Life Medical Zambia

Human Papilloma Virus Vaccination

The best laid schemes o’ mice an’ men / Gang aft a-gley.”  – Robbie Burns

WARNING: This may be interesting for you if you enjoy observing the trials and tribulations of logistical planning, but otherwise, it might be rather boring. Even the accompanying photographs.

The Ministry of Health’s plan was simple: vaccinate all 14-year-old girls and give them a booster a year later to provide protection against cervical cancer. Repeat annually with each cohort of young girls.

Now, vaccinating infants is easy; their mothers bring them along to our community clinics to be immunised. But how do you access teenage girls? The obvious answer is to vaccinate them in school.

Not all girls go to school, however, especially in rural areas.

And students change schools, moving to different locations, for a better education, often at age 14.

Then Covid-19 arrives and schools close down, completely wrecking your strategy.

“Can you help us boost our coverage, Dr Ian?” asked D, who is in charge of immunisation campaigns at the health centre. I agreed and asked to see what had been accomplished so far.

D handed me six huge registers, in which the teams had recorded the vaccinations, given at six local schools.

“What does this mean?” I asked, pointing to rows of children’s names where the column indicating the date of HPV vaccination was blank.

“I am sure that they have had the vaccine, we just didn’t record it.”

That sounded very odd. If you bother to record the name and village, why wouldn’t you add the date of vaccination. Even if you just put ditto marks in the column.

D with three girls waiting for their HPV vaccination

We did some investigating. It turned out that the vaccinating teams were understaffed, so they asked the teachers to write down the names of all the girls in their classes who were 14. But not all of these girls were at school on the day the vaccination team arrived, or had refused to have the vaccine.

“Did you not know about this, D?” I asked him. “Ah, doc, I didn’t vaccinate at this school.”

“Right, how many 14-year-old girls did you vaccinate last June/July?” I enquired.

D didn’t know exactly, but the nurse in charge said that he had reported 269 to the Ministry.

OK, so how many girls are recorded in the registers as having been vaccinated? He didn’t know, so we copied the information from the registers into an Excel workbook and counted 311.

“Why do you think there is a discrepancy?” D didn’t know and neither did the nurse in charge. “Perhaps you vaccinated 269 schoolgirls and 42 girls who were not attending school?” I suggested.

“How about coming at this problem from a different angle. How many doses of vaccine did you use last year?” I asked. D said that the Ministry of Health had collected all the unused doses in August 2019 at the end of the campaign, so he couldn’t check.

“But that was last year, doc. I am worried about this year,” D said.

“So what is your target?” I asked.

“All the girls we vaccinated last year who are now 15, plus the girls who have turned 14,” he replied.

“What’s your estimate of the numbers?” I asked. D said that the Ministry of Health had worked out how many doses we should have based on some ten-year-old census data uprated by the estimated growth in population.

“So, how many do you think this year?” I asked. D wasn’t sure and wouldn’t hazard a guess.

“Okay, we don’t have precise figures, but is it logical to assume that at least the same number of girls are born each year? We vaccinated 269 or 311 girls who were 14 last year, so we should be aiming to vaccinate that number plus a similar number of girls who turned 14 this year.”

“If you say so, doc.”

“Let’s say about 600. How many doses of vaccine did the Ministry of Health deliver to us?”

“We got 550 this year,” he said after checking the records.

“And how many doses are left?”

“About 300.”

 “Good, so we are about half way there,” I offered. “How did you manage to vaccinate so many when the schools were closed?”

“The students who are in their examination years are still attending school.”

We looked at the Excel spreadsheet, where 145 15-year-old girls had received their second dose and 88 14-year-old girls had received their first dose, during the past two months.

“So, what can we do now? How do we get to the girls who are not at school?” I asked.

“We can use our community health volunteers to mobilise them,” he said. “Then we can vaccinate them all in one day going from village to village.”

“But students don’t always go to the school nearest to where they live. They try to get into the best schools or they get rejected from other schools. We are lucky to have their villages recorded in the register.”

The prospect of trawling through six registers was daunting until I discovered that D had a database of all the villages in the health centre’s catchment area. There are ten neighbourhood health committees, each with a volunteer health worker. A bit of magic with Excel and we were able to print out a list of all the 15-year-old girls who were eligible for their second dose in each location. We delivered the list to each volunteer health worker. They had 48 hours to locate the girls on their list, plus any 14-year-old girls, and we would be along to vaccinate at a particular time.

