be highly beneficial. Cohesive national HPV vaccine buy-in and understanding the success and challenges of prior LMIC HPV vaccine implementation is crucial to developing effective, efficient, and sustainable HPV vaccination programs.

Vaccination Effectiveness against Human Papillomavirus in Kazakhstan

OBJECTIVE

The purpose was to determine the effectiveness of human papillomavirus immunization and its impact on cervical cancer development in Kazakhstan.

METHODS

The current research is a case-control study with two groups: a main group and a control group. A total of 725 subjects participated in the research.

RESULTS

The association between vaccination and cervical cancer development was calculated both for the two groups as a whole and for individual patients, who were selected based on criteria of residence, presence of immunodeficiency or chronic cardiac or renal pathology, as well as analysis of age at which the vaccine dose was received. There was a statistically significant association between the absence of the human papillomavirus vaccine and the risk of cervical cancer in all groups. When considering the entire cohort, the chance of finding a risk factor (lack of vaccination) was almost 7 times higher in the main group than in the control group. Thus, an association between vaccination and cervical cancer risk was found in each of the pairs of subjects.

CONCLUSION

The effectiveness of vaccination in preventing cervical cancer was not observed in patients who were vaccinated after 18 years of age, while most patients in the control group were vaccinated in their teens. The practical significance of the research is not only to further study the problem of human papillomavirus (HPV) vaccination in Kazakhstan but also to popularize HPV immunization to prevent cervical cancer (CC).

Barriers and facilitators of HPV vaccination in sub-saharan Africa: a systematic review

BACKGROUND

Human Papilloma Virus (HPV) is the most common sexually transmitted infection worldwide. Globally, both men and women have a 50% risk of being infected at least once in their life. HPV prevalence is among the highest in sub-Saharan Africa (SSA), at an average of 24%. HPV causes different types of cancers, including cervical cancer (CC), which is the leading cause of cancer deaths among women in SSA. HPV-vaccination has been proven to be effective in reducing HPV induced cancers. SSA countries are delayed in reaching the WHO's target of fully vaccinating 90% of girls within the age of 15 by 2030. Our systematic review aims to identify barriers and facilitators of HPV-vaccination in SSA to inform national implementation strategies in the region.

METHODS

This is a mixed method systematic review based on the PRISMA statement and The Joanna Briggs Institute Reviewers' Manual. Search strategies were adapted to each selected database: PubMed/MEDLINE, Livivo, Google Scholar, Science Direct, and African Journals Online for papers published in English, Italian, German, French and Spanish between 1 December 2011 and 31 December 2021. Zotero and Rayyan were the software used for data management. The appraisal was conducted by three independent reviewers.

RESULTS

A total of 20 articles were selected for appraisal from an initial 536 articles. Barriers included: limited health system capacities, socio-economic status, stigma, fear and costs of vaccines, negative experience with vaccinations, COVID-19 pandemic, lack of correct information, health education (HE) and consent. Additionally, we found that boys are scarcely considered for HPV-vaccination by parents and stakeholders. Facilitators included: information and knowledge, policy implementation, positive experience with vaccinations, HE, stakeholders' engagement, women's empowerment, community engagement, seasonality, and target-oriented vaccination campaigns.

CONCLUSIONS

This review synthesizes barriers and facilitators of HPV-vaccinations in SSA. Addressing these can contribute to the implementation of more effective HPV immunization programs targeted at eliminating CC in line with the WHO 90/70/90 strategy.

REGISTRATION AND FUNDING

Protocol ID: CRD42022338609 registered in the International Prospective Register of Systematic Reviews (PROSPERO). Partial funds: German Centre for Infection research (DZIF) project NAMASTE: 8,008,803,819.

Human papillomavirus vaccination in low- and middle-income countries: progression, barriers, and future prospective

Human papillomavirus (HPV) is a viral infection that, if does not go away, can cause health problems like genital warts and cancer. The national immunization schedules for individuals before sexual debut, significantly decreased HPV-associated mortality and it will be affordable. However, immunization programs remain vulnerable to macroeconomic factors such as inflation, fiscal policy, employment levels, and national income. This review aims to investigate the association between national income in lower-middle-income countries to explore recent advances and potential issues, as well as how to deal with challenges.

