Cervical cancer, caused by human papillomavirus (HPV), is
the leading cause of cancer mortality among women in Botswana (1). Three
vaccines prevent infection with HPV types responsible for the majority of
cervical cancer worldwide. Two of these vaccines also protect against types
that cause anogenital warts. Two vaccines are currently prequalified by the
World Health Organization (WHO); these were >90% efficacious in preventing
precancerous lesions caused by HPV types 16 and 18 (the cause of 70% of
cervical cancers) in clinical trials studying women who received the
recommended 3-dose series before exposure to targeted HPV types. WHO recommends
targeting HPV vaccination to girls aged 9–13, before initiation of sexual
activity and thus HPV exposure (2). This report summarizes HPV
vaccination coverage among girls aged ≥9 years enrolled in grades 4–6 in 23
primary schools in Molepolole, Botswana, during a 2013 HPV vaccination
demonstration project conducted by the Botswana Ministry of Health (MOH). Of
the 2,488 eligible school girls, 83% received the first dose and 79% completed
the 3-dose HPV vaccination series. Drop out between first and third dose was
5%. No serious adverse events were reported. Given the successful pilot, the
project was expanded to immunize approximately 6,000 girls in 2014, followed by
national rollout of the HPV vaccine in 2015.
Botswana is an upper middle income country with a population
of 2 million in southern Africa. Approximately 22,000 females are born
annually. Human immunodeficiency virus (HIV) prevalence among women aged 15–49
years is 28%.* Cervical
cancer, the fourth most common cancer worldwide (3), is the most common
cancer among women aged 15–44 years and the leading cause of cancer mortality
among women in Botswana, reflecting the 4–5 times increased risk for cervical
cancer among HIV-infected women (3). Primary prevention of cervical
cancer via HPV vaccination might be particularly beneficial to Botswana, given
the country's challenges with both HIV infection and cervical cancer. However,
establishing a sustainable program to deliver HPV vaccine to a population not previously
targeted for immunizations can be challenging in resource-limited countries.
In 2012, the Botswana MOH initiated its National Cervical
Cancer Prevention Program Comprehensive Strategy (2012–2016). The same year,
the Pink Ribbon Red Ribbon (PRRR) initiative, a public-private partnership for
breast and cervical cancer prevention and treatment, was implemented to expand
cervical cancer screening and treatment with a focus on HPV-related disease.
With PRRR and other donor support, the Botswana MOH decided to conduct a
grade-based HPV vaccination demonstration project in primary schools. The
project was completed during the 2013 school year (January–December) in
Molepolole, a town with a population of 63,000 located 31 miles (50 kilometers)
from the national capital. The objectives were to evaluate HPV vaccine
implementation among age-eligible girls enrolled in school and to improve
planning for possible expansion of HPV vaccine activities.
A multidisciplinary team, with representatives from the
Botswana MOH, including Expanded Program on Immunization, Ministry of
Education, WHO, nongovernmental organizations, and other key stakeholders,
developed the project protocol, educational materials, a parental consent form,
and data-gathering tools. The Botswana MOH determined the project to be public
health practice. Multiple educational meetings for community stakeholders,
sensitization meetings for parents and educators, and training sessions for
local public health providers participating in the project were held before
implementation. All girls aged ≥9 years attending grades 4–6 at any of
Molepolole's 17 public primary schools, five private primary schools, or one
school for special needs students, and who had written parental consent, were
eligible for vaccination. Participating schools provided enrollment lists of
female students. The quadrivalent HPV vaccine, Gardasil (Merck and Co.), was
administered in schools by public health workers in March, May (approximately 2
months after the first dose), and early October 2013 (approximately 6 months
after the first dose). Immunization teams visited each school twice during each
of the three vaccination campaign rounds. Girls who missed a dose at school
could receive it at Scottish Livingston Hospital in Molepolole. Vaccination
data on each girl were collected on paper-based records and transferred to a
spreadsheet. To identify the number of girls who received HPV vaccination
during March–December 2013, staff reviewed the line lists of girls by school,
which contained birthdate, grade, documentation of parental consent, and HPV
vaccination date.
There were 2,742 girls registered in grades 4–6 in the 23
participating schools (median enrollment = 135 girls;
range = 12–227 girls). Of the 2,590 (94%) girls with a recorded date
of birth, 2,488 (96%) were aged ≥9 years on the first day of school vaccination
in March 2013. Among these girls, 83% (n = 2,075) received the first dose, 82%
(n = 2,049) received 2 doses, and 79% (n = 1,967) completed the 3-dose series (Table). Overall vaccination
completion among girls who received the first dose was 95%. Approximately one
fifth (431/2488) of girls with known date of birth were without documented
parental consent, 88 of whom received vaccination. The proportion of school
girls vaccinated increased with increasing age (Cochran-Armitage trend test
p<0.001) and was higher among girls who attended public school compared with
those who attended private school (p<0.001). Passive surveillance for
adverse events (following girls for 30 days postimmunization) was designed for
this campaign. No serious adverse events were reported.
By: Mmakgomo Mimi Raesima, MD1; Sara E. Forhan, MD2; Andrew C. Voetsch, PhD2; Shannon Hewitt3; Susan Hariri, PhD4; Susan A. Wang, MD5; Andrew R. Pelletier, MD2; Mpho Letebele, MD2; Tlhomamo Pheto1; Doreen Ramogola-Masire, MD6,7; Shenaaz El-Halabi, MPH1
