Girls at risk of HPV transmission: Vaccinations eliminate cervical cancer
The Freetown Secondary School for Girls, known fondly as “FSSG”, is a haven for pre-adolescent and teenage girls in the heart of Freetown, Sierra Leone. The junior secondary school hosts around 1,100 girls and Daniella Bangura, 14, will soon transition into senior secondary school with approximately 1,500 other girls. “Yes, I see girls getting pregnant; some show up with bruises or sores and are quiet in class; some bring their market to sell after school and many of my friends are tired. It’s not easy being a girl in Sierra Leone.”
The countless girls and young women across Sierra Leone are at a tremendously high risk of human papillomavirus, or HPV, transmission and resulting cervical cancer. Contributing to the risks facing girls and young women are: violence and sexual abuse, poverty, harmful cultural beliefs, early marriage, and the lack of sex education in schools, among others.
“At around 10-12, is a critical age for children and in the school system,” said Dr Austin Demby, the Minister of Health and Sanitation (MoHS). “It’s where you see the largest group of students and they are transitioning from primary to secondary school. We want HPV vaccinations to be like a rite of passage – a gift from the Ministry that will empower girls and women and protect them from cervical cancer for the rest of their life.”
At one time, in the not-too-distant past, Sierra Leone was considered the worst place to be a girl and certainly one of the worst places to be a young woman. The myriad of challenges across economic, social, health, judicial, political and psychological spheres were almost overwhelming. That’s slowly changing but for many young women, their futures remain in peril.
Violence and Sexual Abuse
According to the Demographic and Health Survey of 2019, 61% of females aged 15 to 49 reported having experienced physical violence. And, 40% of women around 15-years of age have experienced “intimate partner physical and/or sexual violence in the last 12 months,” noted Statistics Sierra Leone (Stats SL) and ICF in 2020.
The rate of sexual abuse of Sierra Leonean girls is staggering. In 2022, UNICEF reported 22% of adolescent girls under 18-years have had sex with a man at least ten years older than them. One of every four Sexual, Gender-Based Violence (SGBV) cases reported was sexual penetration of a minor (Human Rights Commission of Sierra Leone, 2020;). In 2020, the Rainbo Initiative, who offer services to SGBV victims, recorded 3,548 referrals for SGBV; 70% were 15-years-old or younger, rising to 97% of under 18-year-olds. The Family Support Unit of the Sierra Leone Police, in 2021, registered 4,468 cases of violence against children, with almost half of these cases (2,064) constituting sexual offences, mostly against girls.
A UNDP Report on the Drivers of SGBV, in 2021, cited two young interviewees. “Some men are even proud that they are the first to dis-virgin a girl” (Surv0005) and that there is still a belief that when “men lie down with virgins and take the blood to a sorcerer, they will have more power” (Surv0003).
Female Genital Mutilation (FGM)
UNICEF, based on the government’s health survey and other representative surveys, notes 86.1% of girls and women aged 15 to 49 years have undergone FGM/C. In rural areas of Sierra Leone, the FGM rates are closer to 90% and urban rates are around 76%.
A Freetown-based, female lawyer who asked not to be identified said, “The lack of nurturing relationships in families has been a key factor contributing to SGBV because there is lack of parenting for the children, which puts girls at risk…. From my experiences with judicial cases, most of them do not have good relationships with their parents; there is no bond between them. Because of this, even when they are abused, the girls don’t explain to the parents what happened… and so the issue comes up 3-4 months later when the girl is pregnant.”
Abibatu M Bangura is a bright 12-year-old girl in Junior Secondary School in Freetown. She said, “I don’t really talk to my step-mother, (her father’s second wife). She does not have much time for us at home. There are four of us girls in the house. My mother goes to sell in the morning and comes back late at night. When she’s home, she is tired.”
