Coverage Performance and Lessons Learned from the Multi Age Cohort Campaign for HPV Vaccine Introduction in Phase One States of Nigeria

Coverage Performance and Lessons Learned from the Multi Age Cohort Campaign for HPV Vaccine Introduction in Phase One States of Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Coverage Performance and Lessons Learned from the Multi Age Cohort Campaign for HPV Vaccine Introduction in Phase One States of Nigeria Rufai Garba Ahmed, Elizabeth Hassan, Daniel Ali, Abdulrasheed Abdulraheem, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7703369/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Nigeria introduced the quadrivalent HPV vaccine into its Expanded Programme on Immunization (EPI) in 2023 using a two-phase rollout. Phase one experienced several challenges underscoring the need to analyze vaccination coverage, identify factors influencing uptake and drawing lessons learned for future strategies. Methods We employed a mixed-method approach using call-in data from the multi-age cohort vaccination campaign and implementation reports from the 15 states and the Federal Capital Territory. We analyzed coverage rates and trends as well as thematic ally analyzed factors influencing uptake. Results Coverage varied across the 16 states; 12 (80%) achieved the national target of 80%. School-based vaccine delivery strategy proved the most effective approach. Factors that influenced coverage disparities across the implementing states include robust state technical working groups, timely financial support, leveraging local workforce, efficient vaccine distribution, real-time monitoring, comprehensive strategies, and rigorous ACSM activities engaging community influencers and mass media. Lessons learned revealed emphasizing the integration of the different working groups, ensuring the timely release of funds, adopting diverse service delivery strategies and sustained advocacy as central for future rollout. Conclusion The success of the phase one HPV vaccine introduction was linked to effective coordination, and diverse service delivery strategies. Lessons learned highlight the importance of early planning, early release of funding, involving community gatekeepers, and the integration of adolescents and civil society organizations in the promotion of vaccine uptake. Cervical cancer HPV vaccine Multi-Age Cohort Coverage rates Lessons learned Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Cancer of the cervix remains a significant global health concern and ranks as the fourth most diagnosed malignancy among women, particularly in low and middle-income countries. With a high incidence rate of 14.8 cases per 100,000 women aged 35–64, Nigeria continues to grapple with the burden of the disease, contributing an estimated 12,075 new cases of global cervical cancer cases every year [ 1 , 2 ]. It is the second most common cancer in women aged 15 to 44 years in Nigeria [ 3 , 4 ]. Cervical cancer is caused by the human papillomavirus (HPV). HPV comprises a group of more than 150 related viruses and is the most widespread Sexually Transmitted Infection (STI), with an estimated transmission rate of 80% [ 5 , 6 ]. The burden of HPV infections, particularly the high-risk strains 16 and 18 are more pronounced in low- and middle-income countries (LMICs) [ 7 , 8 ]. Amidst the grim reality of cervical cancer, the emergence of the Human Papillomavirus vaccine represents humanity’s hope against the devastating disease, providing a potent preventive defense against the HPV strains that cause cervical cancer [ 9 – 11 ]. The efficacy of the HPV vaccine is well established with compelling evidence indicating a substantial decrease in the incidence of cervical cancer particularly when administered to women early in life [ 12 – 17 ]. As of November 2023, there are 6 distinct HPV vaccines available for use globally. One of the vaccines, the bivalent vaccine, is designed to prevent acquisition of infection with the high-risk HPV strains 16 and 18 responsible for most cervical cancer cases [ 4 ]. Early vaccination of girls between the ages of 9 to 14 has proven to be an effective strategy for combating the HPV strains associated with cancer and other HPV-related malignancies [ 18 – 21 ]. One of the 6 HPV vaccines available is the quadrivalent HPV vaccine (Gardasil 4v HPV), which is a recombinant vaccine that has been shown by studies to be very immunogenic and highly tolerated [ 22 ]. In addition to its efficacy in minimizing the risk of infection with cervical cancer-causing HPV strains, the vaccine has also been shown to prevent precancerous conditions, cervical cancer, and genital warts, demonstrating long-term effectiveness [ 4 , 23 – 29 ]. Recognizing the importance of this vaccine, Nigeria introduced the HPV vaccine using a phased approach. The first phase was rolled out on October 24th, 2023, using a multiage cohort campaign approach. This phase comprises fifteen states plus the federal capital territory. A combination of school and community-based approaches was adopted to vaccinate girls aged 9–14 who were supposedly not sexually active following the WHO suggestion that this age is the most suitable time for vaccination against HPV [ 30 ]. Despite the 80% coverage recorded across different states in phase one, the HPV vaccine launch faced severe hesitancy owing to diverse myths and misconceptions about the vaccine. This study therefore intends to analyze the coverage performance, and the lessons learned from the phase one HPV vaccine introduction in Nigeria. 2. Method 2.1. Study Design and setting Our study is a mixed method study that adopts quantitative and qualitative approaches to document the best practices and lessons learned from the HPV vaccine MAC campaign phase one introduction in 15 states and the FCT. 2.2. Study location and population All phase one vaccine introduction states were eligible to be included in the analysis if they had introduced the vaccine. This study analyzed HPV vaccination performances in only 15 states out of the 16 phase one states that had rolled out the vaccine starting on October 24, 2023. These states include Abia, Adamawa, Akwa Ibom, Bauchi, Bayelsa, Enugu, Jigawa, Kano, Kebbi, Lagos, Nasarawa, Ogun, Osun, Taraba and the FCT (Fig. 1 ). The NPHCDA identified the age cohort of 9 to 14 as the target recipient of HPV vaccine to maximize reaching adolescent girls before their sexual debut and potential exposure to the virus. Given that the vaccine is more effective at preventing HPV acquisition in the uninfected. Targeting this age group provides immunity before potential exposure to the virus, thus helping to control the burden of the disease in the future. 2.3. Vaccination strategies The HPV vaccine campaign implementation lasted five days across 15 states (24th- 29th October) with some states mopping up for an additional 2 days) The target population was reached using health facilities and outreach approaches. During the outreach session, public schools and private schools were visited to vaccinate girls who fall within the target age bracket. Markets, religious places, private sectors, and communities were visited to vaccinate girls outside school. 2.4. Data source Prior to vaccine introduction, these indicators: Penta 3 coverage, Age at first sexual intercourse, teenage pregnancy, Mean number of Sexual Partners, STI prevalence in the last 12 months, Male Circumcision, and Prevalence of HIV were used to assess how ready the states are for vaccine introduction (Table 1 ). The Penta 3 coverage was obtained from 2019 District Health Information Software (DHIS) administrative data, prevalence value for HIV was obtained from 2019 NAIS while other indicators were obtained from Nigeria Demographic and health survey (NDHS) 2018. The table below shows the criteria value used for each indicator. Table 1: Determinants of State Prioritization Across Phases Indicators Criteria Value Data Source Age at first sexual intercourse women National median age = 17.2 years NDHS, 2018 Teenage pregnancy National value = 19% of girls between 15 -19 years have begun childbearing NDHS, 2018 MSP (Mean number of Sexual Partners) National Mean number of Sexual Partners in a lifetime = 2.1 NDHS, 2018 STI prevalence in the last 12 months National value = 14% NDHS, 2018 Male Circumcision National value = 96.1% NDHS, 2018 Prevalence of HIV National value = 1.4% NAIS, 2019 MAC vaccination data was generated from the daily records of the number of girls vaccinated by the vaccination team. The data is compiled from the settlements level to the ward level to the Local Government Area and then to the state level. From the state level, the summary data was then transmitted to the operational department of the (NERICC) daily using a call-in spreadsheet. They were transmitted and compiled daily at the ward level. The compiled daily vaccination data was then transmitted to the LGA the same day by the ward focal person. The LGA immunization officer then transmits to the state and from the state to the national level using the daily call-in template from the 24th- 29th October 2023. For the post-implementation of the campaign, the data team of each SPHCDB came up with a comprehensive report capturing thematic areas such as: planning and coordination, advocacy, communication and social mobilization, vaccine logistics, implementation strategies, adverse event following immunization (AEFI), vaccination results, etc., and shared with the national team. Secondary data was also extracted from National Demographic and Health Survey (“NDHS”) NDHS”, RI administrative data, and (District Health Information Software)” DHIS2”. 2.5. Data Analysis We conducted a 5-day coverage rate and trend analysis from the 24th - 29th October 2023, for the 15 phase 1 states to examine the daily performance rate and disparities in coverage among the implementing states. Using the World Health Organization (WHO) Health System Building Block framework, we analyzed the qualitative report by developing thematic codes from the state-specific report. Best practices and challenges excerpts were extracted under respective adaptive building block domains. After reading the reports and consultation with experts, the WHO health system building block (Leadership/governance, health care financing, health workforce medical products, vaccines and technologies, information and research, service delivery) was adjusted with additional domains (monitoring and evaluation, advocacy, communication and social mobilization). The analysis was conducted with the new domains (coordination, Leadership and governance, health care financing, health and human resources, vaccines supply and cold chain/logistics, monitoring and evaluation mechanisms, service delivery, advocacy, communication and social mobilization. 2.6. Ethical Approval This analysis solely involved the use of pre-existing publicly available data of vaccine coverage rates, and review of existing program reports for the purpose of gaining insights to improve the quality of the next phase of the HPV vaccine roll out in the country. 