Copyright aljazeera
In September, Pakistan launched its first-ever national human papillomavirus (HPV) vaccine campaign, aiming to immunise more than 13 million girls aged nine to 14 in its first phase. HPV is the most common cause of cervical cancer, which kills eight Pakistani women every day, according to Dr Dapeng Luo, the head of the World Health Organization (WHO) in Pakistan. The United Nations health agency has set a goal of eradicating cervical cancer globally by 2030. But the vaccine has met resistance in Pakistan, as conspiracy theories about inoculations have circulated. Here is more about what HPV is, how it causes cervical cancer, and why the vaccine rollout in Pakistan has faced a backlash. What is HPV and what are the symptoms? HPV is a common group of viruses that enter the body via skin-to-skin contact, typically through a cut or abrasion. There are more than 100 types of HPV, and they are often spread through sexual contact. Infection can be hard to identify because many people who have contracted an HPV have no symptoms at all, and it can take many years for cancer to develop. Some types of the virus eventually cause warts on the genitals or other parts of the body. These may appear flat or bumpy. How does HPV cause cervical cancer? More than 95 percent of the 660,000 cervical cancer cases recorded each year worldwide are caused by HPV, according to the WHO. In Pakistan, more than 5,000 new cases of cervical cancer are reported every year, it said. Some strains of HPV can cause different types of cancer, such as cervical cancer, vulvar cancer or vaginal cancer. However, cervical cancer typically develops 20 years after the onset of the HPV infection. While the body’s immune system can clear away many strains of HPV within two years of infection, certain strains are more persistent. When the body’s immune system is unable to fight off the more persistent HPV strains, the virus interferes with normal cell growth, causing cells to become abnormal and potentially leading to a pre-cancerous state. If this is left untreated, cancer can develop. Sufferers of cervical cancer do not experience symptoms in its early stages. Hence, women aged 30 to 65 are advised to have a pap smear every three years, according to the Mayo Clinic. How have vaccines been rolled out in Pakistan? Pakistan’s HPV vaccine campaign began on September 15. While the first phase was scheduled to run until September 27, it was later extended to October 1. Some 49,000 government health workers – all women – have been trained by the WHO to administer the vaccines across the country. The WHO and Pakistan’s government partnered to conduct this training with funding support from GAVI, the Vaccine Alliance, a public-private partnership that works to improve access to immunisations. In advance of the first phase, vaccine centres were set up in public buildings such as schools. Health workers also went door-to-door to administer the HPV vaccine. A single dose of Cecolin, an HPV vaccine developed in China, was administered free of charge. While most HPV vaccines require either two or three doses, WHO confirmed in October last year that Cecolin could be used as a single dose. In the first phase of the rollout in Pakistan, girls between the ages of nine and 14 from Sindh, Punjab, Pakistan-administered Kashmir and the Islamabad Capital Territory received the single-dose vaccine. Pakistan’s federal health minister, Syed Mustafa Kamal, said at a launch ceremony for the vaccine on September 16 in Islamabad, “I urge all parents to ensure their daughters and sisters are vaccinated. Do not fall prey to negative campaigns. This vaccine is safe, effective and essential for protecting our girls.” Kamal told Al Jazeera that when the vaccine campaign started, there was a lot of criticism and scepticism towards it. “A few unknown people had spread some fake videos and fake information.” He said that during the first four days of the campaign, the response to the vaccine was negative. “The refusals were very high, so much so that there are schools which had committed before [to serve as vaccination centres], but refused our workers entry into the school.” On the fifth day, Kamal got his own daughter publicly vaccinated during a ceremony at the Drug Regulatory Authority of Pakistan (DRAP) office in Karachi. During the event, Kamal told journalists: “I have never brought my family into the public eye in my 30-year political career. But to put an end to these baseless rumours, I have taken this step.” He said that after this, the refusals went down and acceptances went up. He added that this upward trend of acceptance