Authors: Lora Shimp, Technical Director, GAVI-NVI Project, and Heather Casciato, Program Manager, GAVI-NVI Project, May 4 2016 - This World Immunization Week [April 25] 2016, eyes are focused on countries' progress towards achieving the global immunization goals laid out in the World Health Organization’s (WHO) Global Vaccine Action Plan 2011-2020 (GVAP). One GVAP goal that the world is on track to meet is: 86 of at least 90 low- and middle-income countries have introduced one or more new or underutilized vaccines. Moving forward, it is critical to leverage this country enthusiasm and commitment to vaccine introduction, including with one of the world’s newer vaccines, Human Papillomavirus (HPV) vaccine. HPV vaccine protects women from the most dangerous strains of HPV that lead to approximately 70% of cases of cervical cancer in women worldwide[1].

In Madagascar, with funding from Gavi, the Vaccine Alliance and in partnership with the Malagasy government and its inter-agency partners, JSI provided technical support for the introduction of the HPV vaccine. Madagascar’s strategy with Gavi involved an initial 2-phase pilot, conducted from 2013 to 2015 in the urban district of Toamasina I and the rural district of Soavinandriana. In terms of meeting the goals and expectations, the pilot introduction was successful (i.e. exceeding the 50% pilot coverage objective). Based on the HPV pilot coverage survey (card and history for girls that received all 3 doses of HPV in the first year of the pilot), coverage was 61% and 69% for Toamasina I and Soavinandriana, respectively.  As with most pilots, it was also not without its challenges, particularly related to planning - as well as information sharing and acceptance - with various stakeholders and communities. The country is learning from this experience to develop its strategy for continued roll-out of HPV vaccination in the future.

Introducing HPV vaccine has special considerations, given that Expanded Program on Immunization (EPI) departments, including in Madagascar, have not typically been structured to reach a target population such as adolescent girls as part of routine services. Additionally, some of the vital actors involved with HPV vaccination (e.g., schools; programs that work with adolescents) have not previously been closely engaged in immunization activities. With the Ministry of Health and Family Welfare (MoHFW), the Ministry of Education (MoE), and many new and traditional partners all involved in the effort, Madagascar’s experience demonstrated how effective collaboration between stakeholders is critical to success - for overall planning and implementation as well as to quickly and diplomatically address and resolve sensitivities (e.g. if there is confusion on why the vaccination is being conducted in schools and with this target population).

As soon as the decision to introduce the HPV vaccine is made, an HPV pilot committee should identify and engage with a comprehensive list of people and groups who have access to and influence over the target population to garner their support, explain the rationale, and assist with addressing questions and any concerns. In addition to health staff and community health workers, these stakeholders will likely include many actors within the MoE system (e.g., school district leaders, public and private school directors, and teachers), as well as parents’ associations, community leaders, religious leaders, groups that work with adolescents, and local civil society and non-governmental organizations.

Here are seven key lessons  learned from Madagascar’s experience that HPV pilot committees need to consider when engaging stakeholders:

  1. The committee’s leadership should have a thorough understanding of the structure and chains of command for new partners outside of the usual immunization program. Appropriate protocols should be followed to include these partners and their key focal points in the planning and management of the respective aspects of the introduction process for which they have an influence.
  2. The pilot committee should ensure that adequate time is given to engage the different partners at all levels, so that they feel prepared to manage introduction activities that will affect them and have sufficient time to familiarize themselves and prepare to carry out their roles.
  3. It is important that community dialogues are conducted with the various influential leaders and community members and that they are engaged in disseminating information and promoting the vaccination activities. Their input should be sought when strategies are being developed for reaching the target population as well as when identifying critical messages and potential bottlenecks or challenges. Their support of the program will build the community’s confidence, and these community members should be enlisted to conduct targeted advocacy to prevent and/or address cases where there is vaccine resistance.
  4. Roles should be assigned to the appropriate stakeholders who have the most influence and direct involvement in implementing the vaccination strategy. For instance, while higher-level school administration needed to be informed and collaborate on providing approval to implement the vaccination strategy in Madagascar, it was the school directors and teachers who were most actively involved and who therefore need to have sufficient training and clarity about their roles.
  5. There should be sufficient training for all key players, well in advance, in addition to refresher trainings after each dose is administered to reduce the incidence of drop-out (i.e. girls not returning for subsequent doses). This is particularly essential during the pilot phase and initial introduction, but can potentially be scaled-down, once the vaccine is accepted and established in the routine system. In order to efficiently train the highest number of stakeholders, cascade trainings should be well-organized and followed-up on to ensure that capacity is built from the central level and effectively with lower levels.
  6. It is critical that sufficient time is allotted to the planning process (including trainings, development and dissemination of communications materials, and scheduling of vaccine administration), given the multiple stakeholders and the need for coordination between institutions that may not be actively providing health services.
  7. All relevant stakeholders providing leadership during the introduction should be recognized and treated equally in terms of input and compensation (notably the MoHFW, MoH and MoE partners at all levels).

Madagascar’s experience during its initial introduction of the HPV vaccine can serve as an example for other countries that are planning similar introductions. These lessons learned can help to guide the vaccine introduction planning, including considerations to facilitate coordination with multiple stakeholders and most effectively and efficiently reach the target population.

This World Immunization Week and beyond, let’s continue to build on knowledge and successes in new vaccine introductions such as HPV vaccination, so that more women across the globe can have the vital protection from cervical cancer that they need.
[1] World Health Organization, “Human papillomavirus (HPV),” 20 March 2016. [Online]. [Accessed 23 April 2016].

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