The East African country’s campaign to end cervical cancer through the HPV vaccine has had to overcome cultural taboos and rumours about infertility – but it’s saving lives.

Rwanda’s economy and history also made it seem an improbable candidate for achieving high HPV vaccination coverage. After the 1994 genocide, it was ranked as one of the poorest countries in the world. High-income countries had only achieved moderate coverage of the HPV vaccine; if the United States and France couldn’t achieve high coverage, how could Rwanda?

It was an ambitious goal. Cervical cancer is the most common cancer in Rwandan women, and there were considerable cultural barriers to the vaccination programme – HPV is a sexually transmitted infection and talking about sex is taboo in Rwanda. Added to this, rumours that the vaccine could cause infertility made some parents reluctant to allow their daughters to be vaccinated.

This was the first time an African country had embarked on a national prevention programme for cervical cancer. Could Rwanda become the first country in Africa to eliminate it?

Three years before, Rwanda had decided to make preventing cervical cancer a health priority. The government agreed a partnership with pharmaceutical company Merck to offer Rwandan girls the opportunity to be vaccinated against human papillomavirus (HPV), which causes cervical cancer.

Girls began queuing at their local school with their friends, waiting for their names to be called. Many were apprehensive. After all, most of them had not had a vaccination since they were babies. It was 2013 and a new vaccine had arrived in Kanyirabanyana, a village in the Gakenke district of Rwanda. Reached by a reddened earth road, the village is surrounded by rolling hills and plantations growing crops from bananas to potatoes. Unlike the 10 vaccines already offered to young children as part of the country’s immunisation programme, this vaccine was different: it was being offered to older girls, age 11–12, in the final year of primary school.

Worldwide, cervical cancer is the fourth most common cancer in women. There were an estimated 570,000 new cases in 2018 – and over 310,000 deaths, the vast majority in low- and middle-income countries. Sub-Saharan Africa has lagged behind the rest of the world in introducing the HPV vaccine and routine screening, which means the cancer often isn’t identified and treated until it has reached an advanced stage. Almost all cases of cervical cancer are caused by HPV. It is one of the commonest sexually transmitted infections globally, and most of us are infected with at least one type of genital HPV at some point in our lives – usually as teenagers or young adults. In most cases the virus is harmless and resolves spontaneously without causing any symptoms such as genital warts. There are more than 100 strains of HPV, at least 14 of which can cause cervical cancer and a range of less common cancers, including of the penis, vagina and anus. Persistent infection with two strains of HPV, 16 and 18, is responsible for 70 per cent of cervical cancer cases. The first vaccine against HPV became available in 2006. This was the culmination of decades of work, notably by scientists in Germany, who in 1983 discovered the link between HPV infection and cervical cancer. Ian Frazer and Jian Zhou at the University of Queensland, Australia, then jointly developed the technology that enabled the HPV vaccine. Using recombinant DNA technology, they built the shell of the virus from scratch and made an ‘empty’ human papillomavirus in the lab. “This was something nobody had achieved before,” Frazer says. They realised this empty, non-infectious HPV could be used as a vaccine to prevent HPV and cervical cancer. The news that there was a new vaccine which could drastically reduce the number of women getting cervical cancer went around the world. But with the excitement about the new vaccine came the realisation that not all girls would have the same opportunity to receive it. It was likely that at least a decade would pass between its introduction in high-income countries and in low-income countries. Today there are three HPV vaccines – Gardasil and Gardasil 9, made by Merck, and Cervarix, made by GSK. All are highly effective at preventing infection with virus types 16 and 18. The newest – Gardasil 9 – was licensed in 2014 and protects against nine types of HPV, which between them cause around 90 per cent of cervical cancers.

© Shonagh Rae at Heart Agency More than 800,000 people died in the Rwandan genocide, and its widespread destruction left the country devastated. Coverage of most World Health Organization-recommended childhood vaccinations plummeted to below 25 per cent. But within 20 years, the number of babies in Rwanda receiving all recommended vaccinations, such as polio, measles and rubella, had increased to around 95 per cent. Rwandans’ life expectancy more than doubled between 1995 and 2011. The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV? Before the HPV vaccine arrived in Kanyirabanyana, 63-year-old Michel Ntuyahaga, a community health worker, spent weeks canvassing his village, going to each of the 127 mud-brick houses to inform parents about the upcoming vaccination campaign. Joined by a nurse, he explained to parents that if they had an adolescent daughter, they had an opportunity for her to be vaccinated against a deadly women’s disease – cervical cancer. “I explained to parents that the cancer is a disease and that the one measure to prevent it is vaccination,” he says. Ntuyahaga wasn’t the only person educating the community about the vaccination campaign. Constantine Nyiransengiyera has been a primary school teacher in Kanyirabanyana for the past 13 years. In addition to teaching maths, science, French and English, she was – and continues to be – responsible for gathering all the 12-year-old girls at the local school to educate them about the HPV vaccine. Silas Berinyuma, a leader in Kanyirabanyana’s Anglican church for the past 24 years, preached about the importance of the vaccine for weeks before it arrived in the village. The church used drama to depict scenes of cervical cancer’s devastating impact. This continues today. The same awareness campaign was taking place around the country – Rwanda has a network of 45,000 community health workers, volunteers who are present in every village. Bugesera is a district in the Eastern Province, not far from the border with Burundi. Billboards line roads through the district, advertising soft drinks alongside public health messages. One says: “Talk to your children about sex, it may save their lives.” Not far off the main road is Karambi, a village surrounded by banana plantations. Toddlers roll tyres down the red-earth roads, teenagers carry handfuls of firewood on their heads, and adults herd cows and goats. In 2013, the then 12-year-old Ernestine Muhoza was vaccinated against HPV at her school. “The teachers called just girls for assembly and told us that there was a rise of a specific cancer among girls aged 12 and that it was time for us to get vaccinated,” she says.

The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV?