Cervical cancer, most commonly caused by the sexually transmitted Human Papilloma Virus, (HPV) poses a great risk to the Indian women.
Globally it is the fifth most common cancer in humans and second most common cancer for women.
In India, it is the most common cancer for women. It is also a leading cause of death, especially in developing countries where awareness is low and irregular screening (through pap smear tests) means late detection. India is particularly vulnerable in this regard with 132,000 new cases diagnosed and 74,000 deaths annually. This makes it about a third of global cervical cancer deaths.
Cervical cancer strikes earlier and it is estimated that almost 80% of sexually active women acquire genital HPV by 50 years of age. Early on there are almost no symptoms and they manifest quite late making treatment difficult. However, the good news is that there are effective and safe vaccines available against the virus. All of these protect against at least HPV type 16 and 18 that cause the greatest risk of cervical cancer.
World Health Organisation has recommended the vaccine as part of a routine vaccine for all countries mainly for girls between the ages of nine to thirteen. It has been thus been adopted by almost all the developed countries. The National Cancer Institute estimates that if protection turns out to be long-term and all women were to take the vaccine then cervical cancer deaths around the world would reduce by as much as two-thirds. Besides this, it will be a great cost-cutting measure in the long term since it will reduce the need for pap smears, follow up invasive procedures and of course the treatment. This will be providential for developing countries where screening is poor, treatment expensive and morbidity and mortality high.
Given its benefits and high disease burden in India, it is surprising that HPV vaccine is struggling to pick up here and most are not even aware of it. At the moment the vaccine does not form part of all India Universal Immunisation Programme even though pilot programmes have been launched in some government hospitals of Delhi and Punjab. Reports suggest that while 1,200 doses have been administered in Delhi as of March 2017, nearly 10,000 girls have been covered in two high prevalence districts – Bathinda and Mansa – in Punjab. Moreover, Delhi intends to expand the vaccination programme to cover 250,000 school-going girls annually, while Punjab will be expanding the HPV vaccination to five more high prevalence districts in its second phase.
Low uptake and suspicion surrounding the vaccine can be perhaps attributed to its rocky start a few years ago. In June 2009, the HPV vaccine trial in Andhra Pradesh and Gujarat featured in the news following the deaths of young tribal girls who were among the 23,000 women enrolled in PATH (Programme for Appropriate Technology in Health) immunization trials. Media alleged that these deaths were caused by the vaccines and girls used as “guinea pigs”. These deaths brought to the fore issues related to conflicts of interest, violation of moral standards and unethical nature of informed consent and recruitment.
This was accompanied by memorandum to the government in 2010 by citizen advocates of human rights and women groups, academics and experts raising concerns about the safety, efficacy and cost-effectiveness of the vaccine. It demanded the immediate halt of all trials and demonstration projects in India. It also demanded an enquiry into deaths. Later, even though deaths were found to be unrelated to the vaccine, this severely hampered the HPV vaccine uptake in India.
Vaccine’s uptake in the routine immunisation programme now, and thus provision through government especially becomes important because at present the vaccine is expensive. There are two vaccines available in India, bivalent Cervarix that costs around 2200 and quadrivalent Gardasil that costs around 3000. They are available through private hospitals but low awareness means that often, even people who can afford it do not take it. In any case, unless the prices are substantially brought down and the government undertakes massive information campaigns regarding the safety and efficacy of the vaccine, it is unlikely that it will reach every girl.
Introducing a new vaccine in India always remains a challenge in itself, given low routine immunisation coverage.
Some gains have been made due to National Rural Health Mission, but according to the most recent National Family Health Survey, the immunisation coverage is still 62%. Rural India fares much poorer. Some experts have thus argued that it is important to compare the burden of cervical cancer to other public health problems in India such as the absence of primary care, high incidence of vector-borne diseases, poor maternal health and rampant malnutrition and then decide on the best use of financial resources.
However, since the vaccine is already available in the market and accessible to the rich, not making it part of UIP will exclude the poor. The equity concerns are valid since it’s the poor who are least likely to get regular pap smears and also least able to afford treatment should they get cervical cancer. Cheaper, indigenous versions of HPV vaccine are already underway. Serum Institute of India hopes to make its version available by 2018 and sell at a third of the price of Gardasil. Also, the economies of scale are likely to bring the costs down if India includes it in the UIP. The costs of cancer treatment and hospitalisation are going to be more than a vaccine, especially as morbidity is on the rise. In any case, there can be no costs to saving human lives.
Globally, besides issues of efficacy, safety and costs, the vaccine also had to face some issues around ‘morality’.
Religious conservatives in Europe and USA have voiced concerns that getting a vaccine might encourage promiscuity and abstinence must be promoted instead, even though evidence has indicated teenagers who received the vaccine tend to be far more aware of their sexual health. Nor is sexual activity elevated in the vaccinated group.
The vaccine is still in nascent stages in India and not part of compulsory UIP, thus debates have still not been mapped out clearly. However, given the socially conservative climate and India and patriarchal attempts to control the sexuality of girls, the Indian government will need to engage with the question of giving a vaccine to teens that prevents sexually transmitted diseases. This is in a context where sex-education is very limited, misinformation is rampant, parents refuse to believe that teenagers might be sexually active and thus need a vaccine, and the overall stress is either on abstinence or monogamy rather than safe sexual practices, promotion of sexual health, and prevention of STIs.
For any vaccine, besides ensuring safety and efficacy, the government needs to think about the existing disease burden, the costs involved, the integration of the new vaccine with the UIP and the larger public health infrastructure, and organise an extensive information and awareness campaign around the disease, its prevention, the vaccine and its need. Alongside it will need to develop and encourage cost-effective screening methods. This can go a long way in saving the lives of Indian women.
Disclaimer: The opinions expressed in this article are the personal opinions of the author. The facts and opinions appearing in the article do not reflect the views of NEWSD and NEWSD does not assume any responsibility or liability for the same.