A Dose Reduction Immunobridging and Safety Study of Two HPV Vaccines in Tanzanian Girls

Cervical cancer is the most common cancer in women aged 15-44 years in East Africa, and mortality rates are very high. HPV vaccines are most effective if given to girls who have not yet acquired HPV infection. In Tanzania, HPV vaccine has been shown to be safe, acceptable and can be delivered with high coverage (\~80%). However, the cost of delivering HPV vaccine is considerably higher than costs for traditional infant/child vaccinations. This is primarily because of costs to establish outreach programmes and associated personnel costs including nurses who must spend significant time away from their posts to deliver vaccine, especially if multiple doses are needed. There is global interest in simplifying HPV vaccine delivery by reducing the number of doses. If a single dose could be given, this could halve the costs of delivery, making it more accessible to the populations that need it most. Recently, the WHO recommended that 2 doses of HPV vaccine could be given to young girls, based on studies in high and upper middle-income countries. However in Africa high rates of infections like malaria and worms can affect immune responses to vaccines. It is essential to know that reducing the number of doses does not reduce the protective immune response of these vaccines. The investigators are conducting a trial in Tanzanian girls aged 9-14 years to establish whether a single dose of HPV vaccine produces immune responses that are likely to be effective in preventing cervical cancer. Two different HPV vaccines, the bivalent (2-v) vaccine that protects against HPV 16/18 (the cause of 70% of cancers) and the 9-valent (9-v) vaccine that protects against 9 HPV types, will be compared. The trial will randomise 900 girls to 6 arms and follow them for 36 months. Girls will receive the 2-v or the 9-v HPV vaccine, as 1, 2 or 3 doses. Girls receiving 1 or 2 doses will be compared with those receiving 3 doses of the same vaccine, to ensure that the reduced dose regimen produces an immune response that is not inferior to 3 doses. Girls in the 1 and 2 dose arms will be enrolled in an extension and followed for up to 9 years, to examine the stability of immune responses. The immune responses in this study will also be compared with results from other countries where the vaccine has been shown to be protective. This will provide information about whether a reduced number of doses is likely to be protective in Africa. This work will be extremely important in informing future HPV vaccination strategies and will be one of the first randomised trials of 1 and 2 doses of any HPV vaccine in Africa.

Inclusion Criteria: * Born female; * Aged between 9 and 14 years inclusive; * Enrolled in a government primary or secondary day school in Mwanza city (or neighbouring district if included); * Living in Mwanza city (or neighbouring district if included) without plans to move away in the next 36 months; * Willing to participate in the study and sign the informed assent form; * Supported in this study participation by at least one of their parents (or LAR), who has signed the informed consent document; * In good health as determined by a medical history (a physical examination will be conducted if necessary according to the clinician's judgement); and * Able to pass a Test of Understanding (TOU) if aged 12 years or above, or if younger than 12 years old, a parent or LAR is able to pass a TOU Exclusion Criteria: * They are diagnosed with chronic conditions, such as autoimmune conditions, degenerative diseases, neurologic or genetic diseases among others; * They are HIV positive, or immunocompromised; * They are pregnant, less than three months post-partum or currently breastfeeding; * They are allergic to one of the vaccine components or to latex; * They are sexually active and are not willing to use an effective birth control method from 28 days before the first dose until 60 days after the last vaccine dose; * The nurse or clinician determining the eligibility, in agreement with principal investigator, considers that there is a reason that precludes participation; * They have been previously vaccinated against HPV