The single rising vaccine preventable disease in global public health affecting women in this day and age is cervical cancer.

Cervical cancer mostly results from an infection by the human papillomavirus (HPV). It is the most prevalent reproductive tract infection. Over a 100 types of HPV exist, 13 of which are cancerous. 70 % of cervical lesions leading to cancer result from HPV 16 and 18 (Human papillomavirus (HPV) and cervical cancer, 2018). 90 % of HPV infections can take up to two years to resolve. So, early vaccination before women become sexually active is the best approach to target this issue.

One woman in the world passes away from cervical cancer every two minutes. It is the second prevalent cancer in developed areas leading to 445,000 incidences affecting women worldwide (World Health Organization, 2018).

In 2012, the number of deaths from cervical cancer reached 270,000 and low and middle income countries were responsible for 85 % proving the presence of inequalities that exist in access to healthcare (Human papillomavirus (HPV) and cervical cancer, 2018). These deaths are expected to increase by 25 % in the next 10 years (Temmerman, 2014).

Two of the major WHO recommended guidelines in dealing with cervical cancer:

Administering HPV vaccines from the age of 9 to 13.

Health promotion campaigns. This is done by immunization education for adolescents, parents, teachers, leaders and health system workers (WHO, 2018).

In low and middle income countries, HPV vaccines haven’t been nationally implemented. Currently, Ghana is one of these countries (Gallagher, Lamontagne & Watson-Jones, 2018, pp.4761–4767).

For the purpose of this policy brief, screening for cervical cancer cases will not be discussed because the intervention to be implemented is the HPV vaccination of pre-adolescent girls in Ghana. There is little research done on the incidence of cervical cancer in young girls in Ghana. However, according to the American Society for Colposcopy and Cervical Pathology Consensus 2013 Guidelines, cervical screening should start at the age of 21 because cervical cancer incidences in this age group is low and screening methods aren’t as efficient under the age of 25. In a study by Boardman et al., 1 % of cervical cancer incidences occurred in women under the age of 20 in the United States from 1999 to 2008 – the rate was 0.15 per 100,000 females between the ages of 15 to 19 (Boardmanand Robison, 2013, pp. 257-268).

Why invest in Ghana?

Ghana has high rates of polygamy and no national cervical cancer screening, all of which increase rates of HPV infection due to multiple sexual partners (Edwin, 2010, pp.70–5).

In addition, engaging in sexual practices during adolescents has become more common in some regions of Ghana. Four out of ten girls aged 15 to 19 are sexually active and four out of ten 12 to 24 year old girls have had sex with multiple partners (Edwin, 2010, pp.70–5). 11.8 % of girls aged 15 in Ghana have already engaged in sexual practices (Information Center on HPV and Cancer, 2017).

In 2012, cervical cancer incidence was 32.7 % of all female cancers in Ghana (Binka, Teye Doku & Awusabo-Asare, 2017, pp. 1-12). It is one of the major prevalent cancer types and the most prevalent in Ghanaian women ranging in the ages of 15 to 44. In 2017, the incidence of cervical cancer was 3,052 with a mortality rate of 1,556 (Information Center on HPV and Cancer, 2017).

Between 2002 and 2003, 2.9 % of 18 to 29 year olds were getting screening for cervical cancer every 3 years (Information Center on HPV and Cancer, 2017). These numbers are very low proving that Ghana has opportunistic screening which means that not everybody can afford it, so introducing the vaccine nationally will decrease health inequities (Edwin, 2010, pp.70–5) ultimately saving lives in the future especially because 90 % of cervical cancer patients are diagnosed at late stages increasing mortality rates (Binka, Teye Doku & Awusabo-Asare, 2017, pp. 1-12).

According to sustainable development goal number three, all women should equally be provided with sexual and reproductive health care services including but not limited to education and universal access to vaccines for all. This goal also includes developing affordable vaccines and medicines for all (United Nations Sustainable Development Goals, 2018). With the support of GAVI, Ghana can be one step closer in achieving this goal.

In Ghana, an HPV vaccine demonstration project was approved for the years spanning 2013 and 2014; however, the vaccine wasn’t picked up for a national introduction. Thus, this policy brief aims to target this issue by applying the model used in Tanzania both of which are GAVI member countries. The two countries have similar socio-economic backgrounds:

• Tanzania’s gross national income of $ US920/capita.
• Ghana’s gross national income of $ US 1480/capita (GAVI the vaccine alliance, 2018).

Policy to be implemented (A primary prevention program) Providing HPV vaccines to girls aged 9 to 13 by nationalizing the vaccine through:

1)    Community meetings with stakeholders such as religious leaders for sensitization to prepare the public to gradually start to accept vaccine benefits.

