Objective

To open the "black box" of the "Carmen de Bolívar event".

Methods

Search for literature in Medline, Lilacs and Redalyc with the terms "vaccine", "HPV", and "Colombia"; review of national ends surveys and policy documents published on the website of the Colombian Ministry of Health.

Results

Low knowledge of the vaccine by Colombian women before its introduction, no articulation to the sexual and reproductive health policy, lack of prior training of health workers at all levels of care and non-specific communication plans for HPV vaccine.

Discussion

There could be a new list of responsibles to assess "Carmen de Bolívar" more as an outcome. Such as the introduction of the non-integrated vaccine to sexual and reproductive health programs, the absence of prior strengthening of knowledge and skills about HPV and the vaccine in health workers, especially in primary care, the absence of a specific prior communication plan at the start of vaccination, guided by the indications of problems of acceptability in the population and knowledge gaps in women in deep Colombia, the implementation of an operational strategy identical to vaccines for communicable diseases that did not assess the unique characteristics of the vaccine against HPV. But also, the handling of the crisis in El Carmen de Bolívar that did not comply with the WHO recommendations for these cases could operate as an aggravating circumstance, and not as a determining cause of the current problem.