He is not going to be vaccinated

Unfortunately, some volunteers were unable to identify any of their target population. Others had tracked down every 15-year-old. They could tell us where the girls had relocated: back to Lusaka, to a good school out of our area, or who had become pregnant. We only managed to vaccinate another 20 girls.

In one village, D said he had a message to the girls who had come for their vaccinations. “During this time of Covid, when the schools are closed, keep yourselves busy. Don’t give in to temptation and go with boys because you don’t have anything better to do.” I looked at the group of girls on the mat and thought that they looked like mature, young women.

I foresee that there will be a big rise in teenage pregnancies in 2021.

We still had hundreds of girls to vaccinate. I asked A, the other health inspector, what we should do. She said, “We should contact the girls.” But how? “Some way.” Yes, but how exactly? It’s no good just saying what you want to happen without a plan to make it happen.

“Give me some time, I will think about it,” said A. But we don’t have time. The Ministry will be taking back the vaccines in August as it assumes we will have successfully completed the campaign by then, regardless of the disruption of covid. I had a plan to use the local radio station to spread the word, but I wanted A to come up with that suggestion, so I could make her take ownership of the problem. With some unsubtle prompting, she thought using the radio station would be a good plan.

“Okay, what would you say on the radio, A?” She wasn’t sure, so I drafted a short statement about preventing the number one cancer affecting women in Zambia, how safe the vaccine was, who should have it, and the dates and locations we would be offering the vaccine over the next few weeks.

D stumbled while reading the statement in English, never mind translating it into Kunda, the local language. I suggested a female voice would go down better for a health message directed at girls and young women. A translated the piece and gave a seamless performance. We drove down to Radio Mhkanya and I sold the story to the station manager. “It will make a great two-minute news article,” I said. He agreed and A went next door to do the interview.

I asked the station manager about the catchment area of the radio and he told me it was about 50km in all directions. I asked D to inform his colleagues in other neighbouring health centres so they could deal with any surge in demand for HPV vaccine in the coming weeks.

A wearing her Manchester City shirt. She claims not to know a thing about soccer.

A came out beaming. She wanted to hear her voice on the radio, so the interviewer put headphones over her ears and played the clip back to her over the computer. She was delighted. Even D wanted to hear.

There was a spring in her step as she walked back to the car. She was a radio star; everyone would hear her voice on the news over the next 24 hours. Perhaps this will boost her performance at work, too.   

Footnote: Unfortunately, the radio broadcast has so far resulted in no eligible girls coming forward for vaccination.

Medical Zambia

Pesky National Holidays

Wild dog or Painted Wolf, chewing a kudu (antelope) leg

Zambia is awash with National Public Holidays in early March. Friday 8th was International Women’s Day and Tuesday 12th was National Youth Day. This put a spanner into our well-oiled community health programme.

The Ministry of Health has prioritised data collection for the planned Human Papilloma Virus (HPV) vaccination campaign, which begins in June 2019. This is an expensive vaccine which will protect against cancer of the cervix (as well as other cancers and genital warts) only if it is administered before the girls are exposed to the HP virus. Cancer of the cervix is the most common cancer among women who are living with HIV in Africa. There is no national cervical screening programme, so introducing HPV vaccination is a no-brainer.

On Thursday 7th March, we received orders to collect the names of all girls who would be aged between 14 and 15 at the start of the campaign. We contacted all the schools in the area but, as many girls do not attend school, we had to ask our community health volunteers to go house-to-house to collect this data.

A male kudu – not the one eaten by the wild dogs

The following day was a public holiday, so nothing happened.

Then it was the weekend. Nothing happened.

Following the three day weekend, Monday 11th March was extremely busy in the clinic, but we managed to distribute the forms to list the girls eligible for HPV vaccine. The following day was another public holiday, so nothing was done. The forms should have been completed for Wednesday 13th March, but the teachers had not managed to fill in the information. Nevertheless, a team from headquarters arrived to collect the forms, only to find that, like us, none of the four centres in the district had successfully collated the data.

So they planned to return on 14th March at 10am insisting that the data should be ready. A health worker used his own money to put fuel into a motorbike to collect all the data from the schools in the early morning to meet this deadline. The biggest school still hadn’t finished the data collection, but we were assured it would be done by midday. When we picked up the forms, the teachers had clearly not understood the meaning of a column marked “Age 14 years” and another “Age 15 years”, because they included every girl, regardless of age.