3. Results Sixteen states were selected by the NPHCDA to be in the first phase of the HPV vaccine roll out, but one state did not deploy with the others because of lack of readiness. The six geopolitical zones were represented. Over 51% of the state-selected are into early sexual intercourse and have a high risk of HIV prevalence, with a prevalence value of 1.4% and the mean value of 14. The characteristics of the states are shown in Table 2. Table 2: Cervical Cancer Risk Characteristics of Phase 1 states Zone State Penta 3 Coverage DHIS (%) Age at first sexual intercourse (% women median age) Teenage pregnancy (%) Mean number of Sexual Partners (MSP) STI prevalence in the last 12 months Male Circumcision (%) Prevalence of HIV (%) North-Central FCT 124.2% 18.2% 8.9% 6 6.7% 94.90 1.5% Nasarawa 103.8% 18.2% 7.8% 1 18.9% 98.40 1.9% North-East Adamawa 102.7% 17.1% 20.5% 3 4.9% 97.30 1.3% Bauchi 77.4% 15.5% 32.3% 1 4.6% 98.30 0.4% Taraba 91.3% 16.0% 19.4% 2 11.0% 100.00 2.7% North-West Jigawa 104.9% 15.8% 19.2% 2 5.3% 99.50 0.3% Kano 84.8% 16.0% 25.8% 2 12.9% 100.00 0.5% Kebbi 116.1% 15.9% 18.5% 1 12.6% 98.40 0.6% South-East Enugu 70.3% 5.6% 2 49.6% 98.00 2.1% Abia 75.1% 18.8% 10.1% 2 3.0% 98.90 2.1% South-south Akwa Ibom 70.1% 17.4% 10.7% 4 5.8% 98.70 5.6% Bayelsa 29.0% 16.3% 19.0% 2 4.5% 98.70 1.8% South-West Lagos 78.1% 20.0% 1.1% 3 2.4% 97.90 1.3% Osun 61.4% 18.8% 5.6% 2 2.3% 62.00 0.9% Ogun 85.2% 19.3% 4.4% 2 2.8% 92.60 1.2% 3.1. Descriptive comparison of coverage rate The call-in data shows that overall HPV coverage in the 15 states was 80%. State coverage ranged from 36% in Lagos state to 98% in Taraba state with twelve out of the 15 states attaining 80% or higher coverage (Figure 2). Three states did not achieve the vaccination target, these were Enugu (75%) from south-East, Ogun (70%), and Lagos (36%) from south-West. In the 9 years age cohort, findings showed that more girls were vaccinated than the target population. 130% of 9 years were vaccinated during the implementation. For the 10-14 age cohort, 69% of the target population were vaccinated (Figure 3). Looking at the vaccination coverage and the target population we find out that in the 9 years age cohort, only Lagos state didn’t vaccinate up to 70% of the target population. While in the 10-14 years age cohort, Enugu, Lagos and Ogun didn’t vaccinate up to 80% of the target population (Figure 4). Across the Phase 1 states, adolescent girls between the age of 9-14 were targeted using three service delivery strategies (fixed post, school, and community) (Figure 5). Findings revealed that more girls were vaccinated in schools and communities in most of the states as the vaccination team vaccinated above the target population. 3.2. Factors contributing to variations in immunization uptake across these states using the WHO Health System Building Block Framework . In this study, state-specific reports and expert consultations were used to identify factors contributing to variations in immunization uptake in different thematic areas, leading to the expansion of the Building Block (Table 3). Table 3: Adapted WHO Health System Building Block Framework. Thematics Area Descriptions Coordination, Leadership, and Governance Described the coordination activities conducted at the national and across phase 1 states. Healthcare Financing Provides a description of funding availability, financial mobilization, and effective budget management across all implementation states. Health workforce or Human resources Highlight healthcare provider availability, qualification, job satisfaction, motivation, conducive structure, and appropriate and timely feedback Vaccine supply and cold chain/Logistics Describe states' Cold Chain Equipment capacity and vaccine availability. Monitoring and Evaluation Mechanism Provide monitoring and evaluation mechanisms applied for a successful implementation Service Delivery Describe the service delivery strategy adopted during the implementation Advocacy, Communication, and Social Mobilization Highlight ACSM activities conducted across the Phase 1 states. 3.2.1. Coordination, Leadership, and Governance Following the announcement of the vaccine introduction date, the 15 implementing states replicated the national-level coordination structure by establishing state Technical Working Groups (TWG) to ensure proper coordination of activities. The TWG members included the Executive Secretary of the State Primary Health Care Board (ES), the State Immunization Officer (SIO), the State Director of Disease Control and Immunization (DCI), the Cold Chain Officer, the State Health Educator, the Program Manager of the State Routine Immunization Working Group, and partners such as WHO, IVAC, UNICEF, SOLINA, and CHAI. The ES chairs the TWG but may delegate this role to the DCI or SIO in his or her absence. Typically, the TWG is formed about three to four months before the introduction of the HPV vaccine. They meet weekly to assess the state of preparedness, using the action tracker and the dashboard to monitor progress. When challenges arise, TWG members collaborate to find solutions and escalate issues as needed. A significant challenge faced by the TWG has been difficult meeting consistently due to competing priorities within the state. Political engagement from government officials, including the Governor, Chief of Staff, Ministers of Health and Education, and Commissioners for Health, Education, and Women’s Affairs, showed commitment to reinforcing and implementing intervention strategies. Lessons learned from previous vaccine introductions were applied to strengthen existing coordination platforms. The study revealed that strong coordination, leadership, and governance were key factors in states with high coverage rates. While states with lower coverage also demonstrated effective coordination, states like Enugu and Ogun faced competing priorities that hindered their coordination efforts. 3.2.2. Healthcare Financing Prior to the vaccination campaign, each state developed its specific budget to capture vaccination team stipends and other activities. State counterpart funds were provided across the phase 1 states for the vaccine rollout. Different partners (WHO, UNICEF, IVAC, SOLINA, CHAI among others) also supported the state with funding in different areas. For instance, IVAC engaged CSOs to conduct demand generation activities in two purposively selected LGAs in each of the 15 phase 1 states. Findings from the study showed that the late release of funds for advocacy, communication and social mobilization (ACSM) activities in Lagos due to the postponement of initial campaign dates and lack of budget allocation for school engagement activities at the LGA level hindered effective outreach and contributed to the low vaccination coverage. Ogun, one of the states with low coverage, did not allocate stipends for fixed post team members, which might contribute to low coverage at the fixed post. In Enugu state, most vaccination teams did not have AEFI kits, which the state team attributed to insufficient counterpart funds. 3.2.3. Health workforce or Human Resources Implementation states established adequate vaccination team members from their locality of residence to discourage hesitance and improve acceptance of the HPV vaccine. The vaccination team comprises team supervisor, recorder, community leader/guide, vaccinator. Civil society organizations (CSOs) engaged by partners such as the International Vaccine Access Centre (IVAC), played major roles in advocacy and demand generation for vaccine uptake in some communities. Vaccine champions trained by these CSOs were also integrated into the vaccination team to assist in mobilizing eligible girls for HPV vaccine uptake. Our findings reveal that using vaccination teams established for different service delivery strategies helps to improve coverage across the implementation states. It also shows that integrating vaccine champions into the vaccination teams to mobilize eligible girls as implemented in the LGAs where the CSOs worked enhanced the uptake of the vaccine. 3.2.4. Service Delivery Each state adopted the national implementation strategies using fixed post, school outreach, and out-of-school outreach to vaccinate adolescent girls across each ward. Our study revealed multiple strategies enabled more girls to be vaccinated in schools and communities across all the states. Although States with low vaccination coverage also deployed the three service delivery strategies but have low vaccination coverage at the fixed post. 3.2.5. Vaccine supply and cold chain/Logistics HPV vaccine was available in each implementing state’s cold store a week before the campaign. Vaccines were distributed based on each state-targeted population from national to state. Vaccines are distributed from the national strategic cold store Abuja to zonal cold stores in the six geo-political zones. From the zones, it is distributed to the 36 cold stores of the states through the push system, from there it was distributed to LGA cold stores to equip Health facilities through a mixture of push and pull. From the equipped health facilities, it goes to un-equipped health facilities through a pull system. From the ward level, the vaccination teams COME TO THE equipped health facilities to collect the vaccines they use daily, thereafter, they return unused vaccines every day for proper storage. Each state redistributed vaccines according to utilization by wards across all local governments. However, there was a vaccine stockout in some LGAs in Ogun state during the vaccine rollout. 3.2.6. Supervision, Monitoring and Evaluation Mechanism Immunization program managers from National and partners were deployed to the state to monitor the vaccine rollout. Technical experts (State Immunization Officers, Health educators, cold chain officers, NPHCDA technical officers etc.) from each state were deployed to LGA and wards before and during the vaccine rollout to monitor and account for the quality of the vaccine introduction. During the implementation each state used a call-in data strategy to report data from the ward level to state to National. The National team used a tracking dashboard to track the HPV coverage, challenges and AEFI cases for each state. Also, the National team deployed AEFI teams to all the states to ensure accurate tracking and reporting of any serious and unserious AEFI cases. Findings from the study show that with the help of technical experts, vaccination data were collected, verified, and transmitted in real-time across the implementation state. 3.2.7. Advocacy, Communication, and Social Mobilization In preparation for the HPV vaccination rollout, all the implemented states conducted rigorous and intensive advocacy, communication, and social mobilization (ACSM) activities. These activities include sensitization of schools, involvement of community influencers and religious leaders in advocating the importance of HPV, engaging mass media, etc. At the National and state level, EPI team paid high-level advocacy visits to Traditional leaders, religious leaders, Ministry of Education, state Governors, wives of the State Governors, social club leaders, etc. Partners support the government in paying advocacy visits at different levels and sensitization of key influencers. Religious, mass media and social club platforms were leveraged to create awareness and sensitize key stakeholders on the importance of the HPV vaccine. Civil Society organizations were supported with funding by a partner to conduct intensive advocacy, ACSM and demand generation activities. ACSM teams at both national and state handled rumors and myths around HPV vaccine by debunking all rumors and providing accurate information on the vaccine. The ACSM also makes use of different strategies like drama, and advertisement to debunk rumor and sensitize people on the benefit of the HPV vaccine. All these activities were ongoing to improve vaccine acceptance during the implementation. Although in Lagos state, the anti-vaccination sentiments were critical in their low coverage. Ogun states due to the postponement of initial campaign dates affected the coverage because people who were willing to take the vaccine changed their mind due to rumor spreading before the new date. The late commencement of sensitization in Enugu also contributed to the low coverage in the state. 