In 2019, 30.4% of girls did not live with a biological parent and 12% were orphans; one or both parents were deceased. Only 40% of children live with both biological parents according to the Sierra Leone Demographic and Health Survey, 2019. And, 86.5% of children aged 1-14 years in Sierra Leone experience some form of violent discipline in their households. The same survey found 30% of girls were “performing economic activity” including selling goods on the streets, to help their families. Around 50% of households derive their income from retail trade activities.
According to the Bureau of International Labour Affairs, “the child protection system in Sierra Leone is weak, under-resourced, donor-dependent, and lacking coordination. These factors in combination leave thousands of children vulnerable to exploitation and harm.”
Sierra Leone continues to be ranked among the bottom countries of the world in the UNDP Human Development Index. Shockingly, 81% of its population lives in poverty and 59.2% living in extreme poverty living on less than $1.25 per day and around (55%) are estimated to be food insecure according to a UNDP report in 2020.
This economic situation has left many girls and young women (and men) in an extremely vulnerable position. The World Bank has noted, “The lack of stable employment and means of income generation can lead to a common phenomenon known as “unequal transactional sex out of material need”, which has been reported as a key reason for girl’s and women’s vulnerability to sexual violence. Teenage girls are especially at risk of this arrangement due to the material necessity they have to acquire certain products and the need to help out their own families.”
The 2012 Sexual Offences Act, which was amended in October 2019, provides harsher penalties (up to life in prison) for rape and sexual assault and established the Sexual Offences Model Court. The Act prohibits sexual activity with children (anyone under the age of 18, including those in a marital relationship). The 2017 Child Rights Act prohibits marriage for anyone under the age of 18, among other protective provisions for children. However, this is undermined by the 2008 Customary Marriage Act, which allows marriage under 18-years with parental consent.
According to a UNICEF global database, in 2021, based on DHS, MICS and other government sources, 29.6% of women aged 20 to 24 years who were first married or in union before age 18. In Sierra Leone, the drivers of child marriage are rooted in poverty, lack of access to education, gender inequality and discriminatory gender norms and beliefs. The country is home to around 800,000 child brides, 400,000 of whom were married before age 15. Sierra Leone ranks 19th in child marriage rates in the world, with 13% of girls married by age 15, and 39% by age 18.
According to the World Bank, in 2019 Sierra Leone registered among the world’s highest adolescent pregnancy rates, with 108 births per 1,000 adolescents. The phenomenon of adolescent pregnancy is astounding – 38% of girls have given birth by age 18 and 45% of girls have had babies by the time they are 19-years old, noted the government’s Demographic Health Survey of 2019.
The Ministry of Health and Sanitation has noted pregnancy complications are the number one killer of girls in Sierra Leone, accounting for 25% of all deaths of girls age 15-19.
Leading cause of death for 10-19-year-olds are communicable diseases including HIV/TB, malaria, respiratory infections and diarrhoea, according to the Ministry of Health’s framework for the person-centred life stages approach to health service delivery, 2023-2030.
“We are in the era where no one should suffer or die from diseases that are preventable with the use of vaccines. And, we will make these lifesaving services accessible to safeguard the health of women and girls,” said Dr Steven Velabo Shongwe, WHO Representative in Sierra Leone.
Sexual intercourse forced on children or consented to as adults is the primary route of transmission of genital HPV infection. It also spreads through close skin-to-skin touching during intimate activities. A person with HPV can pass the infection to someone even when they have no signs or symptoms. Most sexually active people have already been exposed to HPV.
Sex Education – or lack of
In the recent past, Sierra Leone has undergone a major shift in educational policies. But, the hangover effects of years of neglect continues to plague school-age children. In 2017, only 45% of children of JSS-age were attending primary school, and almost one fifth (19%) were out of school altogether, with only 36% attending JSS in-line with their age-group. Following the introduction of a free education policy in 2018, enrolment as documented in the Annual School Census, increased across the board by 40% at pre-primary level, 29% at primary, 43% at JSS, and 48% at SSS level.
