Recent events surrounding cervical cancer and the advocacy for its preventive solution, the human papillomavirus (HPV) vaccination, have dominated headlines. On one front, Union Finance Minister Nirmala Sitharaman brought attention to the HPV vaccine during her budget speech. Simultaneously, actress Jhanvi Kapoor has been actively supporting an awareness campaign for the vaccine’s manufacturer, Serum Institute. However, the news took an unexpected turn when Indian model and actor Poonam Pandey shocked the public with a publicity stunt, faking her own death to ostensibly raise awareness about cervical cancer.
Considering the severity of the disease and the significant toll it takes on lives, it unquestionably merits every bit of attention and more. Gynecologist Rahul Manchanda, a staunch supporter of incorporating the HPV vaccine into India’s national immunization program, which would make it accessible to women free of cost, states, “While there is current scrutiny of Ms. Pandey’s methods, it prompts us to question who else was effectively raising awareness about cervical cancer and the HPV vaccine before. The vaccine is relatively unknown, challenging to obtain, and often unavailable at local pharmacies due to a lack of awareness. As a gynecologist, I can affirm that her attempt to bring the issue into the public discourse has, in fact, succeeded. There is a noticeable increase in questions and a surge in interest regarding the HPV vaccine.”
What is cervical cancer? Early signs, and symptoms.
Cervical cancer is a significant health concern in India, ranking as the country’s second most common cancer among women (after breast cancer), constituting 10 percent of all female cancers. Challenges in timely diagnosis and treatment contribute to its high mortality rate, with India accounting for more than one in five of these cervical cancer cases and deaths. Every year, approximately 77,348 women in the country succumb to cervical cancer.
“6-7 percent of Indians have HPV, it encompasses both males and females. Individuals can be infected with the virus, and in many cases, the body naturally clears the virus within 1-2 years. However, it’s noteworthy that clearance chances are higher in females compared to males, with only a 30-40 percent likelihood in males. Importantly, men can serve as persistent carriers, becoming a repeated source of virus transmission. This underscores the importance of understanding and addressing HPV infection in both genders,” said Dr. Sharda Jain, Obstetrician-Gynaecologist, Life Care Centre.
According to a WHO report released on February 1, Indian women have a 17.7% incidence rate of new cervical cancer cases. It’s important to be aware of its symptoms, know the recommended age to start screenings, understand the frequency of these screenings, and know about the appropriate timing for HPV vaccination.
HPV, a widely spread sexually transmitted infection, significantly contributes to cervical cancer. Immunization against HPV not only combats various virus strains but also guards against related health issues, such as genital warts and cancers impacting both genders, including cancers of the mouth, throat, head, and neck caused by HPV.
Dr. Rama Joshi, Director and Head of Department (HOD), Gynaecology Oncology and Robotic Surgery, at Fortis Memorial Research Institute, Gurugram says “approximately half the people diagnosed with cervical cancer die of the disease”.
Symptoms of cervical cancer can include irregular bleeding, such as bleeding between periods or after intercourse or even after menopause, pelvic pain, pain during intercourse, and unusual discharge. It’s important to consult a healthcare provider if any of these symptoms are experienced, as early detection and treatment can significantly improve outcomes.
“Late detection of cervical cancer could also be that cervical cancer in early stages is mostly asymptomatic. However, some individuals could notice bleeding after sexual intercourse as an early sign,” said Dr. Joshi. However, the lack of widespread screening and treatment infrastructure leads to lower detection rates compared to global standards.
Awareness deficit: Biggest barrier to widespread screening
As per National Family Health Survey 5, In India, cervical cancer screening rates are alarmingly low, with only 1% of women undergoing tests, far below the World Health Organization’s advised minimum of 70%. This low screening rate is consistent across other cancers such as oral and breast cancer.
WHO reports that fewer than one in 10 women in India have been screened for cervical cancer in the past five years. The HPV Information Centre, responsible for gathering, analyzing, and distributing nation-specific data on HPV and cervical cancer for the International Agency for Research on Cancer, an expert cancer body of the WHO, estimates that only 2% women in India have been screened for cervical cancer.
Dr. Jain highlights, “limited screening affects not only the treatment outcomes for cervical cancer but also the survival probabilities”.
Recent research featured in the Lancet in October 2023 highlighted significant disparities in cervical cancer survival rates across 11 Indian centers. In urban Ahmedabad, the five-year age-standardized relative survival rate stood at 61.5%, whereas it fell to 31.6% in Tripura.