3.3. Lessons Learned and Proposed Approaches to Enhance Future Vaccine Rollout The HPV implementation in phase 1 state highlighted several key lessons (table 4) across most thematic areas. These lessons were deduced from state reports and expert consultation through the national and subnational feedback systems- evening review meetings and real-time monitoring data/supervision. Advocacy, communication & social mobilization, Service Delivery, and Coordination Leadership and Governance thematic areas provided the most learnings from the implementation. Monitoring & evaluation and health financing were also areas that provided insights. Table 4: Lesson Learned Lessons Thematic Area Integration of HPV TWGs with existing government coordinating structures is crucial for successful HPV introduction Coordination, Leadership and Governance High-level political involvement and endorsement of traditional and religious leaders are key to reducing non-compliance Coordination, Leadership and Governance Early release of funds and availability of counterpart funds to support pre-implementation activities contributed to the success observed in high coverage states Health financing Competing priorities and emergencies like outbreak responses could affect team availability, program integration should be implemented. Health workforce/human resource Cold chain sufficiency and vaccine availability must be confirmed before implementation. Vaccine supply & cold chain Strengthening outreach campaign strategy by emphasizing region-specific targeted interventions Service delivery Adequate pre-implementation planning for security-compromised and hard-to-reach communities to improve coverage/access. Service delivery Need for strengthened rumor management mechanisms and sustained advocacy after the campaign period. Advocacy, Communication and Social Mobilization activities Timeliness of pre-assessment of awareness level Advocacy, Communication and Social Mobilization activities Involvement of adolescents, Civil Society Organization (CSO), Vaccine champions, and other community mobilization groups as peer sensitizers and vaccine champions Advocacy, Communication and Social Mobilization activities 4. Discussion Our study objective was to evaluate the HPV Vaccination coverage performance of the phase one HPV vaccine rollout implementation across 15 states and the FCT in Nigeria. Our goal is to gain valuable insights into the effectiveness of the vaccine rollout campaign, identify disparities in vaccine uptake across the states, and identify the specific factors responsible for the observed disparities in coverage rate. Findings from the data analyzed revealed that 80% of the states in phase one successfully achieved the target set (80% of the eligible girls) by the National Primary Health Care Development Agency for the MAC campaign. Impressively, 40% of these states meet the set target, exceeding 90% coverage rate. An outcome that highlights the significant success of the campaign when compared to other countries especially in Africa that have introduced the HPV vaccine. For example, South Africa introduced the HPV vaccine in its EPI system in 2014. At the end of 2020, only 75% of the age cohort targeted had received the first dose of the HPV vaccine. Of this figure, only 61% received the full recommended vaccine dose [31]. This figure underscores the success achieved by Nigeria, who achieved a higher coverage percentage in a shorter time frame. In contrast to South Africa, who took 4 years to reach 75 percent of the eligible population. However, three states, namely Lagos, Enugu, and Ogun states fell short of meeting the set target, reporting coverage rates of 36%, 75%, and 70% respectively. An in-depth analysis of reports from the states revealed several reasons for the suboptimal performance of these states. In Enugu and Ogun, competing activities impeded coordination efforts. For Lagos, the delayed release of funds for pre-implementation activities, the unexpected postponement of the rollout and the lack of budget for school engagement have been identified as the leading cause of their suboptimal performance. Also, States like Lagos and Enugu encountered hurdles associated with anti-vaccine sentiments among the population Analysis of the vaccination coverage data also revealed a notable trend across the states that implemented the phase one rollout. The vaccination coverage rate of the age cohort of 9 surpassed the target of the NPHCDA, reaching an impressive 130%. In contrast, the vaccination coverage rate for the age cohort of 10 to 14 fell short of the target, with only 69% of the girls within this age cohort vaccinated, suggesting a potential discrepancy in the vaccination strategy adopted for both age cohorts. The success of vaccinating girls in the 9-year-old cohort suggests a target and successful demand generation and service delivery approach, while that for the 10 to 14-year-old cohort suggests specific barriers and challenges that warrant a closer examination as we look forward to phase two rollout and implementation. One vaccination strategy that proved effective is the school-based vaccination strategy, which helped in reaching a significant number of eligible girls. Analyzed results revealed that a significant portion of the vaccinated girls, 44% were reached using this strategy, mostly in primary schools (elementary school). This is the reason for the higher vaccination rate of the age cohort of 9 (130%) than 10 to 14 (67%) because most 9-year-olds were in their later years in Primary school. The success of this strategy is a result of the collaborative effort of the NPHCDA, Federal Ministry of Education, and State Ministry of Education. Directives were issued to school authorities, and parents’ consent after consultation with schools played an important role in the success of this approach. [32] highlight the effectiveness of the school vaccination strategy in their study in Malaysia, where 98% of the targeted age cohort were vaccinated using the school approach. The high coverage rate achieved by Nigeria mirrors the effectiveness of a well-coordinated strategy, good leadership, state support, and robust government structure in the planning and implementation of the HPV vaccine introduction. States that replicated the coordination structure established at the national level demonstrated political commitment, as well as having adequate funds for implementation and the early release of these funds achieved success in the rollout. During the pre-implementation phase, the NPHCDA strategically employed a comprehensive and diverse approach to create awareness and sensitize key stakeholders on the importance of the HPV vaccine. This involved interactive sessions held across the 15 implementing states, leveraging existing platforms with community gatekeepers, religious leaders, school boards, and social club leaders. The study by [33] highlights the importance of dialogue with community gatekeepers in building local confidence and driving demand for health services including immunization. The NPHCDA also undertook an extensive media campaign, leveraging existing and established media platforms to advocate for the acceptance of the HPV vaccine. The aim was not just only to sensitize people but also to counteract infodemics and conspiracy theories about the vaccine. This proactive strategy sought to build confidence in the vaccine as well provide necessary information about the vaccine. [34] report that evidenced based messages leveraging existing media platforms directly counteract infodemics and conspiracy theories. [35] argued the importance of designing and sending specific tailored social media messages was effective in correcting anti-vaccine messages. Another strategy that had on the coverage rate is the involvement of Civil Society organizations (CSOs) in the pre-implementation and implementation phase of the rollout. Their active engagement was effective in creating awareness and mobilizing girls to the vaccination team, thereby adding a grassroots dimension to the demand generation of the campaign. CSO involvement beyond awareness creation, including advocacy visits and mobilization ensured that the campaign resonated well at the local level, addressing specific needs and concerns in the community where they worked. Leveraging their community connection and understanding of community dynamics, CSOs were able to tailor their efforts to address challenges and cultural issues as they relate to the HPV vaccine. [36] assert that CSOs have played an important role in the equity distribution of vaccines, especially COVID-19 vaccine. According to [37], Civil Society Organizations can aid in mobilizing the community and creating awareness for effective service delivery of any intervention. Utilizing the WHO Health System Building Block framework, we assessed the contributing factors to the vaccination coverage rate in the 15 phase one states that rollout of the HPV vaccine thematic areas analyzed were coordination, leadership and governance, healthcare financing, human resources for health, vaccine supply and coal chain/logistics, monitoring and evaluation, service delivery, and advocacy, communication, and social mobilization. Our study underscores the importance of coordination structures at both state and national levels. Political involvement and commitment coupled with lessons learned from past vaccine introductions played a crucial role in fostering coordination. States like Enugu, Lagos and Ogun faced challenges because of competing activities that impacted coordination activities, which led to lower vaccination coverage. Adequate funding and the release of funds were attributed to the success of the MAC campaign. Conversely, states like Lagos faced financial challenges and this affected pre-implementation advocacy and social mobilization activities. In Ogun state, vaccination activities were hindered by lack of stipends of fixed post vaccination teams which potentially led to showing up for vaccination leading to low coverage. 5. Limitation of the study Our study relied on the Multi-Age Cohort (MAC) campaign data and reports from immunization officers involved in the campaign in the 15 states that implemented the rollout in phase one. The campaign data does not include important demographic information about the clients such as ethnicity, educational level, religion, and residence. The absence of this information limits the ability to comprehensively understand the diverse characteristics of the population studied and how these factors influence vaccine uptake. While acknowledging the availability of a study by the NPHCDA and the World Health Organization that assessed people’s knowledge, perception, and intention to take the HPV vaccine. A lot might have changed in the period that this manuscript was developed and the vaccine rollout because of infodemics and conspiracy theories. This may affect generalization and hinder direct comparison. 