In 2022, the MBSSE introduced a new curriculum, which should help improve reading levels and the quality of education for children. However, an independent review of the new curriculum noted significant gaps and problem areas.
According to the Out-Of-School Children Study in November 2021, by UNICEF and the Ministry of Basic and Senior Secondary Education (MBSSE), more than half of 15-year-olds and above (57%) were illiterate and half of those leaving primary school are unable to read or write.
The Study notes, “Girls drop out of school at a higher rate which can be largely attributed to the intersection of poverty and gender norms, involving issues such as transactional sex, early marriage, and the burden of having to perform a disproportionate share of household chores.”
The UNICEF Report also noted, “The concerns about curriculum expressed by out-of-school girls centred around the lack of sexuality education to promote sound sexual and reproductive health (SRH) practices. Numerous adolescent mothers consulted reported that they did not understand contraception or pregnancy.”
A review of the National Curriculum Framework and Guidelines for Basic Education Using the Sexuality Review and Analysis Tool (SERAT), in 2020, sponsored by UNFPA, UNESCO and using International Technical Guidance on Sexuality Education, revealed, “Pupils lacked basic information about their sexual organs, healthy relationships with the opposite sex, harmful practices and an understanding of gender.” The study also found, “Teachers (40% of whom were untrained and volunteer) were using their discretion by teaching about violence and consent and bodily integrity, albeit with a fear-based approach. It was also apparent that despite the absence of learning objectives covering gender, lessons often contained messaging that perpetuated gender unequal norms and attitudes.”
The 2020 assessment of curriculum found, “Between 12-15 years there was no teaching on sexuality and sexual behaviour and teaching on sexual and reproductive health was “present to some extent.” The same curriculum assessment on primary school curriculum, between 5-8 years, found there was no teaching on Understanding Gender, Violence and Staying Safe, Skills for Health, Human Body and Development, Sexuality and Sexual Behaviour and Sexual and Reproductive Health.
Daniella E Bangura is 15-years-old and is looking forward to her senior years in secondary school. She said, “I noticed a lot of changes in my body since primary school. I’ve grown. I see my menses, which I had to learn about from my older sister and friends. At my school, we learned nothing about our bodies or really anything about diseases like viruses, except we learned about COVID-19 and Ebola.”
“It was like my (male) teacher was not going to talk about anything to do with sex or puberty or our bodies. I certainly don’t know anything about HPV or cancer or anything like that,” she added.
Globally, cervical cancer is the fourth most common cancer among women with an estimated 266,000 deaths and 528,000 new cases each year. Around 85% of the global burden of cervical cancer occurs in lower-income countries. According to the Sierra Leone Cancer registry, cervical cancer is the second most common, and number one killer, of all cancers among women aged between 14 and 44-years-old.
Statistics from the Sierra Leone Cancer registry show that cervical cancer is the second most common cancer (after breast cancer) and the biggest killer of all cancers among women aged between 14 and 44 years old. Only 8% of women have ever been screened for cervical cancer in Sierra Leone, according to the Ministry of Health.
In 2020, there were 4,708 new cancer cases detected among men and women. Breast cancer accounted for 20.9% or 985 cases. Cervical or cervix uteri cases accounted for 10.7% or 504 cases. Other cancers 2,189 (46.5%); colorectum (4.7%) or 222 cases; liver cancer (8.6%) or 407 cases and prostate cancer with 401 cases or 8.5% of all cancers detected. WHO figures indicate that if a person is diagnosed with cancer in Sierra Leone they have a 73% chance of dying… or a 27% chance of survival.
The safe, effective HPV vaccine has been available in most wealthier countries since the 2000s. Gavi, the Vaccine Alliance and its Alliance partners are now working to ensure the vaccine is available to girls across the world: Sierra Leone is the 19th African country to introduce the vaccine.