and vaccine administration continued till the end of the campaign. “It was noticed that after clarifying rumours, people started to get vaccine. Especially, schools were requesting to send teams as parents were agreeing to get their daughters vaccinated,” Dr Azra Fazal Pechuho, the health minister of Sindh province, told Al Jazeera in a written statement. The initial reluctance is why, she said, the vaccination campaign was extended by four days. What is Cecolin? The Cecolin vaccine does not contain the live HPV virus. Instead, it contains recombinant L1 capsid proteins, laboratory-made proteins that mimic the outer shell of the virus but do not have any viral DNA and therefore cannot cause infection. Other countries have used the US-manufactured Gardasil HPV vaccine, which also does not contain the live HPV virus and contains recombinant L1 capsid proteins. Why is the vaccine only being given to girls aged nine to 14? The government says that this particular age group of girls was selected per the recommendations of the WHO’s National Immunisation Technical Advisory Groups (NITAGs), responsible for providing evidence-based recommendations for immunisation. “As per WHO, the immune response generated by the body after the vaccine jab is maximum at this age of 9-14 years, and the child gets the best and long-term protection. Hence, this particular age group,” Pechuho said. “Currently, the vaccine is available free of cost for 9-14-year-old girls only. There have been talks at the federal ministry level to make this vaccine available commercially so others [boys, women and teenage girls, etc] can benefit, as well.” What do recipients of the vaccine say about it? In September, Sana Ali Manzoor and her husband – who say they are strongly in favour of vaccinations for their children – took their 11-year-old daughter to be vaccinated at her private school campus in Karachi after school hours. The whole process took about 20 minutes. Manzoor said she heard about the vaccine rollout via a mobile application operated by her daughter’s school, Haque Academy, which is located in the upmarket neighbourhood of Defence Housing Authority. Parents were invited to register on the mobile app and accompany their children for the vaccination. Manzoor, a lactation specialist who supports new mothers, said approximately 30-40 other children were also present when her daughter received her vaccination. “So we went to school, and there were two or three tables set up. The health workers were there. They first checked if our name was on the list. After that, we went and got the vaccination done. And then right after that, there was a manual card entry filling that was done, then they gave us the card.” She described the process as “very organised”. Manzoor says she was encouraged by friends, including a paediatrician and a gynaecologist, to get the HPV vaccine for her daughter. She has also had her children vaccinated against chickenpox, which she travelled to Dubai to get. How successful has the vaccination drive been so far? The rollout has not hit its target, authorities say — though they insist that despite this, the campaign counts as a success. “Around 13 million girls were supposed to be vaccinated in the first phase of the HPV vaccine campaign. So far, 9.2 million have been vaccinated, which is 78 percent of the total target,” Pechuho said. In the southern province of Sindh, the estimated target for the HPV campaign was 4,081,279 girls. Sixty-six percent of the total target was reached, with 2,674,210 girls vaccinated. The low take-up is down to a general hesitancy towards vaccines in Pakistani society, experts say. Compounding this, specific concerns about the HPV vaccine have been fuelled by misinformation, particularly online. Will others get the vaccine? The vaccine will eventually roll out to other provinces, including Khyber Pakhtunkhwa in 2026, and Balochistan and Gilgit-Baltistan in 2027. The government has not yet announced when the next phase will begin. “Every age girl will be vaccinated periodically,” Kamal, the federal minister, said. He added that the government hopes to vaccinate boys and men against HPV once girls and women have been vaccinated. What is driving vaccine hesitancy in Pakistan? While vaccine hesitancy is a global phenomenon, in Pakistan it was aggravated by the CIA’s use of a fake hepatitis B vaccination campaign in Pakistan’s Abbottabad as cover for a manhunt for fugitive al-Qaeda leader Osama bin Laden. The vaccine campaign, carried out in collaboration with a local doctor, was used to covertly collect blood samples to find links to bin Laden and his