How school-based vaccinations put Rwanda and Bhutan on course to stamp out cervical cancer

Rwanda and Bhutan have emerged as global leaders in vaccinations against human papillomavirus (HPV) to prevent cervical cancer – with both countries reaching vaccination rates at or near 90%.

After sustaining high rates of vaccination for more than a decade – their coverage rates are higher than those of the United Kingdom and the United States – both countries are on track to eliminate human papillomavirus, the leading cause of cervical cancer. Their experiences offer key lessons for health leaders since Rwanda and Bhutan both follow a similar cost- effective, efficient, and data-driven model.

To start with, both countries launched national, school-based vaccination programs. Bhutan was the first low- or middle-income country to implement a national HPV vaccination program in schools, launching its program in 2010. Rwanda followed the next year.

School-based programs require partnership across the ministries of health and education and can cost more than health center-based programs. But the evidence suggests their reach is unparalleled. “Vaccinating for HPV in primary schools is a winning strategy,” said Dr. Iacopo Baussano with the International Agency for Research on Cancer, who supported both governments in monitoring the impact of their vaccination campaigns.

Rwanda’s experience is particularly instructive. When schools shuttered because of the COVID-19 pandemic, the country's technical working group – which manages the HPV vaccination effort and includes representatives from the ministries of health, education, and gender and family – quickly shifted from a school-based system to one reliant on health centers and community health workers. Vaccination coverage rates dropped from over 90% to below 80% from 2019 to 2021. In response, health leaders went back to the school-based model as soon as schools reopened in August 2021.

“Because older children do not routinely visit health facilities, vaccination programs based in health facilities struggle to reach them,” said Dr. Edina Amponsah-Dacosta, a researcher at the Vaccines for Africa Initiative. “When schools are open, primary school-based delivery is most effective because you can find the overwhelming number of girls right at their desks.”

This is especially true in countries like Rwanda, where an overwhelming majority of girls, 95%, attend primary school.

To minimize costs and leverage existing infrastructure, school-based vaccination programs can be rolled into existing school-based health programs such as those for deworming, the provision of nutritional supplements, and vision and hearing screenings, said Dr. Amponsah-Dacosta. To reach out-of-school girls, community health workers and other channels must be leveraged, which carries an additional expense.

Both Rwanda and Bhutan also engaged in community mobilization and outreach to girls, parents, and community leaders and have sustained that mobilization for more than a decade, framing the vaccine as a powerful cancer prevention tool.

“Rwanda’s campaigns include speeches by health officials and local government officials, announcements in newspapers, radio, and magazines, and texts and phone calls to parents,” said Patrick Munezero, who formerly worked with the Rwandan Ministry of Health and today supports the Ministry’s HPV vaccination program as a senior analyst with the Clinton Health Access Initiative. “Even teachers are educated about the HPV vaccine, with visualization tools created by the Ministry of Health, so that they can communicate about it to parents and students.”

In the case of Rwanda, community health workers, who know all the families and children in their villages, visit the families of 12-year-old girls in advance of the bi-annual vaccination campaign to educate them about what to expect. If the parents fail to provide consent, staff from the local health facility call them, following the same protocol as outreach for the standard childhood vaccinations, such as polio. This approach helped Rwanda’s school-based program reach 97% coverage within just two years of launch.

Dr. Baussano noted another similarity between Rwanda and Bhutan’s programs – health leaders in both countries did not get drawn into a debate over whether to spend money on vaccinating young children with the standard childhood vaccines or vaccinating older girls for HPV. “This is a false choice,” said Dr. Baussano. “If you save her from polio or diarrhea when she is a toddler, you don’t want her to die when she is 40 from cancer. You want her to live her full lifetime. You need a lifetime vision of her health. And a lifetime vision of health must include HPV vaccination.”

Lastly, both Bhutan and Rwanda included long-term measurement and evaluation systems from the start of their vaccination programs. This is also an additional expense, but has multiple payoffs, said Dr. Baussano. It allows the country to track progress. It also allows government officials who lobbied for the program, and allocated precious funds, to demonstrate impact and “become a champion,” said Dr. Baussano. “They can be rewarded for their commitment when monitoring activities capture the impact and give them information about the lives saved.”

So far, long-term monitoring of HPV vaccination programs in low- and middle-income countries has lagged behind the monitoring of other infectious diseases. In part, said Dr. Baussano, that is because people don’t think of cervical cancer as an infectious disease and also because of the long time-horizon required to follow the impact of the HPV vaccine. Giving a girl the HPV vaccine when she is 10 or 11 will protect her from cervical cancer a decade or two later.

Dr. Baussano and his fellow researchers have found that HPV vaccinations of girls in Bhutan have already reduced the prevalence of the particular strains of HPV targeted by the vaccine by up to 88%. The reduction in prevalence measured in Rwanda has been slightly smaller than the impact measured in Bhutan. More broadly, studies have shown an almost 90% reduction in cervical cancer in girls who receive the vaccine.

About 125 countries have introduced HPV vaccines. Globally, just one in eight girls receive HPV vaccinations. That number looks poised to climb significantly in the next few years as health leaders recognize the powerful tools available for prevention, screening, and treatment of cervical cancer, and new research demonstrating that a single dose of HPV vaccine is as effective at preventing cervical cancer as multiple doses.

At the World Health Assembly in 2020, the World Health Organization (WHO) set a goal of 90% coverage by 2030. The WHO recommends that girls receive the vaccine before they become sexually active and exposed to HPV. Girls who are already sexually active may get less benefit from the vaccine, which is why governments are generally delivering the vaccine to pre-pubescent girls.

Both Rwanda and Bhutan, with support from Gavi, the Vaccine Alliance, have been administering two doses of HPV vaccine as part of their routine immunization programs. The two countries are widely expected to become among the first countries in the world to eliminate cervical cancer caused by the human papillomavirus. The disease is currently the fourth most common form of cancer among women worldwide and claims an estimated 300,000 women’s lives each year.

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