6. Study Implication The study examined the vaccination coverage variation across the 15 states that introduced HPV vaccine and identified the contributing factors to the vaccination coverage rate across the implementing states. The result found that 80% of the 15 states phase one state passed the target set by the NPHCDA for the MAC campaign, with 40% of these states surpassing a 90% coverage rate. The success of the campaign was credited to effective coordination, good leadership, government structure, and the effective demand generation and service delivery strategy employed in Nigeria. The study also found that the vaccination of girls aged 9 exceeded the target of the NPHCDA, with an impressive 130% of this age cohort vaccinated. The success was attributed to the school-based vaccination approach The study identified several factors contributing to the variation in vaccination rate across the 15 phase-one states using the WHO Health System Building Block Framework. The factors identified encompass coordination, leadership, governance, healthcare financing workforce, monitoring and evaluation, vaccine supply chain, and service delivery. In addressing the low coverage rates in states like Lagos, Enugu, and Ogun state, there is a need for a targeted strategy towards anti-vaccination sentiments through advocacy and sensitization campaigns. The sensitization and advocacy campaign should be tailored to the specific cultural and religious context of these communities, to identify and address the root cause of the sentiments, especially as we look forward to phase two. The success achieved in vaccinating eligible girls aged 9 underscores the need for a strategic approach that encompasses a broader age cohort that targets the age cohort of 10 to 14. There is a need for research effort especially as we look forward to phase two that will examine those factors that drive vaccination uptake within this age cohort. There is a need for tailored approaches and strategies that are effective and comprehensive to drive demand for girls within the age cohort. There is also a need for a thorough investigation into the delivery service strategy, especially for states like Enugu and Lagos. We must understand those specific barriers to this method and devise target interventions, for further vaccine introduction as we look forward to phase two. This will involve evaluating the strategies in these states and pinpointing the strengths, weaknesses, and gaps affecting fixed post uptake. Declarations Ethical Approval This analysis solely involved the use of pre-existing publicly available data of vaccine coverage rates, and review of existing program reports for the purpose of gaining insights to improve the quality of the next phase of the HPV vaccine roll out in the country. Clinical trial number not applicable Funding Declaration: The work was conducted as part of programmatic implementation by the National Primary Healthcare Development Agency (NPHCDA), hence did not receive any specific grant from funding agencies Author Contribution Author Contributions: Conceptualization, A.R.G, C.B.W., A.D., E.S., H.E., and B.G.; Methodology, C.B.W., A.D., E.S., H.E., A.P., H.G.T., Y.A., U.F., and B.G.; Validation, J.Z., E.E.M., and S.N.; Formal analysis, E.E.M., A.A.A., N.I.D., A.J., and A.P.; Writing—review and editing, I.C.O., A.A.A., J.Z., H.E., E.A.S...,and A.P Acknowledgement The authors extend our heartfelt gratitude to all those who contributed to the development of this paper. We sincerely thank Dr. Muyi Aina, the Executive Director of the National Primary Healthcare Development Board, for approving the use of administrative data from various interventions. Our appreciation also goes to the dedicated staff of Direct Consulting & Logistics (DCL) for their invaluable support in documenting the workshop's outcomes. We are especially grateful to Gavi, the Vaccine Alliance, for funding the documentation workshop, which served as a crucial step in developing this paper. Data Availability The datasets analysed during the current study are administrative data from the National Primary Health Care Development Agency (NPHCDA) HPV vaccine introduction campaign. These datasets are not publicly available due to government data protection regulations and use restrictions. However, they are available from the corresponding author on reasonable requests and with permission from the NPHCDA References Okolie EA, Nwadike BI. (2023). Spotlight on human papillomavirus vaccination coverage: Is Nigeria making any progress? JCO Global Oncology, 9. https://doi.org/10.1200/go.23.00088 Ola IO, Okunowo AA, Habeebu MY, Miao Jonasson J. 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The role of civil society organizations in fostering equitable vaccine delivery through COVAX. East Mediterr Health J. 2023;29(4):232–5. https://doi.org/10.26719/emhj.23.053 . Muhammad A, Ahmad D, Tariq E, Shafiq Y. Rebuilding Trust on Routine Immunization in Era of COVID-19 Fear–Role that Civil Society Organizations can Play Hands-in-Hand with Immunization Program. Public Health Rev. 2021;42. https://doi.org/10.3389/phrs.2021.1603989 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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16:47:28","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158166,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/dbe4b2ca6cb8bf75b0019179.html"},{"id":94486889,"identity":"a24434af-b9a6-410a-af8d-70c055c63124","added_by":"auto","created_at":"2025-10-27 16:46:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144123,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMap of Nigeria showing HPV Phase 1 selected states\u003c/em\u003e\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/fdeca41a585f975eaf597cd4.png"},{"id":94487344,"identity":"74b9c47a-08e5-4a08-9459-f30c9bb89fde","added_by":"auto","created_at":"2025-10-27 16:47:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122839,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHPV Vaccination coverage across Phase 1 states\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/2d0aec4aca333c7d6430156f.png"},{"id":94487340,"identity":"b92b4643-83c4-46db-965b-c7e2f435d8fb","added_by":"auto","created_at":"2025-10-27 16:47:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55952,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHPV Vaccination target vs coverage in Phase 1\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/d743b08a77c1bf5fe4a3943d.png"},{"id":94487423,"identity":"1a941cf9-c028-4ad1-abc5-38b615fffa5f","added_by":"auto","created_at":"2025-10-27 16:48:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":149788,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHPV Vaccination Target, Coverage and distribution of states by Age Cohort\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/0e949e49f3951ea994b61ddc.png"},{"id":94487291,"identity":"8e53dca5-921e-4e22-aaaa-f4cde497d4d2","added_by":"auto","created_at":"2025-10-27 16:47:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":212845,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of States and Service Delivery Strategies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/0eb33cd4243739d44e3acd42.png"},{"id":95717121,"identity":"d2812dcd-19f7-447b-9a63-4fbe546d6433","added_by":"auto","created_at":"2025-11-12 08:55:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1969235,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7703369/v1/7f938cb1-694f-4dc3-8946-e18fd2d800e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Coverage Performance and Lessons Learned from the Multi Age Cohort Campaign for HPV Vaccine Introduction in Phase One States of Nigeria","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCancer of the cervix remains a significant global health concern and ranks as the fourth most diagnosed malignancy among women, particularly in low and middle-income countries. With a high incidence rate of 14.8 cases per 100,000 women aged 35\u0026ndash;64, Nigeria continues to grapple with the burden of the disease, contributing an estimated 12,075 new cases of global cervical cancer cases every year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is the second most common cancer in women aged 15 to 44 years in Nigeria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Cervical cancer is caused by the human papillomavirus (HPV). HPV comprises a group of more than 150 related viruses and is the most widespread Sexually Transmitted Infection (STI), with an estimated transmission rate of 80% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The burden of HPV infections, particularly the high-risk strains 16 and 18 are more pronounced in low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmidst the grim reality of cervical cancer, the emergence of the Human Papillomavirus vaccine represents humanity\u0026rsquo;s hope against the devastating disease, providing a potent preventive defense against the HPV strains that cause cervical cancer [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The efficacy of the HPV vaccine is well established with compelling evidence indicating a substantial decrease in the incidence of cervical cancer particularly when administered to women early in life [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs of November 2023, there are 6 distinct HPV vaccines available for use globally. One of the vaccines, the bivalent vaccine, is designed to prevent acquisition of infection with the high-risk HPV strains 16 and 18 responsible for most cervical cancer cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Early vaccination of girls between the ages of 9 to 14 has proven to be an effective strategy for combating the HPV strains associated with cancer and other HPV-related malignancies [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the 6 HPV vaccines available is the quadrivalent HPV vaccine (Gardasil 4v HPV), which is a recombinant vaccine that has been shown by studies to be very immunogenic and highly tolerated [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition to its efficacy in minimizing the risk of infection with cervical cancer-causing HPV strains, the vaccine has also been shown to prevent precancerous conditions, cervical cancer, and genital warts, demonstrating long-term effectiveness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecognizing the importance of this vaccine, Nigeria introduced the HPV vaccine using a phased approach. The first phase was rolled out on October 24th, 2023, using a multiage cohort campaign approach. This phase comprises fifteen states plus the federal capital territory. A combination of school and community-based approaches was adopted to vaccinate girls aged 9\u0026ndash;14 who were supposedly not sexually active following the WHO suggestion that this age is the most suitable time for vaccination against HPV [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Despite the 80% coverage recorded across different states in phase one, the HPV vaccine launch faced severe hesitancy owing to diverse myths and misconceptions about the vaccine. This study therefore intends to analyze the coverage performance, and the lessons learned from the phase one HPV vaccine introduction in Nigeria.