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Achieving High Coverage in Rwanda's National Human Papillomavirus Vaccination Programme

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Achieving High Coverage in Rwanda's National Human Papillomavirus Vaccination Programme Lessons fromLessons the from thefield field Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme Agnes Binagwaho,a Claire M Wagner,b Maurice Gatera,c Corine Karema,c Cameron T Nuttd & Fidele Ngaboa Problem Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275 000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years. Approach In 2011, Rwanda’s Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a “public–private community partnership” to ensure effective and equitable delivery. Local setting Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12–23 months receive all basic immunizations recommended by the World Health Organization. Relevant changes In 2011, Rwanda’s HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose. Lessons learnt Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda’s strong vaccination system and human resources framework. Following the GAVI Alliance’s decision to begin financing HPV vaccination, Rwanda’s example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context. Background HPV vaccination rollout and decided to pursue a partnership with Merck to offer Rwanda’s young girls the opportunity to Human papillomavirus (HPV) is a sexually transmitted virus receive a life-saving vaccine. found in virtually all cases of cervical cancer,1 which kills A growing body of scientific literature has emerged in 275 000 women every year2 and is the biggest contributor to recent years concerning the use of the HPV vaccine in the years of life lost from cancer among women in the developing developing world,2,10 but very little evidence on the success world.3 Two HPV vaccines developed in recent years – Merck’s and replicability of nationwide delivery programmes, like quadrivalent Gardasil and GlaxoSmithKline’s bivalent Cer- Rwanda’s, has been published. In this article, we describe the varix – have been prequalified by the World Health Organiza- process by which Rwanda became the world’s first low-income tion (WHO) and approved by national governments in many country to provide universal access to the HPV vaccine. countries, including Rwanda. These vaccines represent a mile- stone in biomedical progress towards mitigating the burden of Context cervical cancer.4 Vaccination programmes have changed the landscape of global health drastically by enabling countries to Before 2011, neither cervical cancer screening nor HPV vac- re-evaluate funding priorities and to invest in prevention when cination was available in public health facilities in Rwanda; cost-effective.5 However, 15 to 20 years usually pass between only a few private clinics and nongovernmental organizations the introduction of a vaccine in rich and poor countries.6 offered screening services. Aware that cervical cancer is highly In recent decades, routine screening programmes have prevalent in Rwanda, the Ministry of Health considered the reduced cervical cancer morbidity and mortality in high- overwhelmingly positive evidence of the effectiveness of the income countries, and this trend is expected to accelerate as HPV vaccine to be a call to action. vaccination coverage is scaled up.7 As a result, 77% of new In April 2009, Rwanda’s First Lady met with senior Merck cases8 and 88% of deaths from the disease now occur in de- officials to initiate advocacy for the HPV vaccine on behalf of veloping countries.2 A five-year delay in introducing the HPV women in Rwanda. An internal technical discussion then oc- vaccine to these countries would result in 1.5 to 2 million curred between Merck and the Ministry of Health, followed by preventable deaths.2 conversations with development partners in Rwanda’s health Cervical cancer is the most common cancer among sector. In April and October 2010, Merck representatives women in Rwanda,9 a country in eastern African with more visited Rwanda to work under the leadership of the Ministry than 11 million inhabitants. In 2010, 986 cases of cervical of Health in developing a national cervical cancer prevention cancer were diagnosed in Rwanda and 678 women died from strategy. Rwanda’s National Strategic Plan for the Prevention, the disease.9 That same year, Rwanda evaluated options for Control, and Management of Cervical Lesions and Cancer11 a Ministry of Health, Kigali, Rwanda. b Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, United States of America (USA). c Rwanda Biomedical Center, Kigali, Rwanda. d Dartmouth