Planning, implementation, and sustaining high coverage of human papillomavirus (HPV) vaccination programs: What works in the context of low-resource countries?

Cervical cancer due to human papillomavirus (HPV) infection is a leading cause of mortality among women in low-resource settings. Many Sub-Saharan African countries have introduced HPV vaccination programs at the national level in the last few years. However, countries are struggling to maintain sustainable coverage. This study focuses on the introduction and sustainability challenges, context-specific key lessons learned, and mechanisms of action to achieve high sustainable coverage from low and lower-middle-income countries (LLMICs) that have introduced HPV vaccination programs by collating evidence from a literature review and key informant interviews. Local data availability was a challenge across countries, with the lack or absence of registries, data collection and reporting mechanisms. Multi-sectoral coordination and early involvement of key stakeholders were cited as an integral part of HPV programs and facilitators for sustainable coverage. Key informants identified periodic sensitization and training as critical due to high staff turnover. Health workforce mobilization was fundamental to ensure that the health workforce is aware of the disease etiology, eligibility requirements, and can dispel misinformation. Schools were reported to be an ideal sustainable platform for vaccination. However, this required teachers to be trained, which was often not considered in the programs. District-level staff were often poorly informed and lacked the technical and logistic capacity to support vaccination rounds and data collection. To improve the sustainability of HPV vaccination programs, there is a need for timely microplanning, efficient preparedness assessment, assessing training approaches, periodic training, finding innovative ways to achieve equity and adoption of a bottom-up approach to ensure that processes between districts and central level are well-connected and resources are distributed efficiently.

Cost of human papillomavirus vaccine delivery at district and health facility levels in Zimbabwe: A school-based vaccination program targeting multiple cohorts

BACKGROUND

After a pilot project in 2014-15 Zimbabwe introduced the human papillomavirus (HPV) vaccine nationally in 2018 for girls aged 10-14 years through a primarily school-based vaccination campaign with two doses administered at 12-month intervals. In 2019, a first dose was delivered to a new cohort of girls in grade 5 of girls age 10 years if out-of-school (OOS), along with a second dose to the 2018 multiple cohorts. Additional effort was made to identify and mobilize OOS girls by Village Health Workers (VHWs) in the community. Zimbabwe reported 1,569,905 doses of HPV vaccine administered during the 2018 and 2019 campaigns. This analysis evaluated the cost of Zimbabwe's national HPV vaccine introduction.

METHODS

A retrospective, incremental, ingredients-based cost analysis from the provider perspective was conducted in 2018 and 2019. Financial and economic cost data were collected at district and health facility levels using a two-stage cluster sampling approach and four cost dimensions: program activity, resource input, payer, and administrative level. Costs are presented in 2020 US$ in total and per dose.

RESULTS

The total weighted costs for combined district and health facility administrative levels were US$ 828,731 (financial) and US$ 2,060,943 (economic). For service delivery, the total weighted cost per dose was US$ 0.16 (financial) and US$ 0.59 (economic). The program activities with the largest share of total weighted financial cost were training (37% of total) and service delivery (30%), while the largest shares of total weighted economic costs were service delivery (45%) and training (19%). Efforts by VHWs to reach OOS girls resulted in an additional US$ 2.99 in financial cost per dose and US$ 7.79 in economic cost per dose.

CONCLUSION

The service delivery cost per dose was lower than that documented in the pilot program cost analysis in Zimbabwe and studies elsewhere, reflecting a campaign delivery approach that spread fixed costs over a large vaccination cohort. The additional cost of reaching OOS girls with the HPV vaccine was documented for the first time in low- and middle-income countries, which may provide information on potential costs for other countries.

