Our Global Voices Posts

Preventing Cervical Cancer in Cambodia: Evaluating the HPV Vaccination Demonstration Project

Posted on by Julie Garon, MPH - Vaccine Introduction Team, GID
A nine-year old girl and her grandmother being interviewed in Svay Rieng province about her knowledge on HPV vaccine
A nine-year old girl and her grandmother being interviewed in Svay Rieng province about her knowledge on HPV vaccine

Cervical cancer claims the lives of a quarter of a million women every year with almost nine out of ten deaths occurring in developing countries.   Cervical cancer is caused by human papillomavirus (HPV), a virus that can cause cancers in the mouth, throat, and reproductive tract, as well as genital warts. Safe and effective vaccines can prevent infection with certain types of HPV and protect against cervical cancer and other conditions. The World Health Organization (WHO) now recommends introduction of HPV vaccine (2 doses) for girls aged 9-14 years for primary prevention of HPV infection in all countries. Improving access to cervical cancer screening and treatment are also key components of a comprehensive cervical cancer strategy. Gavi, the Vaccine Alliance (Gavi), supports introduction of HPV vaccine in eligible countries by providing financial support for vaccine procurement and costs associated with introduction.

Because routine immunization programs in most low- and middle-income countries do not target girls in the 9-14 year age group, Gavi offered support to countries for small demonstration projects. These projects intended to identify effective vaccine delivery strategies that could then be scaled to national introduction. HPV vaccine is commonly delivered in school settings, through campaigns, and in community health clinics. For countries that undertook these two2-year demonstration projects, approximately 15,000 girls were targeted in select geographic areas. Evaluations on implementation, coverage and cost were recommended after the first year of the demonstration project, to inform program improvements and decision-making for future scale-up.

CDC’s Global Immunization Division (GID) is a core partner in international advisory groups, steering committees, and policy decision-making groups related to global HPV vaccine introduction and implementation. Additionally, GID provides targeted technical assistance to specific countries in the areas of decision-making, program planning, and monitoring and evaluation.

Interview teams discussing daily movement plans as part of the community-based survey to assess vaccination coverage in Siem Reap Province
Interview teams discussing daily movement plans as part of the community-based survey to assess vaccination coverage in Siem Reap Province

In Cambodia, cervical cancer is the most common cancer reported among women, with over 1,500 estimated new cases and nearly 800 estimated deaths each year.1 In 2016, the Cambodia Ministry of Health National Immunization Program (NIP) began a Gavi-supported HPV vaccination demonstration project in two provinces. All nine9-year old girls who were residents of defined areas in Svay Rieng and Siem Reap provinces were targeted for vaccination (approximately 11,646 girls). Two doses of bivalent HPV vaccine were administered through a school- and health facility-based delivery strategy to the target population during January and July, 2017. Both in-school and out-of-school girls were eligible for vaccination.

GID supported NIP and the Cambodia National Institute of Public Health (NIPH) in conducting three separate evaluations of the demonstration project, looking specifically at implementation, coverage and cost.

The post-introduction evaluation of implementation took place in July, during administration of the second dose of HPV vaccine. Evaluation teams interviewed immunization stakeholders as well as health workers, teachers, and girls at a sample of health facilities and schools (12 each). Objectives of this evaluation were to document processes, strengths, challenges, and achievements of the first year of implementation and to gather perceptions of key stakeholders around the HPV vaccination program. Main components assessed included planning, training, reporting, service delivery, cold chain, logistics, waste management, communication, and supervision. Findings showed that the HPV demonstration program was well- implemented, and all stakeholders supported inclusion of HPV into the routine immunization system. The existing immunization systems were able to easily cope with storage, distribution, and administration of an additional vaccine.

A vaccination coverage survey was conducted several months after completion of the first round (two doses) of immunization. This community-based survey of caregivers and girls assessed vaccination coverage and explored vaccine acceptability, knowledge, and attitudes surrounding HPV vaccine. The survey involved house-to-house visits, using a standard questionnaire and review of vaccination records. The survey indicated 84% two-dose vaccination coverage with over 90% of girls reporting receiving the vaccine in school. No instances of vaccine refusal were identified, and there was high demand for vaccination among caregivers and communities.

A detailed cost analysis was also done to understand spending on goods and services during planning, training, service delivery, and supervision associated with vaccine introduction. The financial cost (expenditures on goods and services purchased) to vaccinate one girl with two doses of HPV vaccine equaled US $15.49. The economic cost (financial cost plus opportunity cost) equaled US $38.68 per fully- immunized girl. These amounts are in line with average costs found in a multi-country study of Gavi-supported HPV demonstration projects.

A nine-year old girl being vaccinated with HPV vaccine in a primary school in Siem Reap Province
A nine-year old girl being vaccinated with HPV vaccine in a primary school in Siem Reap Province

Clear communication and training for teachers, caregivers, girls, and communities about HPV, cervical cancer, and HPV vaccine are important parts of the vaccination program and will be emphasized as the vaccine is rolled out nationally. The coverage survey indicated very high school enrollment, though it is possible that some out-of-school girls were left out. Cambodia’s migrant communities and other isolated populations can be difficult to access with health services. Globally, challenges remain in reaching out-of-school girls, migrant, and other hard-to-reach populations. Special considerations should be given to these populations during planning to ensure equitable access to vaccination.

A school-based delivery strategy was effective for reaching nine9-year-old girls in Cambodia, and the demonstration project was deemed successful. Strong planning, preparation, and record keeping enabled NIP to vaccinate a large proportion of the target population. Good advocacy encouraged buy-in from stakeholders, and effective social mobilization ensured caregivers were aware and accepting of the vaccination program. Lessons from the demonstration project in Cambodia will inform decision-making and planning for future national introduction.

