After experiencing the distress of caring for a loved one with advanced cervical cancer, Edna Maloya vowed to take proactive measures to ensure that her family and friends would be protected. 

“I was my cousin’s caregiver. I can’t take chances with cervical cancer,” says Maloya, who lives in Blantyre, Malawi’s second largest city.

She happily supported the Ministry of Health’s (MoH) human papillomavirus (HPV) school vaccination campaign aimed at girls aged nine to 14, consenting to her 13-year-old daughter receiving the HPV vaccine.

But some of the other parents in her daughter’s class had reservations and chose not to have their daughters vaccinated -–even though they could have done so either during the school vaccination campaigns or in community health facilities. 

Maloya is firm in her views: “This is my only child. If we have an opportunity to prevent illnesses, let’s utilise it. I’m certain that those who are hesitating now will someday wish they had let their daughters have this vaccine.” 

Malawi’s HPV vaccination rates – rebounding from Pandemic era turmoil 

When Malawi first introduced the HPV vaccination in 2019, the uptake was dramatic with 85% of the first group of eligible girls, nine-year-olds, getting their first dose.  

Then the COVID-19 pandemic hit, followed by Cyclone Freddy, which left more than half a million people displaced – and following that, outbreaks of polio and cholera. 

HPV coverage rates plummeted sharply to just 13% in 2021 and 2022, according to WHO’s immunization dashboard that tracks HPV vaccine uptake around the world.  

Rates are finally rebounding with  a dose of the vaccine reaching 68% of eligible nine-year-old girls in 2023.  And according to the new WHO guideline, approved in 2022, one dose is sufficient to provide lifelong protection. 

The rebounding vaccination rate is good news for Malawi, which has the world’s highest incidence and mortality rates of cervical cancer. The disease is also the leading cause of cancer deaths amongst women in the country, according to the national Cervical Cancer Strategic plan 2022-2026. About 4,000 women are diagnosed every year, while nearly 3,000 women annually die from the disease, according to WHO data. 

In 2023, the WHO African region’s HPV vaccination rate was second highest in the world 

Throughout Africa, a positive trend can be observed in the 2023 HPV vaccine data, just released by the World Health Organization (WHO). 

After a slight dip in vaccination rates during the pandemic year of 2021, rates rebounded quickly reaching 40% of eligible girls.  

That places WHO’s Africa region as second only to the Americas, which had a 68% uptake, in vaccine roll-out last year. It slightly exceeds the WHO’s European Region, whose 53 member states extending from the United Kingdom to Central Asia and Russia registered a 39% rate for HPV jabs. 

These three regions remain far ahead of the others including: South-East Asia, with a 16% uptake; the Western Pacific, including China, Japan and Australia (11%); and the Eastern Mediterranean Region, extending from Tunisia to Afghanistan, which had a woeful 1% rate of HPV vaccination in 2023. 

Simultaneous vaccine campaigns confused parents

Malawi’s Ministry of Health first introduced the HPV vaccine in 2019 through campaign mode focusing on schools. 

In 2021,the vaccine was incorporated into the country’s Extended Programme on Immunisation (EPI) schedule. This meant that girls can now get the vaccine in school during campaign days, which occur quarterly, or in community health facilities. 

However in 2021 and 2022, the COVID-19 pandemic led to school closures. It was followed by Cyclone Freddy, and in its wake, outbreaks of polio and cholera. These led to multiple new vaccine campaigns for older children and adults occurring at overlapping moments, something that confused and put off many parents.

“The parents literally accused us of tricking them into giving COVID-19 vaccine to their girls…. We don’t force them to receive the vaccine if they don’t want,” said Florence Nasava, a senior Disease Control Surveillance Assistant (DCSA) for the Zingwangwa Health Centre in Blantyre. 

Nasava adds that local health workers redoubled their efforts with community volunteers, traditional and religious leaders to help in demystifying the vaccine myths – and explain the difference between the HPV vaccines, COVID jabs and others to parents.

“Since its [HPV’s] introduction, Malawi has grappled with multiple and unforeseen crises such as the COVID-19 pandemic and Cyclone Freddy – which left more than half a million people displaced, and outbreaks of polio and cholera,” noted a spokesperson from Gavi, the Vaccine Alliance, which is providing the vaccines to Malawi and 38 other low-income countries worldwide.    

Stockouts are now the major problem 

Nasava also perceives that demand has now rebounded, reflecting the new 2023 data. Overall, the local health centre typically sees two to three girls a day for the HPV vaccinations, she says, adding that “many more girls get vaccinated during mass school campaigns, where an average of 300 to 400 girls are vaccinated per day.” 

In rural areas, appreciation for the vaccine is also spreading  – in light of the large cervical cancer burden that exists.  

“This vaccine is a life saver for our girls’ generation. I was motivated to have my two daughters vaccinated against the disease since this is an incurable disease,” Zione Limitedi told Health Policy Watch.  She is a DCSA in Gwilima village in Malawi’s southern region.

