Each year nearly 3,000 women in Haiti contract cervical cancer. Just over half of those women will die as a result of the disease.
In an effort to combat that statistic, Zanmi Lasante (ZL) partnered with Haiti’s Ministry of Health in late 2009 to pilot the country’s first vaccination project for human papillomavirus (HPV)—the primary cause of cervical cancer. The project aimed to vaccinate 3,800 girls, between the ages of 10 and 13.
Cervical cancer is overwhelmingly a disease of the poor. For example, the annual mortality rate for the disease in poor countries like Haiti is 54 deaths for every 100,000 women—more than 30 times higher than in the United States. Nearly 80 percent of women who develop cervical cancer live in developing countries, with roughly 275,000 dying as a result of the disease each year. Almost all of these deaths are preventable.
While the HPV vaccine (Gardasil) can save many women’s lives, delivering it in developing countries—especially post-earthquake Haiti—is not without obstacles. Gardasil must be administered in three doses over a period of six months. Delivering multiple doses of a vaccine can be challenging because patients face difficulties in making follow-up visits. In addition, although studies have established a connection between HPV and cervical cancer, and the vaccination is widely available in the US, the virus is relatively unknown to most rural Haitians.
The large number of girls who volunteered to receive the first doses of Gardasil in December 2009 reflected the success of ZL’s education campaign in Cange, Boucan Carré, Mirebalais, and Laschahobas – facilities located throughout Haiti’s Central Plateau. In cooperation with schools, community leaders, educators, and local health teams, ZL raised awareness about cervical cancer, HPV, and the Gardasil vaccine in rural villages and larger towns alike.
After January 12, ZL staff realized it would be even more challenging to locate the 3,806 girls who had received the first dose of Gardasil, and administer the second and third doses. The earthquake strained all medical resources, some of the girls had been displaced, and schools that had hosted the vaccine program were closed or overwhelmed by displaced children.
But project leaders decided to proceed. Radio and community crieurs were used to encourage girls who had moved following the earthquake to return to their schools to complete the vaccination regimen. By the time the schools reopened in February, the ZL team administering Gardasil had already located most of the participating girls in schools within and around Boucan Carré, Mirebalais, and Lascahobas. In late February and early March, a one-week outreach effort in Central Plateau schools was launched, and the ZL vaccine team tracked down more girls who had withdrawn from school or moved after the earthquake.
The team administered the third and last dose throughout June, even though the process was delayed by vaccine shipping problems and changes to school schedules. As an extra incentive to the girls, ZL staff gave small gifts at the completion of all three doses. All of these efforts were successful. Of the 3,806 girls who received the first dose, 2,884 girls—over 75 percent—have received all three doses of Gardasil. This percentage is higher than rates reported in countries with far more resources, including the US. This success rate is especially notable as many girls had unpleasant, initial reactions to the vaccine: 47 percent of girls complained of pain and tenderness at the injection site in the first 15 minutes after they were vaccinated, and two cases of fainting were reported.
The ZL/MOH pilot program demonstrates that implementation of HPV vaccine is possible in rural Haiti, where cervical cancer affects a disproportionate number of women. PIH/ZL will continue to push for the broad scale implementation of HPV vaccine as an essential element of adolescent health care. However, a vaccination program must be part of a comprehensive strategy—the vaccine only protects against two types of HPV, responsible for about 70 percent of cervical cancer cases. Thus, the PIH/ZL team advocates vaccinations as a tool in a national cervical cancer program that should incorporate screening, vaccination, and treatment for all girls and women in Haiti.