HPV vaccination in a school setting provides a unique and important opportunity for collaboration with Ministries of Education and other youth organizations. Success in Cambodia can be attributed in part to the good planning and strong collaboration with the Ministry of Education, enabling a large number of girls to be reached in school. Developing these relationships may open doors to future opportunities to integrate vaccine delivery in schools with other antigens, such as tetanus toxoid, which may be administered to similar age groups as HPV vaccine. Globally, school-based approaches are being increasingly considered for vaccination as well as implementation of broader health interventions such as physical check-ups, deworming, and health education.

As of January 26, 2018, 79 countries had introduced HPV vaccine nationwide, and many national introductions are planned in the coming years. Countries that have been administering HPV vaccine for over 10 years have seen dramatic declines in type-specific HPV infection rates. The Cambodia experience illustrates the great strides being made in other countries toward equitable access of this lifesaving vaccine.

Posted on by Julie Garon, MPH - Vaccine Introduction Team, GIDTags , , ,

Proud to Protect Burkinabè from Meningitis

A child lines up to get her routine MACV vaccination in Burkina Faso in 2017. © Evelyn Hockstein/CDC Foundation

Isaïe Medah, MD, MSc, is a physician and director general of public health in Burkina Faso. Previously he was director of the country’s routine immunization program from 2015–2017 and director of disease control from 2011–2015. Proud to Protect Burkinabè from Meningitis By Isaïe Medah, MD, MSc In a remote village of Burkina Faso, a woman Read More >

Posted on by By Isaïe Medah, MD, MScTags , , , , ,

Message from Hank Tomlinson, PhD, Acting Director of CDC’s Division of Global HIV & TB.

CDC's innovative efforts to find, cure, and prevent TB are creating a safer America and a safer world.

“We are at a key moment in the global fight against tuberculosis. Tremendous progress has been made and, yet, this preventable, curable infection still claims more lives than any other infectious disease or epidemic. As leaders come together on World TB Day and again at the United Nations High Level Meeting on TB in September, Read More >

Posted on by Dr. Hank Tomlinson

Global Health Security Agenda Programs Protect Americans from Infectious Disease Threats

Today’s world of increasing interconnectivity and mobility accelerates the shared global risk to human health and well-being. The United States cannot effectively protect the health of its citizens without addressing infectious disease threats around the world. A pathogen that begins in a remote town can reach major cities on all six continents in 36 hours[1]. Read More >

Posted on by Anne Schuchat, MD (RADM, USPHS)

World Birth Defects Day 2018 Raises Global Awareness of Birth Defects

Every year, millions of babies around the world are born with a serious birth defect. In many countries, birth defects are one of the leading causes of death in babies and young children. Babies who survive and live with these conditions are at an increased risk for long-term disabilities and other health problems. The fourth Read More >

Posted on by Margaret A. Honein, Ph.D, M.P.H., Acting Director, Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental DisabilitiesLeave a commentTags ,

Continuing the Fight Against Zika

Zika virus continues to spread in many countries and territories around the globe. Because there is no vaccine or medicine for Zika, the virus and its associated health outcomes will remain a significant and enduring public health challenge. The Danger from Zika Although many people infected with Zika experience mild or no symptoms, infection during Read More >

Posted on by Olga L. Henao, MPH, PhD, Epidemiologist2 CommentsTags , , , ,

IMPACT Program in Kenya: A Fellow’s Experience

Oren (right) with some of his colleagues Dr. Vincent Yator (center) and Athanasio Omondi (left) engage with a International Union Against Tuberculosis and Lung Disease facilitator, Dr. Gihan El-Nehas (standing) during a group session.

Many doctors and other health workers in my country have limited background or training in leadership and management, yet they often find themselves in leadership positions. This was my case when I was appointed Sub-County Medical Officer in February 2014. Starting out was no easy task, considering I was more used to clinical work. Here, Read More >

Posted on by Dr. Oren Nyambane Ombiro4 CommentsTags , , ,

Creating Strength in Numbers to End Violence Against Women & Girls

Dr. Daniela Ligiero

The 16 Days of Activism Against Gender-Based Violence campaign falls every year between the International Day for the Elimination of Violence against Women on November 25th, and Human Rights Day on December 10th. It is a time to raise awareness and galvanize global support and action to end violence against women and girls around the Read More >

Posted on by Dr. Daniela Ligiero, Executive Director and CEO, Together for GirlsLeave a commentTags ,

Rubella and CRS Elimination: A Race Worth Winning

AEFI management kit

AEFI Management Kit. Photo credit: Rania Tohme/CDC More than 100,000 children worldwide are born with congenital rubella syndrome (CRS) every year to mothers infected with the rubella virus. Sadly, these children will suffer a lifetime because of birth defects such as blindness, deafness, and heart disease, even though a cost-effective vaccine is widely available to Read More >

Posted on by Susan Reef, MD, MPH, Medical Epidemiologist and Rubella Team Lead, Global Immunization Division & Gavin Grant, MD, MPH, Medical Epidemiologist, Global Immunization DivisionLeave a commentTags , , ,

Everyone Needs Somewhere to Go: World Toilet Day

Charcoal briquettes manufactured from human waste in East Africa

Charcoal briquettes manufactured from human waste in East Africa (Photo courtesy of Eric Mintz, CDC) We use toilets every day – at home, school, and work – yet 40% of the world’s population does not have this luxury.  Clean and safe toilets are more than just a place to use the restroom.  They are essential Read More >

Posted on by Madison Walter, MPH, CHESLeave a commentTags ,