The Minister of Health, Dr Demby, noted, “The science is really great and that’s the other thing that will drive this. There’s no longer a question that the HPV causes cervical cancer. When we protect girls, we build a longer life for women.”
Over a two-week period in October 2022, Ministry of Health workers and community mobilizers were involved in a HPV vaccination campaign, sponsored by Gavi, the Vaccine Alliance, UNICEF and WHO, that inoculated more than 182,000 girls between 10 and 14-years-old. The Center for Disease Control and Prevention (CDCP) recommends HPV vaccination for all boys and girls at age 9 to 12-years.
“The campaign is a first step towards protecting girls in Sierra Leone from cervical cancer and providing them with a better chance of living longer, healthier lives and reaching their full potential,” said Thabani Maphosa, the Managing Director of Country Programmes at Gavi, the Vaccine Alliance. “Historically, HPV coverage worldwide, but especially in lower-income countries where the cancer burden is highest, was already too low.”
Health Minister, Dr Demby, noted, “This initiative is part of a broader vision for women and girls… and society. For example, if we build a ‘firewall’ of vaccinated 10-year-olds, who will be protected for life, then, for young women, we make sure we detect any pre-cancerous lesions early with a simple test and a relatively simple procedure, we can eliminate cervical cancer.”
Sierra Leone’s former Minister of MBSS Education, David Sengeh, spoke at the launch of the vaccination campaign. He said, “This is a pivotal moment as we seek to eliminate cervical cancer in Sierra Leone. Part of that strategy is vaccination. It will be disastrous for us to invest in children and girls, who then will grow up to have cervical cancer and die. That is why it’s so critical that our girls can access preventative methods as well as early detection and treatment when necessary,” he explained.
Dr Austin Demby, highlighted, “The goal is to eradicate cervical cancer by ensuring that by age 15, 90% of girls are fully vaccinated, 70% of women aged 25 and above are screened with a simple acetic acid (vinegar) test and 90% of women identified with the cervical disease receive treatment and we manage invasive cases.”
In Freetown, Philipa, 12, whose mother did not want her last name used, said, “I saw the nurses at my school and was told we were supposed to be vaccinated. I didn’t know anything so I called my mother. My mother said I should not do anything because she didn’t know anything about it and I didn’t know anything either.”
Dr Desmond Kangbai, Program Manager of the Child Health and Immunization Program, at the Ministry of Health, said they are working with the Sabine Vaccine Institute to research vaccine hesitancy. “We are examining the causes and develop policies to increase integrated vaccinations at all levels,” he said.
“I don’t want my daughters to be vaccinated unless I really know about the medicine,” said Fatmata Turay, a parent of two teenage girls in Freetown. She said, “I don’t know anything about HPV and the vaccine but I know women are dying of cancer in Sierra Leone. If we can prevent cancer, then that is good, but the government needs to inform parents first.”
Dr Lynda Grant, the Deputy Program Manager of the Child Health and Immunisation Program, at the Ministry of Health and Sanitation (MoHS), outlined some of the strategies used during the campaign in October 2022. She said the Ministry of Health worked with the Ministry of Basic and Senior Education (MBSSE) and different community leaders. The MoHS claims they disseminated over 19,000 posters and pamphlets for girls, parents and teachers across 8,400 schools and 1,560 health centres. Two radio jingles were produced and aired 6,840 times on 34 radio stations, and radio and TV shows and video spots were aired reaching an estimated 3.7 million people.
The Minister of Health noted, “I think we want to build a relationship with the public. It’s partly our inability to communicate well… to educate the 8 million people about these initiatives. When you take the time during quiet moments to explain what we’re trying to do then the messages will get out there and more acceptance will follow.” He added, “Investing in HPV vaccines, preventing cervical cancer alongside the many other women’s empowerment initiatives will go a long way to developing Sierra Leone.
“This reporting was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in the Caribbean, in partnership with Sabin Vaccine Institute.”