HPV vaccination coverage in three districts in Zimbabwe following national introduction of 0,12 month schedule among 10 to 14 year old girls

BACKGROUND

Zimbabwe has one of the highest incidence rates of cervical cancer in the world - 61.7 per 100,000 women. The government of Zimbabwe introduced bivalent HPV vaccine with a 0,12 month schedule to all 10-14 year old girls using a pulsed-campaign approach in May 2018 (dose 1) and May 2019 (dose 2).

METHODS

In August 2019, we conducted a population-based, two-stage cluster survey of households with girls who were eligible for the national HPV vaccination program to determine two-dose HPV vaccination coverage in three districts of Zimbabwe. All households with girls currently aged 11 to 15 years were line-listed through a census conducted in the pre-selected clusters from each district prior to survey administration. A simple random sample of eligible households was selected from these lists to estimate HPV vaccine coverage at sufficient power with a margin of error of +/- 5%. Criteria for district selection included estimated vaccine uptake (low, medium, high), rural/urban/peri-urban, geographic area, estimated number of girls not in school, and recent natural disasters or disease outbreaks. We oversampled households with girls aged 13 or 14 years at the time of dose 1.

RESULTS

On-time dose 1 uptake ranged from 88 to 94% and two-dose HPV vaccine coverage ranged from 75 to 86% across the three districts. Nearly all vaccinations occurred in schools, and less than 2% of girls did not attend school. There were challenges assessing ages of girls at schools prior to vaccination - 9% of girls vaccinated were less than 10 years old at time of dose 1.

DISCUSSION

Zimbabwe has demonstrated that high uptake and successful completion of 2-dose HPV vaccination can be achieved with an annual dosing schedule. Efforts going forward will need to focus on minimizing dropout between doses and routinizing annual vaccinations in schools for every subsequent new cohort of eligible girls in the country.

Tanzania's human papillomavirus (HPV) vaccination program: Community awareness, feasibility, and acceptability of a national HPV vaccination program, 2019

BACKGROUND

In April 2018, Tanzania introduced the human papillomavirus (HPV) vaccine nationally to 14-year-old girls, utilizing routine delivery strategies (i.e. vaccinating girls at health facilities and community outreach, including schools). We sought to assess awareness, feasibility, and acceptability of the HPV vaccination program among health workers and community-level stakeholders.

METHODS

We conducted cross-sectional in-person surveys among health workers, school personnel, community leaders, and council leaders in 18 council areas across six regions of Tanzania in October-November 2019. Regions were purposively selected to provide demographic, geographic, and vaccination coverage variability; sub-regional levels used random or stratified random sampling. Surveys included questions on HPV vaccine training and knowledge, delivery strategy, target population, and vaccine and program acceptability. Descriptive analysis was completed for all variables stratified by respondent groups.

RESULTS

Across the 18 councils, there were 461 respondents, including health workers (165), school personnel (135), community leaders (143), and council leaders (18). Over half of each respondent group (50-78%) attended a training or orientation on HPV vaccine. Almost 75% of the health workers and school personnel respondent groups, and less than half (45%) of community leaders correctly identified the target age group for HPV vaccine. Most (80%) of the health workers indicated HPV vaccination was available at health facilities and schools; most (79%) indicated that the majority of girls receive HPV vaccine in school. Approximately half (52%) of all respondents reported hearing misinformation about HPV vaccine, but 97% of all respondents indicated that HPV vaccine was either "very accepted" or "somewhat accepted" in their community.

CONCLUSION

The HPV vaccination program in Tanzania was well accepted by community stakeholders in 18 councils; adequate knowledge of HPV vaccine and the HPV vaccination program was demonstrated by health workers and school personnel. However, continued technical support for integration of HPV vaccination as a routine immunization activity and reinforcement of basic knowledge about HPV vaccine in specific community groups is needed. The Tanzania experience provides an example of how this vaccine can be integrated into routine immunization delivery strategies and can be a useful resource for countries planning to introduce HPV vaccine as well as informing global partners on how to best support to countries in operationalizing their HPV vaccine introduction plans.