ISLAMABAD — This fall saw Pakistan's first-ever campaign to administer the human papillomavirus (HPV) vaccine, which protects girls from cervical cancer. The vaccine is highly effective, according to global health groups, and is routinely administered in some 150 countries.
It was not a rousing success.
As vaccinators fanned out to schools and other sites in mid-September, they explained that the vaccine would be offered for free to girls ages 9 through 14 and could save their lives if they later contracted HPV, a common sexually transmitted infection that is a major cause of cervical cancer.
In Pakistan, HPV is the third most common cancer, with some 5,000 cases reported annually. The yearly global death toll from the disease is approximately 300,000, with most fatalities in places where screenings and treatment are not easily accessible.
The teams, operating in parts of Pakistan as well as Pakistan-administered Kashmir, met fierce resistance from some parents.
They asked: Why is the vaccine being given only to young girls and not boys? (That's a complicated question – boys are eligible and being vaccinated could protect their future female sexual partners but because cervical cancer only affects women, the emphasis is on vaccinating girls.)
They wanted to know if the vaccine would affect their daughters' ability to have children later on — and why foreign organizations such as Gavi, the Vaccine Alliance, UNICEF and the World Health Organization were involved in the campaign. (Health experts say there's no data to suggest that the vaccine affects fertility. The concern stemmed from videos parents had seen in WhatsApp groups with the longstanding rumor that the vaccine is a population control ploy by Western funders to sterilize Muslims.)
"We went three to four times to try to convince people," Rehana Khan Abbasi, 48, a vaccinator working in Bhara Kahu, a town on the outskirts of Islamabad, Pakistan's capital city, told NPR.
On the last official day of the two-week campaign, Abbasi sat in the office of a school trying to get more parents on board. One mother, Zuleikha Bibi, remained hesitant; she'd read the fertility rumors about the HPV vaccine online. And her husband had made it clear that he would not allow their daughter to be vaccinated. "Maybe what people are saying is true, maybe not. Only God knows the truth — we do not know," Bibi said.
The goal had been to vaccinate about 90% of around 13 million eligible girls. Khurram Akram, technical director at Pakistan Federal Directorate of Immunization's, estimates that the actual percentage of girls vaccinated was around 70%.
"Our biggest challenge was to counter misinformation," says Akram.
This community response underscores the challenge of public vaccination efforts in Pakistan, where skepticism is often fueled by social media hearsay and conspiracies. In Bhara Kahu, schools sent permission forms back marked "no" before families got a chance to see them, and vaccinators were barred by school administrators from entry, said Syed Ehsan Hussain, a supervisor for the area's rural health center.
The reaction to the HPV campaign mirrors longstanding vaccine skepticism in Pakistan, which, along with neighboring Afghanistan, is one of only two countries in the world where wild polio circulates. Vaccine hesitancy has been stoked by the revelation that the CIA sponsored a vaccination drive in 2011 in its effort to uncover Osama Bin Laden as well as by misinformation.
Messaging around the HPV vaccination has been especially tricky, Hussain said, because HPV is often, though not always, spread through sex. "Whenever we bring up sexual contact again and again, it becomes sensitive due to our religious values and our society."
Health officials involved in the campaign say some parents were offended by the introduction of the vaccine as they thought it suggested that their teenage girls were having sex.
Pakistani officials — including the country's federal health minister, Mustafa Kamal — tried to reassure the public by arranging for public vaccination of their own daughters.
Vaccinators also went door-to-door to address parental fears. They downplayed the sexual transmission of the virus in favor of a broader message warning women about other methods of transmission — during childbirth and through contact with contaminated objects, including in hospital delivery rooms if instruments aren't sterilized properly. This type of transmission, although possible according to some research, is unlikely.
Fatima Khan, 13, was vaccinated during the campaign at her private school in Islamabad after explaining to her mother why she thought it was a good idea. "I was raised on the internet," she told NPR. "I did my own research and explained to her why I thought it was important."
Adil Hussain, a 36-year-old hotel security guard in Islamabad, also made up his mind about the vaccine after doing some research. He says when vaccinators didn't show up at his 10-year-old daughter Ayesha's school, he brought her on a Saturday to the local clinic for the shot.
He doesn't use social media, so online rumors didn't dissuade him.
He said he and his family members received other routine vaccines in the past, "and now the same is being done for our children." That's an attitude Pakistani officials hope will gain momentum in future campaigns.
Betsy Joles is a journalist based in Pakistan.
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