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Design and setting\u003c/h2\u003e\u003cp\u003eOur study is a mixed method study that adopts quantitative and qualitative approaches to document the best practices and lessons learned from the HPV vaccine MAC campaign phase one introduction in 15 states and the FCT.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study location and population\u003c/h2\u003e\u003cp\u003eAll phase one vaccine introduction states were eligible to be included in the analysis if they had introduced the vaccine. This study analyzed HPV vaccination performances in only 15 states out of the 16 phase one states that had rolled out the vaccine starting on October 24, 2023. These states include Abia, Adamawa, Akwa Ibom, Bauchi, Bayelsa, Enugu, Jigawa, Kano, Kebbi, Lagos, Nasarawa, Ogun, Osun, Taraba and the FCT (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The NPHCDA identified the age cohort of 9 to 14 as the target recipient of HPV vaccine to maximize reaching adolescent girls before their sexual debut and potential exposure to the virus. Given that the vaccine is more effective at preventing HPV acquisition in the uninfected. Targeting this age group provides immunity before potential exposure to the virus, thus helping to control the burden of the disease in the future.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Vaccination strategies\u003c/h2\u003e\u003cp\u003eThe HPV vaccine campaign implementation lasted five days across 15 states (24th- 29th October) with some states mopping up for an additional 2 days) The target population was reached using health facilities and outreach approaches. During the outreach session, public schools and private schools were visited to vaccinate girls who fall within the target age bracket. Markets, religious places, private sectors, and communities were visited to vaccinate girls outside school.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Data source\u003c/h2\u003e\u003cp\u003ePrior to vaccine introduction, these indicators: Penta 3 coverage, Age at first sexual intercourse, teenage pregnancy, Mean number of Sexual Partners, STI prevalence in the last 12 months, Male Circumcision, and Prevalence of HIV were used to assess how ready the states are for vaccine introduction (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The Penta 3 coverage was obtained from 2019 District Health Information Software (DHIS) administrative data, prevalence value for HIV was obtained from 2019 NAIS while other indicators were obtained from Nigeria Demographic and health survey (NDHS) 2018. The table below shows the criteria value used for each indicator.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e \u003cstrong\u003eDeterminants of State Prioritization Across Phases\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndicators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eAge at first sexual intercourse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003ewomen National median age = 17.2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNDHS, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eTeenage pregnancy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003eNational value = 19% of girls between 15 -19 years have begun childbearing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNDHS, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eMSP (Mean number of Sexual Partners)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003eNational Mean number of Sexual Partners in a lifetime = 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNDHS, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eSTI prevalence in the last 12 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003eNational value = 14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNDHS, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eMale Circumcision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003eNational value = 96.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNDHS, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003ePrevalence of HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003eNational value = 1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNAIS, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eMAC vaccination data was generated from the daily records of the number of girls vaccinated by the vaccination team. The data is compiled from the settlements level to the ward level to the Local Government Area and then to the state level. \u0026nbsp;From the state level, the summary data was then transmitted to the operational department of the (NERICC) daily using a call-in spreadsheet. They were transmitted and compiled daily at the ward level. The compiled daily vaccination data was then transmitted to the LGA the same day by the ward focal person. The LGA immunization officer then transmits to the state and from the state to the national level using the daily call-in template from the 24th- 29th October 2023.\u003c/p\u003e\n\u003cp\u003eFor the post-implementation of the campaign, the data team of each SPHCDB came up with a comprehensive report capturing thematic areas such as: planning and coordination, advocacy, communication and social mobilization, vaccine logistics, implementation strategies, adverse event following immunization (AEFI), vaccination results, etc., and shared with the national team. Secondary data was also extracted from National Demographic and Health Survey (\u0026ldquo;NDHS\u0026rdquo;) NDHS\u0026rdquo;, RI administrative data, and (District Health Information Software)\u0026rdquo; DHIS2\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.5.\u0026nbsp;\u0026nbsp;Data Analysis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a 5-day coverage rate and trend analysis from the 24th - 29th October 2023, for the 15 phase 1 states to examine the daily performance rate and disparities in coverage among the implementing states. Using the World Health Organization (WHO) Health System Building Block framework, we analyzed the qualitative report by developing thematic codes from the state-specific report. Best practices and challenges excerpts were extracted under respective adaptive building block domains. After reading the reports and consultation with experts, the WHO health system building block (Leadership/governance, health care financing, health workforce medical products, vaccines and technologies, information and research, service delivery) was adjusted with additional domains (monitoring and evaluation, advocacy, communication and social mobilization). The analysis was conducted with the new domains (coordination, Leadership and governance, health care financing, health and human resources, vaccines supply and cold chain/logistics, monitoring and evaluation mechanisms, service delivery, advocacy, communication and social mobilization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.6.\u0026nbsp; \u0026nbsp;Ethical Approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis analysis solely involved the use of pre-existing publicly available data of vaccine coverage rates, and review of existing program reports for the purpose of gaining insights to improve the quality of the next phase of the HPV vaccine roll out in the country.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eSixteen states were selected by the NPHCDA to be in the first phase of the HPV vaccine roll out, but one state did not deploy with the others because of lack of readiness. The six geopolitical zones were represented. Over 51% of the state-selected are into early sexual intercourse and have a high risk of HIV prevalence, with a prevalence value of 1.4% and the mean value of 14. The characteristics of the states are shown in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Cervical Cancer Risk Characteristics of Phase 1 states\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"726\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePenta 3 Coverage DHIS (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at first sexual intercourse (% women median age)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTeenage pregnancy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean number of Sexual Partners (MSP)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTI prevalence in the last 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale Circumcision (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of HIV (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNorth-Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eFCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e124.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e6.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e94.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNasarawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e103.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNorth-East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAdamawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e102.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e17.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e20.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e97.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBauchi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e77.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e15.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e32.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTaraba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e91.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNorth-West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eJigawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e104.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e15.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e5.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e99.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eKano\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e84.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e25.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eKebbi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e116.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e15.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eSouth-East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eEnugu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e70.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e49.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAbia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e75.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eSouth-south\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAkwa Ibom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e70.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e17.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e5.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBayelsa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e29.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eSouth-West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eLagos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e78.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e20.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e97.