Increasing HPV Vaccine Awareness in Nepal’s Schools

Nepal will begin a Human Papillomavirus (HPV) vaccination campaign next month, and Dr. Alisha Manandhar is ready. According to Manandhar, an estimated four women die of cervical cancer every day in Nepal, and vaccinating adolescents against HPV could prevent most of those deaths in the future.  

As Provincial Project Coordinator for strengthening competency and quality improvement for maternal and newborn care in hospitals at the Simulation Society of Nepal, Manandhar knows information is key to acceptance and uptake of the vaccine. So, she proposed developing an educational program for for students, teachers, and parents that combined information about the HPV vaccine with information about preventing other non-communicable diseases to present to students and teachers in schools. Her proposal earned a 2023-2024 COVID-19 Recovery for Routine Immunization Programs Fellowship offered by the Sabin Vaccine Institute and the World Health Organization — which aims to support immunization professionals by strengthening their capacity to plan and implement immunization programming. Last spring, initial presentations of the material she created as part of the fellowship led to 87% of all students and 93.7% of teachers showing interest in and understanding of HPV vaccines in post-presentation tests. Manandhar hopes to use the material as the 2025 HPV vaccination campaign rolls out. 

Why did you choose to develop a project educating about HPV vaccination? 

In the context of Nepal, there were several factors driving an HPV vaccination project, including: 

  • A high burden of cervical cancer. The burden of cervical cancer is particularly high in Nepal, with many cases diagnosed at later stages.  As of 2023, there were approximately 2,244 new cases and 1,493 deaths annually due to cervical cancer,  
  • Cervical cancer is one of the leading causes of cancer-related deaths among women in Nepal. HPV infection is the primary cause, and vaccination against HPV has proven to be a highly effective preventive measure. Developing such a project directly addresses a critical public health challenge. 
  • Cervical cancer is preventable. HPV vaccination offers an opportunity to prevent cervical cancer, which is largely avoidable with appropriate interventions. Promoting vaccination can significantly reduce the burden of the disease, especially in a low-resource setting like Nepal. 
  • It is a national health priority. The Government of Nepal has recognized the importance of cervical cancer prevention and has included HPV vaccination in its national health strategy. Nepal’s national health priorities for cervical cancer focus on enhancing screening programs, increasing access to HPV vaccination, and improving treatment options. This project aligns with national goals and demonstrates commitment to strengthening public health programs. 

By focusing on HPV vaccination, the project aims to save lives, reduce healthcare costs, and contribute to achieving Nepal’s Sustainable Development Goal (SDG) targets, particularly those related to health and gender equity. 

Do you work with adolescents in your medical practice? 
Students hearing presentation at the Shanti Shik Sha Mandir Secondary School.

While I may not always work directly with them, this age group is an integral part of my broader public health initiatives. Through programs like HPV vaccination, reproductive health education, and school-based health advocacy campaigns, I address their needs indirectly. Family-centered care often involves counselling parents on issues such as nutrition, hygiene, and vaccination for their children in this age group. Additionally, community outreach programs and training sessions for healthcare workers enable me to contribute to the wellbeing of adolescents, making them a key focus of my preventive and public health efforts. 

Your project involved both boys and girls. Is the national HPV vaccine rollout in Nepal gender-neutral? 

I aimed to make my project gender-neutral, as HPV affects both genders and vaccinating boys contributes to herd immunity. However, in Nepal’s national immunization schedule, the HPV vaccine is currently recommended only for girls. This decision likely reflects practical considerations, including vaccine shortages, prioritization of the most vulnerable gender — girls, who face the highest risk of cervical cancer — and financial constraints. Expanding the program to include boys would require addressing these challenges, but it remains an important long-term goal for equitable and comprehensive HPV prevention. 

What was the reaction to the education program you developed by parents and teachers? 
Dr. Alisha Manandhar with teachers at Shanti Shik Sha Mandir Secondary School.

The reaction was largely positive from both parents and teachers. Parents appreciated the program for raising awareness about HPV, cervical cancer, and preventive measures, as it addressed critical knowledge gaps and helped them make informed decisions about their children’s health. Teachers valued the program for its interactive and informative approach, which complemented school health curricula and empowered them to discuss sensitive health topics with students more effectively. However, some initial hesitancy was observed, particularly regarding cultural sensitivities and misconceptions about vaccination, but these concerns were addressed through open communication and evidence-based explanations. Overall, the program was well-received as a vital initiative for adolescent health. 

Your data showed significant improvement in understanding of HPV vaccination – is this helping now with the upcoming HPV vaccination campaign? 

Yes, the improvement in understanding of HPV vaccination — about 87% of the students and 93.7% of teachers showed good understanding on a test after the material was presented— will contribute positively to the ongoing HPV vaccination campaign. Enhanced awareness among parents, teachers, and adolescents has increased HPV vaccine acceptance and reduced hesitancy, particularly in communities where misconceptions and cultural barriers previously hindered uptake. The education efforts have also empowered local stakeholders to advocate for vaccination, creating a ripple effect of awareness and trust.  

Have you used the material you developed in other schools? 

I would like to use the material developed for the project in other settings beyond the initial school targeted during the Fellowship, but budgetary constraints make it difficult to expand the program to other schools, as it requires additional funding for materials, training sessions, and logistical support. Nonetheless, the material remains a valuable resource, and I am hopeful it can be utilized more extensively when funding allows, especially now that the HPV vaccine has been included in the national immunization schedule. 

Has there been a lot of education around HPV vaccination in Nepal in advance of the vaccine rollout this year? 
Dr. Alisha Manandhar presenting at a school.

Ideally, there should be a lot of education ahead of this year’s vaccine rollout, but it’s difficult. However, I am pleased that I was able to contribute by disseminating information and raising awareness through the implementation of my project. This effort, though small in scale, served as a meaningful step toward bridging the knowledge gap and fostering understanding about the importance of HPV vaccination.  

What are you hoping will be the outcome of the HPV vaccination program in Nepal? 

I hope the HPV vaccination program will significantly reduce the incidence of cervical cancer, which remains the leading cause of cancer-related deaths among Nepalese women. Cervical cancer is responsible for the deaths of an estimated four women every day in the country. 

The upcoming HPV vaccination campaign, supported by Gavi, the Vaccine Alliance, WHO, and UNICEF, is set to launch on 4 February, coinciding with World Cancer Day, is a major step forward. The campaign aims to immunize over 1.6 million adolescent schoolgirls (grades 6 to 10) and out-of-school girls (10 to 14 years of age) nationwide. This initiative will see the introduction of HPV vaccination into Nepal’s National Immunization Program, which is a significant milestone in the country’s efforts to combat cervical cancer.