2)    Workshops that target rural areas about health benefits.

3)    Providing teaching sessions to health care workers.

4)    Allocation of material resources (vaccine price with shipment and storage).

5)    Implement mass media campaigns including posters in schools, television advertisements, and interviews with media personnel (Hutubessy et al., 2012, p.136).

Funding

Vaccine costs are one of the challenges faced by low and middle income countries because prices range from $15 to $130 for each dose. The GAVI Alliance has developed a new scheme to provide the HPV vaccine to its member countries for about $5 per dose (Hutubessy et al., 2012, p.136) and by doing so, it can prevent 90 % of cervical cancer cases (Kim, Jane J. et al., 2013, pp.F60–F72).

According to a study by Kim et al. (2013), cervical cancer incidence (by age standardized incidence rate) in Ghana was 39.5 with 23.66 cases prevented in 1000 vaccinated and a total of 17,270 DALYs prevented for a GDP of 1,469 per capita (Kim, Jane J. et al., 2013, pp.F60–F72) (see appendix 4). This proves that introducing the vaccine is cost-effective.

So, by applying the model used in Tanzania, a vast majority of girls get vaccinated and DALYs are reduced all within cost-effective ranges.

Tanzania Model

The WHO collaborated with the Ministry of Health and Social Welfare and a plan was set to initiate HPV vaccine dissemination in the country. This was made possible by the Cervical Cancer Prevention and Control Costing tool which the WHO employed to determine the costs of the program, how to plan the interventions and the supplies required to deliver the vaccine over five years. In return, the ministry consented to receiving the vaccine for free for three years by GAVI. Tanzania’s approach was school-based; it covered 3 areas in the first year, 10 in year two and 26 in the remaining years. The ministry trained health care workers, had “sensitization” summits with society members and involved the media to disseminate information about health benefits. The program plan constituted of four school visits to be able to vaccinate all girls. (Hutubessy et al., 2012, p.136).

The program between 2011-2015 cost: (See appendix 1, 2 and 3)

$9.2 million without vaccines ($5.77 per fully immunized girl)

$ 31.5 million with the vaccines

The total program cost $59 million over the total of 5 years including the cost of all the necessary resources (Hutubessy et al., 2012, p.136.).

Since both Ghana and Tanzania are low to middle income countries, dispensing the vaccine nationally in Ghana as was done in Tanzania will be financially feasible.

Barriers and Facilitators

1) Inadequate health service infrastructure for program delivery: Common obstacles are the strict cold chain requirements of the vaccine and vaccine prices; however financing agents such as GAVI would help in funding. Another obstacle would be school girl absenteeism which will be targeted by 4 school visits that will aim to vaccinate all the girls (Wigle, Coast & Watson-Jones, 2013, pp. 3811-3817).

2) Political factors: Politicians might prioritize funding to other less costly vaccines that have short term benefits rather than long term ones such as rotavirus vaccine. Also, their objectives might be to achieve millennial development goal number 4 and decrease the mortality rate of children under five and thus not focus on adolescent health (Wigle, Coast & Watson-Jones, 2013, pp. 3811-3817).

3) Encouraging earlier sexual relations: 50% of Ghanaian women believed that vaccination will lead their daughters to start having sex at a younger age and that the vaccination might affect fertility rates of the girls receiving them (Coleman, Levison & Sangi-Haghpeykar, 2011, pp. 3945–3950). However, this problem can be averted by introducing the vaccine to the population as a preventer of cervical cancer and not a preventer of sexually transmitted diseases. Moreover, by incorporating the vaccine in the national program, most girls will be immunized and eventually less stigma will surround the issue of vaccination at an early age (Edwin, 2010, pp.70–5).

4) Lack of Knowledge: Women in Ghana are well-informed about cervical cancer; however, less is known about HPV vaccines. 77% of women were even concerned about possible side effects (Coleman, Levison & Sangi-Haghpeykar, 2011, pp. 3945–3950). Thus, all the stakeholders must be involved to ensure program application through encouragement about benefits of immunization by physicians, religious leaders and teachers.

Similar barriers were found in a Tanzanian study. Parents, female pupils, teachers, health workers and religious leaders in Tanzania were knowledgeable of cancer but not of cervical cancer, HPV and HPV vaccinations. The majority of participants stated that they will vaccinate their daughters; however, some were apprehensive of infertility and side effects (Remes et al., 2012, pp. 5363-5367). This proves that both populations had similar concerns because of similar attitudes. Thus, the transition of the program to Ghana is a realistic expectation.