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eOsun\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e61.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e62.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eOgun\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e85.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e19.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e92.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1. \u0026nbsp; \u0026nbsp; Descriptive comparison of coverage rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe call-in data shows that overall HPV coverage in the 15 states was 80%. State coverage ranged from 36% in Lagos state to 98% in Taraba state with twelve out of the 15 states attaining 80% or higher coverage (Figure 2). \u0026nbsp;Three states did not achieve the vaccination target, these were Enugu (75%) from south-East, Ogun (70%), and Lagos (36%) from south-West.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the 9 years age cohort, findings showed that more girls were vaccinated than the target population. 130% of 9 years were vaccinated during the implementation. For the 10-14 age cohort, 69% of the target population were vaccinated (Figure 3). Looking at the vaccination coverage and the target population we find out that in the 9 years age cohort, only Lagos state didn\u0026rsquo;t vaccinate up to 70% of the target population. While in the 10-14 years age cohort, Enugu, Lagos and Ogun didn\u0026rsquo;t vaccinate up to 80% of the target population (Figure 4).\u003c/p\u003e\n\u003cp\u003eAcross the Phase 1 states, adolescent girls between the age of 9-14 were targeted using three service delivery strategies (fixed post, school, and community) (Figure 5). Findings revealed that more girls were vaccinated in schools and communities in most of the states as the vaccination team vaccinated above the target population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Factors contributing to variations in immunization uptake across these states using the WHO Health System Building Block Framework\u003cem\u003e.\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, state-specific reports and expert consultations were used to identify factors contributing to variations in immunization uptake in different thematic areas, leading to the expansion of the Building Block (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Adapted WHO Health System Building Block Framework.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThematics Area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescriptions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eCoordination, Leadership, and Governance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eDescribed the coordination activities conducted at the national and across phase 1 states.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eHealthcare Financing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eProvides a description of funding availability, financial mobilization, and effective budget management across all implementation states.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eHealth workforce or Human resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eHighlight healthcare provider availability, qualification, job satisfaction, motivation, conducive structure, and appropriate and timely feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eVaccine supply and cold chain/Logistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eDescribe states\u0026apos; Cold Chain Equipment capacity and vaccine availability.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eMonitoring and Evaluation Mechanism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eProvide monitoring and evaluation mechanisms applied for a successful implementation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eService Delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eDescribe the service delivery strategy adopted during the implementation \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003eAdvocacy, Communication, and Social Mobilization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 421px;\"\u003e\n \u003cp\u003eHighlight ACSM activities conducted across the Phase 1 states.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCoordination, Leadership, and Governance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the announcement of the vaccine introduction date, the 15 implementing states replicated the national-level coordination structure by establishing state Technical Working Groups (TWG) to ensure proper coordination of activities. The TWG members included the Executive Secretary of the State Primary Health Care Board (ES), the State Immunization Officer (SIO), the State Director of Disease Control and Immunization (DCI), the Cold Chain Officer, the State Health Educator, the Program Manager of the State Routine Immunization Working Group, and partners such as WHO, IVAC, UNICEF, SOLINA, and CHAI. The ES chairs the TWG but may delegate this role to the DCI or SIO in his or her absence.\u003c/p\u003e\n\u003cp\u003eTypically, the TWG is formed about three to four months before the introduction of the HPV vaccine. They meet weekly to assess the state of preparedness, using the action tracker and the dashboard to monitor progress. When challenges arise, TWG members collaborate to find solutions and escalate issues as needed. A significant challenge faced by the TWG has been difficult meeting consistently due to competing priorities within the state.\u003c/p\u003e\n\u003cp\u003ePolitical engagement from government officials, including the Governor, Chief of Staff, Ministers of Health and Education, and Commissioners for Health, Education, and Women\u0026rsquo;s Affairs, showed commitment to reinforcing and implementing intervention strategies. Lessons learned from previous vaccine introductions were applied to strengthen existing coordination platforms. The study revealed that strong coordination, leadership, and governance were key factors in states with high coverage rates. While states with lower coverage also demonstrated effective coordination, states like Enugu and Ogun faced competing priorities that hindered their coordination efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHealthcare Financing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the vaccination campaign, each state developed its specific budget to capture vaccination team stipends and other activities. State counterpart funds were provided across the phase 1 states for the vaccine rollout. Different partners (WHO, UNICEF, IVAC, SOLINA, CHAI among others) also supported the state with funding in different areas. For instance, IVAC engaged CSOs to conduct demand generation activities in two purposively selected LGAs in each of the 15 phase 1 states. \u0026nbsp;Findings from the study showed that the late release of funds for advocacy, communication and social mobilization (ACSM) activities in Lagos due to the postponement of initial campaign dates and lack of budget allocation for school engagement activities at the LGA level hindered effective outreach and contributed to the low vaccination coverage. Ogun, one of the states with low coverage, did not allocate stipends for fixed post team members, which might contribute to low coverage at the fixed post. In Enugu state, most vaccination teams did not have AEFI kits, which the state team attributed to insufficient counterpart funds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHealth workforce or Human Resources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImplementation states established adequate vaccination team members from their locality of residence to discourage hesitance and improve acceptance of the HPV vaccine. The vaccination team comprises team supervisor, recorder, community leader/guide, vaccinator. \u0026nbsp;Civil society organizations (CSOs) engaged by partners such as the International Vaccine Access Centre (IVAC), played major roles in advocacy and demand generation for vaccine uptake in some communities. Vaccine champions trained by these CSOs were also integrated into the vaccination team to assist in mobilizing eligible girls for HPV vaccine uptake. Our findings reveal that using vaccination teams established for different service delivery strategies helps to improve coverage across the implementation states. It also shows that integrating vaccine champions into the vaccination teams to mobilize eligible girls as implemented in the LGAs where the CSOs worked enhanced the uptake of the vaccine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eService Delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach state adopted the national implementation strategies using fixed post, school outreach, and out-of-school outreach to vaccinate adolescent girls across each ward. Our study revealed multiple strategies enabled more girls to be vaccinated in schools and communities across all the states. Although States with low vaccination coverage also deployed the three service delivery strategies but have low vaccination coverage at the fixed post.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.5. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eVaccine supply and cold chain/Logistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHPV vaccine was available in each implementing state\u0026rsquo;s cold store a week before the campaign. Vaccines were distributed based on each state-targeted population from national to state. Vaccines are distributed from the national strategic cold store Abuja to zonal cold stores in the six geo-political zones. From the zones, it is distributed to the 36 cold stores of the states through the push system, from there it was distributed to LGA cold stores to equip Health facilities through a mixture of push and pull. From the equipped health facilities, it goes to un-equipped health facilities through a pull system. From the ward level, the vaccination teams COME TO THE equipped health facilities to collect the vaccines they use daily, thereafter, they return unused vaccines every day for proper storage. Each state redistributed vaccines according to utilization by wards across all local governments. However, there was a vaccine stockout in some LGAs in Ogun state during the vaccine rollout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.6. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSupervision, Monitoring and Evaluation Mechanism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImmunization program managers from National and partners were deployed to the state to monitor the vaccine rollout. Technical experts (State Immunization Officers, Health educators, cold chain officers, NPHCDA technical officers etc.) from each state were deployed to LGA and wards before and during the vaccine rollout to monitor and account for the quality of the vaccine introduction. During the implementation each state used a call-in data strategy to report data from the ward level to state to National. The National team used a tracking dashboard to track the HPV coverage, challenges and AEFI cases for each state. Also, the National team deployed AEFI teams to all the states to ensure accurate tracking and reporting of any serious and unserious AEFI cases. Findings from the study show that with the help of technical experts, vaccination data were collected, verified, and transmitted in real-time across the implementation state.