Spatio-temporal variation in the uptake of the Human Papilloma Virus (HPV) vaccine among Malawian girls between 2019 and 2024

Abstract Background Malawi has one of the highest incidences and mortality due to cervical cancer, which is caused by the human papillomavirus (HPV). Achieving high HPV vaccination coverage is critical for advancing the World Health Organization (WHO) cervical cancer elimination strategy. This study aims to describe the spatio-temporal uptake of the first and second doses of the HPV vaccine in Malawi and to investigate the covariates associated with the uptake. Methods We analysed HPV vaccination coverage data from routinely collected administrative data across 28 districts in Malawi from 2019 to 2024. We used spatio-temporal Bayesian models in R-INLA to investigate the association between environmental factors, such as urbanization and climatic conditions, and vaccination uptake. Results HPV vaccine uptake was 46.83% (95% Credible interval, CrI: 46.52%, 47.21%) for the first dose, and 32.44% (95% CrI: 32.09%, 32.96%) for the second dose, across the study period, with distinctive subnational heterogeneity. A negative relationship was observed between nighttime light intensity and vaccination coverage (first dose: posterior mean: -0.599, (95% CrI: -1.160, -0.040); second dose: posterior mean: -2.164, (95% CrI: -3.415, -0.967)). Conclusions HPV vaccination uptake in Malawian districts remains below the WHO 90% vaccination target. These findings emphasise the need for decentralised planning to improve coverage. Targeted interventions, mobile outreach programmes, and strengthened community engagement, particularly in urban settings, may help close coverage gaps and accelerate progress toward cervical cancer elimination in Malawi.