South Africa becomes a 'poster child' for eliminating cervical cancer

Cervical cancer is the main cause of cancer-related deaths among women in South Africa, with an estimated 10,000 South African women diagnosed with the disease and more than 5,000 dying of the condition each year. But a partnership between the country’s ministries of health and basic education has produced one of the continent’s most ambitious programs to drive down these numbers and save lives.

“South Africa’s self-funded HPV (human papillomavirus) vaccination program is a poster child for what a middle-income country can do to reduce the risk of this disease,” said Dr. Edina Amponsah-Dacosta, a researcher at the Vaccines for Africa Initiative. “South Africa’s national program, which has been sustained for almost a decade, is impressive.”

The country, one of the first on the continent to roll out a national vaccination campaign for HPV, the leading cause of cervical cancer, has achieved and maintained vaccination coverage rates of roughly 70% to 80% from its launch in 2014 to just before the program was disrupted by COVID-related school closures in 2020. Long-term global studies have shown an almost 90% reduction in cervical cancer in girls who receive the vaccine.

As health leaders around the world respond to a call by the World Health Organization (WHO) to adopt HPV vaccination programs as part of a broader strategy to eliminate cervical cancer, South Africa’s experience could hold lessons for other countries.

Key to the school-based vaccination program’s success has been a partnership between the ministries of health and basic education. In 2012, the ministries jointly established the Integrated School Health Program to implement school-based health initiatives, such as screening for learning disabilities. Two years later, in 2014, the ministries tapped the Integrated School Health Program to begin rolling out the HPV vaccine to 9-year-old girls in grade four in more than 12,000 public schools across the country. The effort relies on school nurses supplemented by a surge workforce of hundreds of vaccinators to visit every single primary school twice each year.

Another key to success, said Dr. Lesley Bamford, a child health specialist with South Africa’s Ministry of Health, is the program’s earmarked funding, which prevents it from being used for anything other than HPV vaccinations.

To boost support, health leaders have been framing the vaccination as a powerful cancer prevention tool. “We always present it as a cancer prevention effort,” said Dr. Bamford. “There are concerns among some in South Africa that if the vaccination is framed … as protection against a sexually transmitted disease, it might encourage risky behavior. We want to sidestep that debate and focus on the vaccine’s proven efficacy in preventing cancer.”

Monitoring and evaluation efforts have also helped South Africa’s HPV vaccination program shift to respond to challenges as they arise. For example, early on, vaccinators reported that many of the girls in grade four were not yet 9 years old and therefore not eligible for the vaccine. This reflects a practice common across South Africa where parents enroll their children in school a year early. In response, the South African National Advisory Group on Immunization recommended pivoting the HPV vaccination program to adolescent girls in grade five, so they could be sure that all girls in that grade were in their target population, having already turned 9. This pivot, made when schools reopened after the COVID-19 pandemic, ensured that girls who were in grade four when schools closed during the pandemic and went unvaccinated received their HPV vaccine when schools reopened and they joined grade five.

Still, the country is struggling to reach the WHO’s target of 90% vaccination rate by 2030.

Experts say part of the challenge may be South Africa’s approach to parental consent. Currently, when parents enroll their children in school each year in South Africa, they are presented with a stack of papers to fill out and sign. Usually, among those papers is a consent form that gives health and school officials permission to vaccinate their child. South African leaders say including the consent form with school registration forms increases the likelihood that it is signed and returned.

But if the form is not signed and returned, follow-up by school officials varies and largely reflects the capacity and priorities of each local school. Conversely, in Rwanda, the only country on the African continent that has achieved higher HPV vaccine coverage, staff from the local health facility follow up with any parent who doesn’t respond to the request for permission.

Researchers have also suggested that “declining public demand for the HPV vaccine may be a result of weakening social mobilization over time, inadequate reminder and tracking systems, and vaccine hesitancy.”

South Africa’s health leaders are currently examining the data on this. “We have found that although COVID has undermined trust in health systems, people still trust teachers,” said Dr. Bamford. “The research shows that people want to hear about health information from people they trust."

In an effort to reach the WHO’s target of vaccinating 90% of 9-year-old girls, South Africa’s vaccination program will likely be expanded to include private schools, said Dr. Bamford. Approximately 5% of South Africa’s young people study in private schools.

But even if successful at reaching these girls, South Africa will come close to, but ultimately miss the WHO’s target. South Africa’s health leaders are looking for other ways to streamline the program and maximize impact while staying within their budget. The South African government fully finances its own HPV vaccination program without donor support.

In response to new research showing that a single dose of a HPV vaccine is as effective at preventing cervical cancer as the traditional multiple doses, the government’s National Advisory Group on Immunization, a panel of experts appointed by the minister of health, will consider switching to a single-dose regimen that would simplify and reduce the costs of the immunization campaign.

Meanwhile, South Africa’s health leaders see the infrastructure they have established with the HPV vaccination program as the foundation for a “comprehensive adolescent vaccination campaign,” said Dr. Bamford. “Because this is a population that doesn’t access health systems regularly, this school-based system we have established will be a particularly effective channel for delivering essential healthcare.”

South Africa has already expanded the school-based adolescent vaccination program to include Td (Tetanus, Diphtheria) in addition to HPV vaccines and will begin offering Tdap (Tetanus Diphtheria Pertussis) in the coming years.

South Africa is one of about 125 countries that have introduced HPV vaccine schemes. Globally, just one in eight girls receive HPV vaccinations. There is great urgency in South Africa to ensure coverage, as a growing body of research indicates that cervical cancer is not only more common in women who are HIV positive, but also more deadly. Indeed, cervical cancer is the leading cause of cancer deaths in women in sub-Saharan Africa. The WHO recommends that girls receive the vaccine before they become sexually active and exposed to HPV. Girls who are sexually active may get less benefit from HPV vaccination.

Thanks to the WHO’s Cervical Cancer Elimination Initiative, adopted by the World Health Assembly in 2020, a growing number of countries are expected to eliminate cervical cancer caused by the human papillomavirus, including Rwanda and Bhutan. The disease is currently the fourth most common form of cancer among women worldwide and claims an estimated 300,000 lives each year.