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.7. \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAdvocacy, Communication, and Social Mobilization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn preparation for the HPV vaccination rollout, all the implemented states conducted rigorous and intensive advocacy, communication, and social mobilization (ACSM) activities. These activities include sensitization of schools, involvement of community influencers and religious leaders in advocating the importance of HPV, engaging mass media, etc. At the National and state level, EPI team paid high-level advocacy visits to Traditional leaders, religious leaders, Ministry of Education, state Governors, wives of the State Governors, social club leaders, etc. Partners support the government in paying advocacy visits at different levels and sensitization of key influencers. Religious, mass media and social club platforms were leveraged to create awareness and sensitize key stakeholders on the importance of the HPV vaccine. \u0026nbsp;Civil Society organizations were supported with funding by a partner to conduct intensive advocacy, ACSM and demand generation activities. ACSM teams at both national and state handled rumors and myths around HPV vaccine by debunking all rumors and providing accurate information on the vaccine. The ACSM also makes use of different strategies like drama, and advertisement to debunk rumor and sensitize people on the benefit of the HPV vaccine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll these activities were ongoing to improve vaccine acceptance during the implementation. Although in Lagos state, the anti-vaccination sentiments were critical in their low coverage. Ogun states due to the postponement of initial campaign dates affected the coverage because people who were willing to take the vaccine changed their mind due to rumor spreading before the new date. The late commencement of sensitization in Enugu also contributed to the low coverage in the state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. \u0026nbsp; \u0026nbsp; Lessons Learned and Proposed Approaches to Enhance Future Vaccine Rollout\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe HPV implementation in phase 1 state highlighted several key lessons (table 4) across most thematic areas. These lessons were deduced from state reports and expert consultation through the national and subnational feedback systems- evening review meetings and real-time monitoring data/supervision. Advocacy, communication \u0026amp; social mobilization, Service Delivery, and Coordination Leadership and Governance thematic areas provided the most learnings from the implementation. Monitoring \u0026amp; evaluation and health financing were also areas that provided insights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Lesson Learned\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLessons\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThematic Area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eIntegration of HPV TWGs with existing government coordinating structures is crucial for successful HPV introduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eCoordination, Leadership and Governance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eHigh-level political involvement and endorsement of traditional and religious leaders are key to reducing non-compliance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eCoordination, Leadership and Governance\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eEarly release of funds and availability of counterpart funds to support pre-implementation activities contributed to the success observed in high coverage states\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eHealth financing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eCompeting priorities and emergencies like outbreak responses could affect team availability, program integration should be implemented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eHealth workforce/human resource\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eCold chain sufficiency and vaccine availability must be confirmed before implementation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eVaccine supply \u0026amp; cold chain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eStrengthening outreach campaign strategy by emphasizing region-specific targeted interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eService delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eAdequate pre-implementation planning for security-compromised and hard-to-reach communities to improve coverage/access.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eService delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eNeed for strengthened rumor management mechanisms and sustained advocacy after the campaign period.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eAdvocacy, Communication and Social Mobilization activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eTimeliness of pre-assessment of awareness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eAdvocacy, Communication and Social Mobilization activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eInvolvement of adolescents, Civil Society Organization (CSO),\u0026nbsp;Vaccine champions, and other community mobilization groups as peer sensitizers and vaccine champions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eAdvocacy, Communication and Social Mobilization activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur study objective was to evaluate the HPV Vaccination coverage performance of the phase one HPV vaccine rollout implementation across 15 states and the FCT in Nigeria. Our goal is to gain valuable insights into the effectiveness of the vaccine rollout campaign, identify disparities in vaccine uptake across the states, and identify the specific factors responsible for the observed disparities in coverage rate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFindings from the data analyzed revealed that 80% of the states in phase one successfully achieved the target set (80% of the eligible girls) by the National Primary Health Care Development Agency for the MAC campaign. Impressively, 40% of these states meet the set target, exceeding 90% coverage rate. An outcome that highlights the significant success of the campaign when compared to other countries especially in Africa that have introduced the HPV vaccine. For example, South Africa introduced the HPV vaccine in its EPI system in 2014. At the end of 2020, only 75% of the age cohort targeted had received the first dose of the HPV vaccine. Of this figure, only 61% received the full recommended vaccine dose [31]. This figure underscores the success achieved by Nigeria, who achieved a higher coverage percentage in a shorter time frame. In contrast to South Africa, who took 4 years to reach 75 percent of the eligible population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, three states, namely Lagos, Enugu, and Ogun states fell short of meeting the set target, reporting coverage rates of 36%, 75%, and 70% respectively. An in-depth analysis of reports from the states revealed several reasons for the suboptimal performance of these states. In Enugu and Ogun, competing activities impeded coordination efforts. For Lagos, the delayed release of funds for pre-implementation activities, the unexpected postponement of the rollout and the lack of budget for school engagement have been identified as the leading cause of their suboptimal performance. Also, States like Lagos and Enugu encountered hurdles associated with anti-vaccine sentiments among the population\u003c/p\u003e\n\u003cp\u003eAnalysis of the vaccination coverage data also revealed a notable trend across the states that implemented the phase one rollout. \u0026nbsp;The vaccination coverage rate of the age cohort of 9 surpassed the target of the NPHCDA, reaching an impressive 130%. In contrast, the vaccination coverage rate for the age cohort of 10 to 14 fell short of the target, with only 69% of the girls within this age cohort vaccinated, suggesting a potential discrepancy in the vaccination strategy adopted for both age cohorts. The \u0026nbsp; \u0026nbsp;success of vaccinating girls in the 9-year-old cohort suggests a target and successful demand generation and service delivery approach, while that for the 10 to 14-year-old cohort suggests specific barriers and challenges that warrant a closer examination as we look forward to phase two rollout and implementation.\u003c/p\u003e\n\u003cp\u003eOne vaccination strategy that proved effective is the school-based vaccination strategy, which helped in reaching a significant number of eligible girls. Analyzed results revealed that a significant portion of the vaccinated girls, 44% were reached using this strategy, mostly in primary schools (elementary school). \u0026nbsp;This is the reason for the higher vaccination rate of the age cohort of 9 (130%) than 10 to 14 (67%) because most 9-year-olds were in their later years in Primary school. The success of this strategy is a result of the collaborative effort of the NPHCDA, Federal Ministry of Education, and State Ministry of Education. Directives were issued to school authorities, and parents\u0026rsquo; consent after consultation with schools played an important role in the success of this approach. [32] highlight the effectiveness of the school vaccination strategy in their study in Malaysia, where 98% of the targeted age cohort were vaccinated using the school approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe high coverage rate achieved by Nigeria mirrors the effectiveness of a well-coordinated strategy, good leadership, state support, and robust government structure in the planning and implementation of the HPV vaccine introduction. \u0026nbsp;States that replicated the coordination structure established at the national level demonstrated political commitment, as well as having adequate funds for implementation and the early release of these funds achieved success in the rollout. During the pre-implementation phase, the NPHCDA strategically employed a comprehensive and diverse approach to create awareness and sensitize key stakeholders on the importance of the HPV vaccine. This involved interactive sessions held across the 15 implementing states, leveraging existing platforms with community gatekeepers, religious leaders, school boards, and social club leaders. The study by [33] highlights the importance of dialogue with community gatekeepers in building local confidence and driving demand for health services including immunization.\u003c/p\u003e\n\u003cp\u003eThe NPHCDA also undertook an extensive media campaign, leveraging existing and established media platforms to advocate for the acceptance of the HPV vaccine. \u0026nbsp;The aim was not just only to sensitize people but also to counteract infodemics and conspiracy theories about the vaccine. This proactive strategy sought to build confidence in the vaccine as well provide necessary information about the vaccine. [34] report that evidenced based messages leveraging existing media platforms directly counteract infodemics and conspiracy theories. [35] argued the importance of designing and sending specific tailored social media messages was effective in correcting anti-vaccine messages.