Mozambique and the Human Papillomavirus Vaccine: From Recommendation to Reality in Two Decades

[This article has been originally published in Spanish in El País-Planeta Futuro. Authors: Clara Menéndez, Núria Casamitjana, Azucena Bardají and Anna Lucas (ISGlobal); and Khátia Munguambe y Esperanza Sevene (Manhiça Health Research Centre, CISM)]

The Government of Mozambique recently announced a nationwide rollout of the human papillomavirus (HPV) vaccine, marking the end of a cycle that began more than 20 years ago. Steps taken two decades ago in collaboration with various institutions—the Mozambican Ministry of Health, researchers, development organisations, advocacy groups, donors and Gavi, the Vaccine Alliance —set in motion a process that has continued until the present day, with the aim of addressing the complex challenges inherent in the introduction of a new health intervention.

Vaccinating pre-adolescent girls against the types of HPV that cause cervical cancer is the safest, most effective and most equitable tool for reducing the incidence of a cancer that claims the lives of more than 300,000 women worldwide each year

Vaccinating pre-adolescent girls against the types of HPV that cause cervical cancer is the safest, most effective and most equitable tool for reducing the incidence of a cancer that claims the lives of more than 300,000 women worldwide each year. More than 85% of these women are concentrated in low- and middle-income countries (LMICs)—mainly in sub-Saharan Africa—and 87% of deaths occur due to late detection and limited access to effective treatment.

With an incidence of 50.2 cases per 100,000 inhabitants and a mortality rate of 38.2 per 100,000 inhabitants in Mozambique, cervical cancer accounts for one third of cancer cases in adult women and 21% of all cancer deaths in the country. Research has demonstrated the link between HPV infection and cancerous lesions, in keeping with global patterns showing that more than 70% of cervical cancers are attributable to HPV types 16 and 18, against which the vaccine provides protection.

Photo: Andalu Vilasanjuan.

In 2001, strategic collaboration on HPV and cervical cancer between ISGlobal, the Manhiça Foundation (CISM) , Maputo Central Hospital, the Mozambican Ministry of Health and the Catalan Institute of Oncology (ICO) generated basic information and key data that would facilitate progress on this urgent public health issue in Mozambique. Those initial studies made it possible to determine the prevalence of HPV infection in women, identify vaccine-related HPV genotypes in women with and without cervical cancer, and describe the prevalence and aetiology of sexually transmitted infections and the prevalence of cervical neoplasia.

How did this generic recommendation become a reality in Mozambique? Lots of hard work, resources and determination have come together over time to make progress on this issue

In 2011, Gavi announced its decision to introduce cervical cancer vaccines in eligible countries, responding to demands from the countries themselves and World Health Organisation (WHO) recommendations to vaccinate girls between the ages of 9 and 13 years against HPV through national immunisation programmes in places where cervical cancer was a public-health priority and where introduction was feasible.

How did this generic recommendation become a reality in Mozambique? Lots of hard work, resources and determination have come together over time to make progress on this issue. The Maternal, Child and Reproductive Health Initiative was created around the same time, and introducing the HPV vaccine in Mozambique has been one of our lines of work at ISGlobal ever since. To this end, we lobbied Gavi to include Mozambique on the list of LMICs that would receive the vaccine.

Since 2012, Gavi has funded the introduction of the HPV vaccine in LMICs. However, this funding is conditional on the implementation of a pilot project prior to national rollout, in order to assess the feasibility and capacity of the proposed delivery model.

Following Gavi’s approval of an HPV vaccine pilot project in Mozambique, CISM, ISGlobal and the Foundation for Community Development (FDC) collaborated with Mozambique’s Ministry of Health and Ministry of Education and Human Development to implement the first such project in the country. CISM was also tapped by the Ministry of Health to oversee the evaluation of the pilot project.

Mozambique’s decision is a cause for celebration, as it will help to improve the health and lives of thousands of women in the coming years

In addition to the Gavi-funded pilot project, Mozambique also implemented two additional government-funded projects in different provinces (Maputo City, Manica, Cabo Delgado) in order to encompass socio-cultural aspects in a diverse range of settings.

In order to lay the groundwork for evidence-based, context-specific decision-making, researchers from CISM and ISGlobal conducted crucial additional studies between 2013 and 2016, with the aim of obtaining key information prior to the HPV vaccine rollout in Mozambique. One study looked at the feasibility and acceptability of implementing an HPV vaccination programme in pre-adolescent girls in rural and urban areas (through a collaboration project funded by the Barcelona City Council’s Department of International Cooperation and the Aga Khan Foundation). In addition, a cost assessment was conducted during the vaccine pilot project and two coverage studies were carried out to determine the reach of immunisation and awareness-raising messages in schools and communities.

Finally, a capacity-building project for health professionals in Mozambique and other groups such as teachers, provincial and district education officials, and community leaders, funded by the ”la Caixa” Foundation, was implemented with the aim of preparing the groups that would be involved in the administration of the nationwide vaccination programme.

By 2016, most beneficiary countries had completed their pilot projects, but few had scaled up their administration to the national level . This last step—translating the knowledge from the previous stages to the programmes themselves—is often the most difficult. Political will, driven in this case by the office of Mozambique’s first lady, was the key to completing this last stage of the process. Mozambique has finally taken this last step and now forms part of the small group of LMICs that have included the HPV vaccine in their immunisation programmes . This is the country’s only chance to meet one of the targets set out in the recently announced WHO strategy: vaccinating 90% of girls by age 15 before the year 2030.

This is the country’s only chance to meet one of the targets set out in the recently announced WHO strategy: vaccinating 90% of girls by age 15 before the year 2030

The HPV vaccine is highly effective and safe against infection and precancerous lesions. The most recent evidence shows an 87% reduction in cervical cancer rates among women who received the vaccine when they were 12 or 13 years old. In addition, the growing body of evidence on the benefits of single-dose HPV vaccination is also encouraging.

These findings are particularly relevant for vaccination programmes in LMICs, where cervical cancer is a much greater public-health problem than it is in countries with well-established vaccination systems, and also for screening in the current pandemic context, where the availability of vaccines (not to mention their distribution and administration) is even more complicated and access to sexual and reproductive health services is more difficult for many women, especially from the most disadvantaged groups.

Therefore, Mozambique’s decision is a cause for celebration, as it will help to improve the health and lives of thousands of women in the coming years.