Center for Health Care Delivery Science, Hanover, USA. Correspondence to Claire M Wagner (e-mail: [email protected]). (Submitted: 10 October 2011 – Revised version received: 15 February 2012 – Accepted: 28 February 2012 – Published online: 23 May 2012 ) Bull World Health Organ 2012;90:623–628 | doi:10.2471/BLT.11.097253 623 Lessons from the field Human papillomavirus vaccine rollout in Rwanda Agnes Binagwaho et al. includes screening and vaccination Table 1. Cumulative human papillomavirus vaccination coverage, by vaccination round, programmes for women between 35 and Rwanda, 2011 45 years of age, the specifics of which will be detailed in future articles. A Coverage Round 1 Round 2 Round 3 memorandum of understanding signed Girls vaccinated in school, no. 91 752 89 704 88 927 in December 2010 guaranteed Rwanda three years of vaccinations at no cost Girls vaccinated outside school, no. 2 136 3 066 3 180 and concessional prices for future doses. Total no. of girls vaccinated 93 888 92 770 92 107 On 26 and 27 April 2011, 93 888 Cumulative coverage (%) 95.04 93.90 93.23 Rwandan girls in primary grade six re- ceived their first shot of Gardasil with no Malaria, and other Epidemics, and The second major decision was to out-of-pocket payment. Data collected health workers engaged in cancer care. partner with the Ministry of Education by the Ministry of Health during the Multidisciplinary subcommittees were to design a school-based strategy to first round of vaccination showed that tasked with identifying cold chain re- deliver the standard three doses of the 94 141 girls were present at school and quirements; numbers of girls in and out HPV vaccine. Because 98% of Rwandan that 4 651 girls were either absent or not of school; nurse and community health girls attend primary school,16 imple- enrolled, resulting in a total of 98 792 worker training capacity; procurement menters felt that the highest coverage eligible girls across Rwanda. The pro- and distribution logistics; a budget for rates could be attained through schools. gramme’s first round achieved 95.04% implementation; education and sen- Some girls in rural settings are unaware coverage, the second 93.90% and the sitization requirements; and tools for of their exact ages, and a demonstration third, 93.23% (Table 1). data collection and social mobilization. project in Uganda described difficulties Committees met as often as needed – identifying girls through an age-based Rwanda’s health sector often every other day – for about four programme,10 so Rwanda elected to months. After the memorandum of pursue a grade-based strategy. Driven by the pursuit of equity, value understanding between Merck and the Third, the technical working group and quality, the health sector in Rwanda government of Rwanda was signed, the decided on a multi-phased vaccina- has made immense progress in recent following two months were spent devis- tion strategy spanning three years years. Through a decentralization strategy ing a strategic plan for rollout prepara- (Fig. 1). Every year beginning in 2011, harnessing Rwanda’s 45 000 community tion, implementation and evaluation. girls enrolled in primary grade six will health workers, the Ministry of Health and Concurrently, a nationwide popula- receive the full three-dose course of its partners have succeeded in decreasing tion sensitization campaign was planned HPV vaccine. During the programme’s the burden of major infectious diseases and undertaken months in advance of second and third years, a “catch-up” and have scaled up disease prevention vaccination. Speeches by health-care phase targeting girls in the third year of programmes efficiently and effectively. professionals, local government officials, secondary school will ensure complete Between 2005 and 2010, Rwanda reduced clergy and the First Lady were made to coverage of all pre-adolescent and ado- malaria incidence by 70% and under-five inform parents and children of the new lescent girls. In 2014 and beyond, only mortality by 50%. The country increased vaccine. Announcements via newspa- primary grade six vaccinations will be the proportion of infants aged 12–23 pers, magazines, radio and television necessary. months receiving all basic WHO immuni- were included in the communications Each course of vaccination takes zations from 75.2% to 90.1% (with all but strategy. Teachers were trained and en- place over six days: school-based vac- oral polio vaccine coverage rates exceed- couraged to discuss cervical cancer and cinations across the country during ing 95% in 2010) and assured universal ac- the HPV vaccine with students.
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