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother strategy that had on the coverage rate is the involvement of Civil Society organizations (CSOs) in the pre-implementation and implementation phase of the rollout. Their active engagement was effective in creating awareness and mobilizing girls to the vaccination team, thereby adding a grassroots dimension to the demand generation of the campaign. CSO involvement beyond awareness creation, including advocacy visits and mobilization ensured that the campaign resonated well at the local level, addressing specific needs and concerns in the community where they worked. Leveraging their community connection and understanding of community dynamics, CSOs were able to tailor their efforts to address challenges and cultural issues as they relate to the HPV vaccine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[36] assert that CSOs have played an important role in the equity distribution of vaccines, especially COVID-19 vaccine. According to [37], Civil Society Organizations can aid in mobilizing the community and creating awareness for effective service delivery of any intervention.\u003c/p\u003e\n\u003cp\u003eUtilizing the WHO Health System Building Block framework, we assessed the contributing factors to the vaccination coverage rate in the 15 phase one states that rollout of the HPV vaccine thematic areas analyzed were coordination, leadership and governance, healthcare financing, human resources for health, vaccine supply and coal chain/logistics, monitoring and evaluation, service delivery, and advocacy, communication, and social mobilization. Our study underscores the importance of coordination structures at both state and national levels. Political involvement and commitment coupled with lessons learned from past vaccine introductions played a crucial role in fostering coordination. States like Enugu, Lagos and Ogun faced challenges because of competing activities that impacted coordination activities, which led to lower vaccination coverage. Adequate funding and the release of funds were attributed to the success of the MAC campaign. Conversely, states like Lagos faced financial challenges and this affected pre-implementation advocacy and social mobilization activities. In Ogun state, vaccination activities were hindered by lack of stipends of fixed post vaccination teams which potentially led to showing up for vaccination leading to low coverage.\u003c/p\u003e"},{"header":"5. Limitation of the study ","content":"\u003cp\u003eOur study relied on the Multi-Age Cohort (MAC) campaign data and reports from immunization officers involved in the campaign in the 15 states that implemented the rollout in phase one. The campaign data does not include important demographic information about the clients such as ethnicity, educational level, religion, and residence. The absence of this information limits the ability to comprehensively understand the diverse characteristics of the population studied and how these factors influence vaccine uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile acknowledging the availability of a study by the NPHCDA and the World Health Organization that assessed people\u0026rsquo;s knowledge, perception, and intention to take the HPV vaccine. A lot might have changed in the period that this manuscript was developed and the vaccine rollout because of infodemics and conspiracy theories. This may affect generalization and hinder direct comparison.\u003c/p\u003e"},{"header":"6. Study Implication","content":"\u003cp\u003eThe study examined the vaccination coverage variation across the 15 states that introduced HPV vaccine and identified the contributing factors to the vaccination coverage rate across the implementing states. The result found that 80% of the 15 states phase one state passed the target set by the NPHCDA for the MAC campaign, with 40% of these states surpassing a 90% coverage rate. The success of the campaign was credited to effective coordination, good leadership, government structure, and the effective demand generation and service delivery strategy employed in Nigeria. The study also found that the vaccination of girls aged 9 exceeded the target of the NPHCDA, with an impressive 130% of this age cohort vaccinated. The success was attributed to the school-based vaccination approach\u003c/p\u003e\n\u003cp\u003eThe study identified several factors contributing to the variation in vaccination rate across the 15 phase-one states using the WHO Health System Building Block Framework. The factors identified encompass coordination, leadership, governance, healthcare financing workforce, monitoring and evaluation, vaccine supply chain, and service delivery. In addressing the low coverage rates in states like Lagos, Enugu, and Ogun state, there is a need for a targeted strategy towards anti-vaccination sentiments through advocacy and sensitization campaigns. The sensitization and advocacy campaign should be tailored to the specific cultural and religious context of these communities, to identify and address the root cause of the sentiments, especially as we look forward to phase two.\u003c/p\u003e\n\u003cp\u003eThe success achieved in vaccinating eligible girls aged 9 underscores the need for a strategic approach that encompasses a broader age cohort that targets the age cohort of 10 to 14. There is a need for research effort especially as we look forward to phase two that will examine those factors that drive vaccination uptake within this age cohort. There is a need for tailored approaches and strategies that are effective and comprehensive to drive demand for girls within the age cohort. There is also a need for a thorough investigation into the delivery service strategy, especially for states like Enugu and Lagos. We must understand those specific barriers to this method and devise target interventions, for further vaccine introduction as we look forward to phase two. This will involve evaluating the strategies in these states and pinpointing the strengths, weaknesses, and gaps affecting fixed post uptake.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical Approval\u003c/h2\u003e\n\u003cp\u003eThis analysis solely involved the use of pre-existing publicly available data of vaccine coverage rates, and review of existing program reports for the purpose of gaining insights to improve the quality of the next phase of the HPV vaccine roll out in the country.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003enot applicable\u003c/p\u003e\n\u003ch2\u003eFunding Declaration:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe work was conducted as part of programmatic implementation by the National Primary Healthcare Development Agency (NPHCDA), hence did not receive any specific grant from funding agencies\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthor Contributions: Conceptualization, A.R.G, C.B.W., A.D., E.S., H.E., and B.G.; Methodology, C.B.W., A.D., E.S., H.E., A.P., H.G.T., Y.A., U.F., and B.G.; Validation, J.Z., E.E.M., and S.N.; Formal analysis, E.E.M., A.A.A., N.I.D., A.J., and A.P.; Writing\u0026mdash;review and editing, I.C.O., A.A.A., J.Z., H.E., E.A.S...,and A.P\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors extend our heartfelt gratitude to all those who contributed to the development of this paper. We sincerely thank Dr. Muyi Aina, the Executive Director of the National Primary Healthcare Development Board, for approving the use of administrative data from various interventions. Our appreciation also goes to the dedicated staff of Direct Consulting \u0026amp; Logistics (DCL) for their invaluable support in documenting the workshop\u0026apos;s outcomes. We are especially grateful to Gavi, the Vaccine Alliance, for funding the documentation workshop, which served as a crucial step in developing this paper.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets analysed during the current study are administrative data from the National Primary Health Care Development Agency (NPHCDA) HPV vaccine introduction campaign. These datasets are not publicly available due to government data protection regulations and use restrictions. 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Rebuilding Trust on Routine Immunization in Era of COVID-19 Fear\u0026ndash;Role that Civil Society Organizations can Play Hands-in-Hand with Immunization Program. Public Health Rev. 2021;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/phrs.2021.1603989\u003c/span\u003e\u003cspan address=\"10.3389/phrs.2021.1603989\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer, HPV vaccine, Multi-Age Cohort, Coverage rates, Lessons learned","lastPublishedDoi":"10.21203/rs.3.rs-7703369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7703369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNigeria introduced the quadrivalent HPV vaccine into its Expanded Programme on Immunization (EPI) in 2023 using a two-phase rollout. Phase one experienced several challenges underscoring the need to analyze vaccination coverage, identify factors influencing uptake and drawing lessons learned for future strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe employed a mixed-method approach using call-in data from the multi-age cohort vaccination campaign and implementation reports from the 15 states and the Federal Capital Territory. We analyzed coverage rates and trends as well as thematic ally analyzed factors influencing uptake.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eCoverage varied across the 16 states; 12 (80%) achieved the national target of 80%. School-based vaccine delivery strategy proved the most effective approach. Factors that influenced coverage disparities across the implementing states include robust state technical working groups, timely financial support, leveraging local workforce, efficient vaccine distribution, real-time monitoring, comprehensive strategies, and rigorous ACSM activities engaging community influencers and mass media. Lessons learned revealed emphasizing the integration of the different working groups, ensuring the timely release of funds, adopting diverse service delivery strategies and sustained advocacy as central for future rollout.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe success of the phase one HPV vaccine introduction was linked to effective coordination, and diverse service delivery strategies. Lessons learned highlight the importance of early planning, early release of funding, involving community gatekeepers, and the integration of adolescents and civil society organizations in the promotion of vaccine uptake.\u003c/p\u003e","manuscriptTitle":"Coverage Performance and Lessons Learned from the Multi Age Cohort Campaign for HPV Vaccine Introduction in Phase One States of Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 16:34:59","doi":"10.21203/rs.3.rs-7703369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c72b6986-e467-4ddc-ad56-6673b1f30c93","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-12T08:54:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 16:34:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7703369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7703369","identity":"rs-7703369","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}