“I know of a woman from my village who died of cervical cancer…. It’s difficult to manage in a poverty stricken rural area, so the vaccine is our only hope to protect the future,” adds Limitedi.

Lezzita Mphundi, a DCSA based in Chikwawa, a rural area about an hour’s drive from Blantyre, says parents seem to be most comfortable having their girls receive the vaccine with their classmates during school campaigns rather than going alone to the outreach clinics or at a facility.

“Many parents consented to having their girls vaccinated. I vaccinated over 200 girls before supplies ran out,” she said of a recent campaign day. That reflects a new problem. Now that demand is high, stockouts are a growing problem. 

LMICs have the highest rates of cervical cancer deaths

The WHO says nearly 94% of the cervical cancer deaths in 2022 occurred in low- and middle-income countries (LMICs), where the burden of cervical cancer is greatest, due to limited access to routine screening tools and treatment services for the disease at early stage. These are almost universally available in developed countries. 

That’s what makes HPV vaccination, which sharply reduces risks of developing cervical cancer from the most common cause, human papillomavirus, all the more important in Malawi and other African countries.

Rwanda was the first African country to implement the HPV vaccination program successfully in 2011, followed by Zambia in 2013, then South Africa in 2014, which even managed to maintain an 80% vaccination rate through the pandemic years.  In November 2023, Togo became the latest country to introduce the HPV vaccine, following Nigeria, in October. 

All in all,  27 African countries have incorporated the HPV vaccine into their routine immunization programmes, with a primary focus on girls aged 9-14.  

Malawi was also an early adopter, launching an HPV vaccination pilot program for adolescent girls in Rumphi, a district of northern Malawi, and Zomba, in the country’s eastern region. That scored an early success, achieving 80% coverage, said  Dr Atupele Kapito-Tembo, epidemiologist and public health specialist at Kamuzu University of Health Sciences (KUHes).  

“This demonstrated the country’s capacity and ability to cover the targeted population,” she observed.

As for the sharp decline seen during the pandemic years, she said, “In my view and experience, Malawi needs more engagement with stakeholders since girls and their caregivers may not be fully aware of their HPV vaccine eligibility and benefits.

“They might have heard about the vaccine or cervical cancer, but made no initiative to get screened or have their daughters vaccinated because they haven’t been exposed to enough information.”

“There’s a need for more sensitisation to restore confidence in vaccines,” she urges.

Cancer also takes time to manifest and therefore it can be difficult to appreciate the impacts of the vaccine right away, Tembo observes.

“If we compare with high income countries, they introduced this vaccine in the 1990s and the impact is seen now. For us it may take a decade or two from 2017/2018 [when vaccination began] to see the impact.”

MOH aims to reach 90% coverage goal 

In 2020, the World Health Assembly approved a global strategy to eliminate cervical cancer by 2030, setting out the so-called ‘90-70-90’ targets. Those aim to have 90% of girls worldwide fully vaccinated with HPV vaccine by age 15; 70% of women are screened with a high-performance test by age 35; and 90% of women identified with cervical cancer receiving treatment.  

Last March, governments, donors and other partners pledged some $600 million at the first-ever global forum on cervical cancer in Cartagena de Indias, Colombia – putting those  goals closer than ever within reach.

In Malawi’s Ministry of Health, EPI Programme Manager Dr Mike Chisema says the ministry aims to reach the 90 percent vaccination coverage target by 2030, perceiving it as a key lever in the country’s cervical cancer elimination strategy. 

Additionally, if cervical cancer deaths can be reduced, that can also help reduce HIV-related deaths insofar as there are significant co-morbidities, he points out. 

At the same time, vaccines need to be deployed alongside screening and treatment for women, he notes saying: “we have to control for other factors such as HIV prevalence and [other] risk factors for developing cervical cancer.”

Important to sustain demand despite occasional stockouts

Chisema says that vaccine stock outs observed recently, especially in rural Malawi, are largely due to district internal logistical challenges and not necessarily due to inadequate vaccines at central level.

He said that it remains critical, however, for girls to continue coming forward – so that valuable supplies of the vaccine do not expire. 

In recognition of this, Chisema says that the Ministry of Health has come up with several initiatives including expansion of the age eligibility for the vaccine from 9-14 years old, enabling multi-cohort vaccination and more attention to stockouts in the “last mile”. 

The Ministry is also gearing up for a major multi-age campaign in 2025 or earlier working with both primary and secondary school teachers to identify eligible children. Although the results will be reaped decades later, Malawi sees that as a long-term investment in women’s health. 

“We just need to continuously review our health system and strengthen it accordingly, evaluating what works for us or not,” Chisema says.

Image Credits: Nadia Marini/ MSF , Josephine Chinele , WHO, Josephine Chinele.