Domestic disagreement between vultures

This whole process made me feel despondent. The campaign is not scheduled to start for two and a half months, but because of two public holidays, we only had two days to make arrangements. The quality of data suffered as a consequence of unrealistic, unnecessary deadlines. Even more sad is the fact that Zambia is planning to vaccinate the wrong group of girls. Instead of providing three vaccinations over two months, the Zambian programme will provide two vaccinations a year apart (the immunogenicity of the vaccine is excellent, so it may be that this will generate adequate immunity).

In the UK, we give the vaccine to 11 and 12 year olds in school. One of the head teachers told us that the majority of girls in her school were sexually active by age 15. They even have pregnancies at school in children as young as 12. Girls aged between 12-16 who do not attend school are more likely to be sexually active, married or pregnant.

I contacted the District Health Officer to express my concerns about this and he agreed with me completely. Policy is made at the highest level in the Ministry without consulting grass roots health workers. It is too late to change the strategy. The vaccine isn’t cheap, so the country is wasting millions of kwacha targeting girls who are already likely to be infected with HPV and so will not benefit from the programme.

Rant over.

Cute child at the community clinic

Normally, the second Tuesday of the month is Chikosi’s community clinic. Because this was a public holiday, we informed the mothers that we would be coming on Wednesday instead. But people forgot and turned up late. One of the community volunteers was absent, so we asked a health centre volunteer to help out with the weighing. He rigged up the scales, hanging from a tree branch and started weighing the children.

Within ten minutes, the mothers were up in arms. All their children had lost weight since last month and they were not standing for that! I checked the scales to find that they had not been zeroed. The children were weighed again and the mothers were happy with their infants’ progress.

During the minor riot, I saw an infant (strapped to his mother’s back) attempt to capitalise on the confusion and suckle on another mother’s breast, deftly pushing her baby’s head aside. It reminded me of the behaviour of cuckoos. Or perhaps he just wanted to find out if milk tasted differently from different breasts. Enterprising little chap.

The public health inspector gave a long talk on interpretation of the weight chart (“Road to Health”) which documents average weight over the first five years of life. Unfortunately, the official charts have not been available since August 2018 when they went out of print. An enterprising local pharmacist photocopied the charts on blue and pink card, but charged the mothers 10 kwacha (=US $1). Most of the babies under six months of age have school exercise books with the vaccination schedule, de-worming, vitamin A supplementation, HIV checks, etc., all written by hand. But there is obviously no graphic representation, which made the talk on growth rates, centiles and danger zones rather academic.

Kojak – bald, lollipop-sucking detective. Selinge = syringe spelt phonetically by Zambians.

We had some more great names. It is common to combine two names into one – Izaister is Isaiah combined with Esther. Rolister is Rosa combined with Alister. I believe that “truncated concatenation” is the correct term. The public health inspector comes from northern province and is unfamiliar with the local names. He also finds it difficult to read the names written in English. When he struggles, I take over and spout “Mwukambwiko” fluently, much to the amusement of the mothers, who hoot with delight at the muzungu who knows more Kunda than the Zambian health worker.

Some children had missed out on their vitamin A booster a few months ago. The vitamin is an oily liquid in a soft capsule with a teat. I bite off the teat and squirt the oil into the child’s mouth at an opportune moment. It doesn’t taste of anything, but it has a greasy sensation in the mouth. I devised a cunning plan to have the child breast feeding, the mum takes the nipple out of the child’s mouth, I squirt in the vitamin and the child latches on again within a second. Seemless. I am still trying to get the oil stains out of my trousers, however.

Children are eligible for measles vaccine at nine months. Health workers use a crude month reckoner, but one mother pulled out her smart phone and did the precise calculation, demonstrating that her child just met the criterion to have the vaccine. We didn’t argue with her.

A little girl attending the clinic in her party dress, with socks and sandals, eating a fritter.

The date of the next clinic is not quite four weeks away, which is the interval between the first three vaccinations. Health workers like to stick to the official guidance for vaccination, because they will be criticised by supervisors if they don’t. But this was a tricky one. Do we vaccinate slightly early, do we defer the vaccination to the following month or ask the mothers to come to a different clinic location? Life is too short to worry about this, so I made an executive decision to ignore the slightly shorter interval. If their supervisor detects this deviation, they can always blame the muzungu doctor, who has by then left the Valley.