A survey conducted in 2020 by CAPED revealed that out of 1,305 participants, merely 45% knew about cervical cancer, and just 34% understood that it affects the uterus. Furthermore, 73% of women have neither received a vaccine to prevent cervical cancer nor undergone a PAP test to detect it, primarily because of insufficient information and advice.
Dr. Joshi mentioned, “Efforts to enhance participation in screening for cervical and breast cancer (among women) and oral cancer, as part of the National Programme on non-communicable diseases (NCDs) which is being implemented in districts nationwide, are being supported by awareness campaigns.”
How does a vaccination campaign help?
As reported by The Indian Express, India intends to implement its HPV vaccination campaign through government schools, a strategy deemed highly favorable. The campaign will reportedly use the quadrivalent vaccine, aimed at guarding against the four predominant HPV types responsible for cancer — 16, 18, 6, and 11. “Over 95 per cent of cervical cancer instances are associated with a persistent infection by certain high-risk HPV strains, a government-led vaccination initiative could significantly lower both the occurrence and mortality rates. Furthermore, since HPV infections are connected to anal, vaginal, and oropharyngeal cancers, such a vaccination drive is expected to also reduce the incidences of these cancers,” says Dr. Joshi.
In India, two HPV vaccines are currently available: Gardasil, distributed by Merck, and Cervavac, an indigenously produced vaccine by the Serum Institute of India. Cervavac, being the more economical option at Rs 2,000 per dose, still poses affordability issues with the recommended two-dose regimen for comprehensive protection. Dr. Joshi noted, “for widespread accessibility among women, it’s imperative for India to integrate the HPV vaccine into its Universal Immunization Programme”.
Is there a case of vaccine hesitancy?
Concerns and hesitancy around the HPV vaccine in India were heightened following reports of adverse events, including deaths, that were temporally associated with the administration of the Gardasil vaccine during a demonstration project conducted in the states of Andhra Pradesh and Gujarat between 2009 and 2010. The project was a collaboration between the Indian Council of Medical Research (ICMR) and the non-profit organization PATH.
These reports garnered significant media attention and public scrutiny, contributing to fears and skepticism about the safety of the HPV vaccine. It’s important to note, however, that subsequent investigations by the government did not find the vaccine to be the cause of the deaths. The events were instead attributed to various causes unrelated to the vaccine, such as suicide, snake bite, and severe malaria.
In response, Dr. Jain emphasizes that “public health authorities and organizations have been working to address these concerns by increasing transparency, providing more information about the vaccine’s safety, and emphasizing its importance in preventing cervical cancer. Building trust through community engagement and addressing specific cultural and knowledge gaps are essential strategies to overcome vaccine hesitancy”.
What is the current evidence on the vaccine and what are the ongoing initiatives?
Reports indicate that more than 100 countries with HPV vaccination programs have reported a decrease in cervical cancer cases. Initially approved to prevent HPV infections, by the late 2000s, vaccines were found to also reduce pre-cancerous lesions. Recent studies from Sweden and England have shown that vaccinating teenagers can lower their risk of cervical cancer by over 85% by the age of 30.
Between 2009 and 2011, 500 girls in India were vaccinated and monitored for seven to eight years. The Sikkim government observed that these girls grew up healthily, got married, and had children, using this data to assess the vaccine’s safety and effectiveness.
The Indian government, bolstered by positive outcomes from countries like the UK and Australia adopting HPV vaccination, decided to proceed in 2017. Sikkim, leading the initiative, acquired the FDA-approved Gardasil vaccine at a discounted rate through UNICEF, a vital step as India didn’t have its own HPV vaccine at the time.
The major concern revolved around the potential impact of the HPV vaccine on girls’ reproductive health, with reassurances provided by medical professionals, including general practitioners and gynecologists. To address this and boost the reach, the government initiated targeted awareness programs and specific training programmes for ASHA workers.
Applauding the Sikkim model, Dr. Joshi said, “ASHA and Anganwadi workers received targeted training to enhance their understanding and involvement in the HPV vaccination initiative. Furthermore, educational campaigns and tailored meetings with parents at schools were held to alleviate their concerns. The extensive population and reliance on state healthcare infrastructure significantly contributed to the initiative’s positive momentum.”
While the evidence on the efficacy of HPV vaccination is solid, uncertainties persist regarding its inclusion in the national immunization program, despite government assurances. Discussions surrounding the vaccine and cervical cancer are widespread today, with challenges primarily centered on cost and the strategy for ensuring the success of a highly anticipated immunization program.