family. The plan was to compare the DNA of any of bin Laden’s children to that of his sister, who had died in Boston in 2010. The al-Qaeda leader was eventually killed in a military operation in Abbottabad by US Marines in 2011. It was never revealed whether the CIA obtained any DNA from bin Laden’s family. However, news outlets at the time said that one source suggested the operation had not succeeded. In 2014, the White House promised that the CIA would never again use a false vaccination campaign for espionage. However, mistrust towards vaccines persisted. This was apparent during the COVID-19 pandemic, when vaccines were free, but according to a recent study, 30 percent of people in Pakistan did not want to get vaccinated. An opinion piece, co-written by a Pakistani doctor and published on the website of GAVI, said: “Misconceptions that the [COVID] vaccine could lead to infertility, death or be tied into shadowy foreign agendas circulated rapidly through social media and community gossip.” Manzoor said she has herself noticed “anti-vaxxer” sentiment among some of her clients. She recalled advising a young mother not to bring her unvaccinated newborn into her house, explaining that it is not a sterile environment. The young mother responded, “It’s fine, we don’t believe in such things.” What are the specific concerns about the HPV vaccine? The HPV vaccine has faced especially heated pushback in Pakistan. Some argue that, as HPV is a sexually transmitted infection, it is not required in Pakistan, where consensual sex before marriage is not only culturally frowned upon, but is also illegal. A Pakistani user wrote on X, “Cerv. Cancer is spread via Sexual contact which is NOT IN PAKISTAN for 9-14 year old – only in west.” Another user wrote, referring to the vaccine, “its common in societies where women has multiple sex partners!” Manzoor said that she had her daughter vaccinated because, to her, it made sense to ensure that her daughter remains safe from the virus. “It’s not even about being sexually active, it’s even about, God forbid, molestation. It’s not always consensual,” Manzoor said. In 2023, Islamabad-based NGO Sahil reported that, on average, one child was sexually abused every two hours in Pakistan. According to the World Population Review, 5,867 rape cases were reported in Pakistan in 2023. Another conspiracy theory circulating online is that the HPV vaccine causes infertility. There is no evidence to support this claim. Pakistan, with a population in excess of 250 million, is the fifth most populous country in the world, according to World Population Review. While birthrates in the country have declined, much like the rest of the world, Pakistan’s current birthrate is 3.32, well above the replacement rate of 2.1 required to maintain current populations. In May 2020, a peer-reviewed US study found no evidence of increased infertility among women who received the HPV vaccine. However, this study was conducted in the US, and the sample was inoculated with a different vaccine – Gardasil. Other rumours, along with pictures and videos, have spread online. A video which attracted more than 340,000 views on X this year shows girls in school uniforms collapsing, with the caption asserting that these girls became sick after “forced vaccinations”. In fact, the video was filmed last year and shows a scene in which police are clashing with protesters over electricity taxes in Pakistan-administered Kashmir. Tear gas shells fired by the police are what caused the girls at the school to collapse. Is the HPV vaccine safe? “The vaccine has an excellent safety profile. It has been around for almost two decades now. It doesn’t contain any virus, but the active component is the HPV L1 protein,” Pechuho said. In an assessment of Cecolin published last year, the WHO said that “the vaccine was safe and showed a good immunogenicity”. It can cause a few mild side effects, Pechucho said. “Most common side effects are related to any other vaccine, like fever, pain at the injection site and, rarely, allergic reactions,” he said. Kamal too insisted that the most common side effect is a fever, which subsides in a day or two with the help of over-the-counter medicines. “People used to die of diseases like polio and tuberculosis. They’re not dying today because we now have vaccines. People are not dying of COVID because we have vaccines. The world has moved to prevention,” Kamal said. “The point of an effective healthcare system is to prevent people from becoming patients. And people will be safe from becoming patients when they take preventative measures and get their children vaccinated.”
