Uganda: Vaccinating Schoolgirls Against HPV

Last year Myriam, a 13-year-old high school student from Central Uganda was vaccinated against the Human Papillomavirus (HPV). The health workers who came to her school explained to Myriam’s class that the vaccines would protect them from developing a type of cancer that affects their reproductive systems. “It was my first time to hear about it,” said Myriam. She says she wanted to get the HPV vaccine because “I was scared I would not have children.” Image by Sascha Garrey. Uganda, 2014

Ninty-nine percent of cervical cancer cases worldwide are caused by HPV, a common sexually transmitted infection that has over 100 different strains. In 2007, the Ugandan Ministry of Health (MOH) partnered with the international non-profit PATH to implement a pilot project testing the two different approaches to vaccinate girls between the ages of 10 and 15 against HPV. It was determined that a school-based approach that offered vaccinations to girls in the Primary 4 grade at their schools was optimal. One of the trials took place in the Nakasongola District where Myriam goes to school. Image by Sascha Garrey. Uganda, 2014

Nursing Officer Jane (on the left) pays visits to schools around Nakasongola every so often to give talks on health education. She says that there has been a positive attitude towards the HPV vaccination. “The girls want to be vaccinated and so do their parents,” she said. Image by Sascha Garrey. Uganda, 2014

Several hand-painted signs are nailed to trees scattered throughout the courtyard that is between the three one-room buildings that make up Myriam’s school. The signs offer public-health oriented messages and lessons on kindness. Image by Sascha Garrey. Uganda, 2014.

This sign tacked onto to one of the trees outside of Myriam’s school likens virginity to overall health. According to a report published by the World Health Organization (WHO), in Uganda the average age for male sexual debut is 18 whereas it is 16 for women. The WHO also cites early initial intercourse as a risk factor for cervical cancer. The idea behind vaccinating girls as young as 10 is to elicit immunity against HPV before a girl’s first sexual encounter. Image by Sascha Garrey. Uganda, 2014.

Like many people in Uganda, Myriam is aware and accepting of HIV, but cancer is a new and often scary concept. “I didn’t know, but one of the lady teachers gave us the information,” she said. “When I heard about the cancer I was afraid.” Image by Sascha Garrey. Uganda, 2014.

Amina, age 15, is in the same class as Myriam, but refused to be vaccinated when the healthcare workers came last year. She said her mother, who lives with her two younger siblings in the Lira District of Northern Uganda, does not trust injections and forbade Amina from getting vaccinated. “It felt bad to be the only one without,” she said, “but I could not go against my mother’s wishes.” Image by Sascha Garrey. Uganda, 2014.

During the school year Amina lives with her aunt, who introduces herself as Mama Amina. She is a small-scale farmer in a village that is an hour's walk from the school. “I was very angry with her,” said Mama Amina. “At school when she saw her colleagues being immunized, why didn’t she follow up? It’s her problem. Now that it has come to this she has to accept that she is going to get the vaccination if there is another chance.” Image by Sascha Garrey. Uganda, 2014.

Amina says that she wants to be vaccinated when the health workers come back to her school again. Unfortunately, she might not get a second chance soon. Up until this year, the delivery and administration of the HPV vaccine used in Nakasongola was supported by PATH. It has since been integrated into Uganda’s national childhood vaccine schedule so the Ugandan government is responsible for its cost. Although it was a victory for PATH and the MOH to have the HPV vaccine incorporated into the regular childhood vaccine schedule, health workers who must travel from the centrally located district health clinic to remote areas to deliver the vaccine are no longer paid enough to cover their costs of transportation. Image by Sascha Garrey.

Gardasil, the HPV vaccine that is available in Nakasongola, must be refrigerated and administered three times within a six-month period in order to maximize immunity. According to Edward Sinamanya, the vaccine focal person at the District Health Center in Nakasongola, the recent financial constraints have left many girls in Primary 4 in his District without their second and third rounds of the HPV vaccine. Sinamanya says that it is not likely they will receive the remaining two injections within the required time period, if at all. “Health workers no longer want to go (to the schools),” he said. “They are without motivation, without allowance and transport.” Image by Sascha Garrey. Uganda, 2014.

There is also no money to cover the cost of the gas needed to power the refrigerators that contain the vaccines at the Nakasongola District health center. “If the gas we have now gets used up and there is no power then we’ll have a problem with the vaccines,” said Sinanamanya. Image by Sascha Garrey. Uganda, 2014.

Until Amina gets vaccinated, her aunt says she will keep on encouraging her niece to do whatever she can to avoid being on the path towards early pregnancy and cervical cancer. “It’s very difficult to look after a young girl,” said Mama Amina. “You may be telling her to sit and go to school and she may be thinking of staying, but then she gets off with a man and she goes off. I’d like Amina to go to school so that she earns money, even when she’s married. Men these days don’t want very dependent women.” Image by Sascha Garrey. Uganda, 2014.

In 2007, a pilot project took place in two districts in Uganda to test different methods of delivering Human Papillomavirus (HPV) vaccines to girls between the ages of 10 and 15. The vaccine used—and that continues to be administered in Uganda—was Gardasil, an immunization owned by Merck that protects against HPV strains 6, 11, 16 and 18, the latter two of which are highly related to the development of cervical cancer.

The Nakasongola District of Central Uganda was one of the trial districts. Although most schoolgirls have been vaccinated consistently since the pilot project, recent financial constraints have posed serious threats to its continued success.