This project will help Ghana invest in the future health of Ghanaian women by reducing HPV and cervical cancer cases moving one step closer to achieving sustainable goal number three.

References

• Bernard, V.B., Watson, M., Castle, P.E., Saraiya, M. (2012) Cervical carcinoma rates among young females in the United States.
  
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• Binka, C., Teye Doku, D., & Awusabo-Asare, K. (2017) Experiences of cervical cancer patients in rural Ghana: An exploratory study.
  
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• Boardman, L.A., Robison, K. (2013) Screening Adolescents and Young Women,
  
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• Coleman, M.A., Levison, J., & Sangi-Haghpeykar, H. (2011) HPV vaccine acceptability in Ghana, West Africa.
  
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• Edwin, A.K. (2010) Is routine human papillomavirus vaccination an option for ghana?
  
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• Gallagher, K.E., Lamontagne, D.S., & Watson-Jones, D. (2018) Status of HPV vaccine introduction and barriers to country uptake.
  
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• Hutubessy, R., Levin, A., Wang, S., Morgan, W., Ally, M., John, T., Broutet, N. (2012) A case study using the United Republic of Tanzania: costing nationwide HPV vaccine delivery using the WHO Cervical Cancer Prevention and Control Costing Tool.
  
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• Remes, P., Selestine, V., Changalucha, J., Ross, D.A., Wight, D., Sanjose, S., Kapiga, S., Hayes, R., Watson-Jones, D. (2012) A qualitative study of HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania.
  
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• Temmerman, M. (2014)
  
  Address inequality: prevent cervical cancer
  
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Appendix 1: Financial Costs of Introducing HPV Vaccine in Tanzania, 2011-2015 (2011 US$) (Hutubessy et al., 2012, p.136).

Activity/Year Number of regions	2011 3 regions	2012 10 regions	2013 26 regions	2014 26 regions	2015 26 regions	Total
Price of vaccine with delivery and wastage	132,880	552,459	963,346	10,162,160	10,491,906	22,302,751
Training workforce, cost of their travels to meetings and hall leases	140,489	203,783	298,912	–	–	643,184
Social mobilization and Information Education and Communication	191,431	472,009	941,007	661,853	668,039	2,934,340
Service Delivery: workforce cost and transportation	97,907	393,447	754,040	754,040	754,040	2,753,473
Monitoring, Evaluation and Supervision (documents, immunization cards	50,181	97,191	171,731	171,731	171,731	662,564
Other (waste management)	72,972	312,303	583,713	602,214	619,534	2,190,735
Totals	685,860	2,031,190	3,712,749	12,351,998	12,705,250	31,487,047

Appendix 2: Financial and economic cost per dose and per fully immunized girl without and with vaccine costs (2011 US$) (Hutubessy et al., 2012, p.136).

	Without vaccine		With vaccine
	Financial Cost	Economic Cost	Financial Cost	Economic Cost
Cost per dose	1.66	3.56	5.68	10.62
Cost per Fully Immunized Girl (65 % coverage)	5.77	12.40	19.79	37.01

Footnotes: coverage rates for girls age 10 is 85%, 77% and 65% in the 1st, 2nd and 3rd round, respectively

Appendix 3: Financial Costs of Introducing HPV Vaccine through school- and health facility-based strategies in Tanzania, 2011-2015 (2011 US$) (Hutubessy et al., 2012, p.136).

	Delivery strategy: School-based	Delivery strategy: Health facility- based
Age of target population Number of girls in target population	10 years 605, 000	10 years 605, 000
Introduction costs per eligible girl	3.07	3.07
Recurrent cost per dose	1.59	1.17
Recurrent costs for three doses per eligible girl	4.78	3.51

Country (Both GAVI eligible)	Cancer Incidence Age-standardized incidence rates (per 100,000 persons)	Prevented cases per 1000 vaccinated	DALYs prevented (3 % yearly reduction)	Per capita GDP (is 2010 value in 2005 I$: International dollars	ICER (I $/DALY averted) Incremental cost-effectiveness ratio
					Cost per vaccinated girl including all resource costs (cost per dose)
					I $5 ($0.55)	I $ 10 ($2)	I $25 ($ 5)	I $ 50 ($12.25)	I $ 75 ($19.50)	I $ 100 ($26.75)
Ghana	39.5	23.66	17,270	1,469	Cost saving (CS) compared to no vaccination Cost saving	<100	200	500	800	1,100
Tanzania,	50.9	25.84	41,200	1,286		CS	200	400	700	1,000

Appendix 4: Cost-effective analysis of HPV 16/18 vaccine (Kim, Jane J. et al., 2013, pp.F60–F72).