Worldwide, cervical cancer is the fourth most common cancer in women. There were an estimated 570,000 new cases in 2018 — and over 310,000 deaths, the vast majority in low- and middle-income countries. Sub-Saharan Africa has lagged behind the rest of the world in introducing the HPV vaccine and routine screening, which means the cancer often isn’t identified and treated until it has reached an advanced stage.
Almost all cases of cervical cancer are caused by HPV. It is one of the commonest sexually transmitted infections globally, and most of us are infected with at least one type of genital HPV at some point in our lives — usually as teenagers or young adults. In most cases the virus is harmless and resolves spontaneously without causing any symptoms such as genital warts.
There are more than 100 strains of HPV, at least 14 of which can cause cervical cancer and a range of less common cancers, including of the penis, vagina and anus. Persistent infection with two strains of HPV, 16 and 18, is responsible for 70 per cent of cervical cancer cases.
The first vaccine against HPV became available in 2006. This was the culmination of decades of work, notably by scientists in Germany, who in 1983 discovered the link between HPV infection and cervical cancer.
Ian Frazer and Jian Zhou at the University of Queensland, Australia, then jointly developed the technology that enabled the HPV vaccine. Using recombinant DNA technology, they built the shell of the virus from scratch and made an ‘empty’ human papillomavirus in the lab.
The news that there was a new vaccine which could drastically reduce the number of women getting cervical cancer went around the world. But with the excitement about the new vaccine came the realisation that not all girls would have the same opportunity to receive it. It was likely that at least a decade would pass between its introduction in high-income countries and in low-income countries.
Today there are three HPV vaccines — Gardasil and Gardasil 9, made by Merck, and Cervarix, made by GSK. All are highly effective at preventing infection with virus types 16 and 18. The newest — Gardasil 9 — was licensed in 2014 and protects against nine types of HPV, which between them cause around 90 per cent of cervical cancers.
More than 800,000 people died in the Rwandan genocide, and its widespread destruction left the country devastated. Coverage of most World Health Organization-recommended childhood vaccinations plummeted to below 25 per cent. But within 20 years, the number of babies in Rwanda receiving all recommended vaccinations, such as polio, measles and rubella, had increased to around 95 per cent. Rwandans’ life expectancy more than doubled between 1995 and 2011. The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV?
Before the HPV vaccine arrived in Kanyirabanyana, 63-year-old Michel Ntuyahaga, a community health worker, spent weeks canvassing his village, going to each of the 127 mud-brick houses to inform parents about the upcoming vaccination campaign.
Ntuyahaga wasn’t the only person educating the community about the vaccination campaign.
Constantine Nyiransengiyera has been a primary school teacher in Kanyirabanyana for the past 13 years. In addition to teaching maths, science, French and English, she was — and continues to be — responsible for gathering all the 12-year-old girls at the local school to educate them about the HPV vaccine.
Silas Berinyuma, a leader in Kanyirabanyana’s Anglican church for the past 24 years, preached about the importance of the vaccine for weeks before it arrived in the village. The church used drama to depict scenes of cervical cancer’s devastating impact. This continues today.
The same awareness campaign was taking place around the country — Rwanda has a network of 45,000 community health workers, volunteers who are present in every village. Bugesera is a district in the Eastern Province, not far from the border with Burundi. Billboards line roads through the district, advertising soft drinks alongside public health messages. One says: “Talk to your children about sex, it may save their lives.”
Not far off the main road is Karambi, a village surrounded by banana plantations. Toddlers roll tyres down the red-earth roads, teenagers carry handfuls of firewood on their heads, and adults herd cows and goats.
In 2013, the then 12-year-old Ernestine Muhoza was vaccinated against HPV at her school. “The teachers called just girls for assembly and told us that there was a rise of a specific cancer among girls aged 12 and that it was time for us to get vaccinated,” she says.
The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV?
When she went home to tell her parents about the vaccination, they’d already heard about it on the radio and via community health workers.
Muhoza’s parents readily agreed. But not every parent did. Some were sceptical. Why, they wondered, would their girls be getting vaccinated now, at this age? Why couldn’t all girls and women receive the vaccine? And rumour had it that the vaccine would make girls infertile.
Community health worker Odette Mukarumongi worked tirelessly in Karambi to counteract the rumours. “I told parents that a girl will go into constant menstruation — like endless bleeding — if she gets cervical cancer,” she says.
Mukarumongi says parents eventually “surrendered” and allowed their daughters to be vaccinated. Today, she says, parents rarely refuse, now that they can see the widespread acceptance of it in the community.
In Kanyirabanyana, Ntuyahaga worked similarly hard to convince parents that the vaccine wouldn’t stop their daughters from being able to conceive.
“Parents had heard that the vaccine made girls infertile. We struggled to explain to them it wasn’t true — that it was better to vaccinate their daughters against the cancer because if they got it they would become infertile,” he says.
Community health workers and nurses visited homes with posters of women’s reproductive organs to show parents the damage cervical cancer could do to their daughters.
Felix Sayinzoga, manager of the maternal, child and community health division at the Ministry of Health, says: “Rwandans are really afraid about cancer so it was easy [to roll the vaccine out]. It was also about the trust the community has in the government. That was really important — the community knows that we do not bring things that are not good for them.”
The current health minister, Diane Gashumba, agrees that trust in the government has been critical in supporting the vaccine’s uptake, but admits that the rumours surrounding it were difficult to quash.
“The rumours were not anticipated. But, of course, as the HPV vaccine was a new vaccine for a new target group there were many questions.” She adds that church and village leaders, community health workers and radio programmes played an integral role in dispelling myths about the vaccine.