Barriers to scaling up HPV vaccination in India
Authored by - Parth Sharma, public health physician, Anoushka Arora, medical student and research intern and Siddhesh Zadey, co-founding director, ASAR.
On September 1, 2022, the Government of India launched the new indigenous cervical cancer vaccine, Cervavac, in partnership with Serum Institute of India Private Limited. This vaccine is a consequence of the partnership programme, Grand Challenges India, between the department of biotechnology (DBT) and the Biotechnology Industry Research Assistance Council (BIRAC) with the Bill and Melinda Gates Foundation. The project to develop the vaccine began in 2011 and it was only in July of 2022 that Cervavac got market authorisation from the Drug Controller General of India. The introduction of this vaccine is a welcome step in the battle against cervical cancer in India where every eight minutes, one woman dies of this preventable disease.
Human Papilloma Virus (HPV) causes 95% of all cervical cancers. Currently, two HPV vaccines are for sale in India, Cervarix and Gardasil, which protect against two and four strains of HPV, respectively. These two vaccines have been on the market since 2008. As they are manufactured by foreign manufacturers, they have been sold at steep prices, posing an affordability conundrum. Similar to Cervarix, Cervavac is a quadrivalent HPV vaccine protecting against four strains. The introduction of Cervavac, which is promised to be sold at one-tenth of the price of the previously existing vaccines, solves the problem of affordability. However, there are several barriers to HPV vaccination scoping beyond the vaccine’s cost.
The stigma around reproductive health issues in India is a significant barrier. Women often feel uncomfortable discussing symptoms of diseases associated with sexual organs like the cervix. Coupled with cancer, this problem only worsens. Misplaced beliefs of cancer as a contagious disease, a punishment, and a death sentence have stigmatised cancer as well. Eventually, the stigma associated with these diseases leads to a delay in seeking medical care once the symptoms of cervical cancer develop.
Various cultural beliefs have also resulted in poor uptake of vaccines against cervical cancer. As cervical cancer is linked to sexual activity, Indian parents and guardians believe that offering HPV vaccination might lead to an increase in a person’s sexual activity. The awareness related to cervical cancer and its vaccination is also low in our community which has led to the development of fear and misconceptions related to vaccination and further reduced its uptake.
HPV vaccination uptake, however, has only been studied in women in India. This is mainly because of the misconception that HPV infection causes cancer only in women. HPV is known to cause anorectal, oral, nasopharyngeal, oesophageal, and penile cancers in men too. Lack of awareness has therefore resulted in close to no uptake of HPV vaccination in men who also could benefit from the same.
Community health workers could play a crucial role in addressing these barriers by interacting with the people and addressing the misconceptions and myths. In Kolkata, interaction with trained social workers and the distribution of factsheets increased vaccine acceptance. Therefore, addressing the drivers of stigma, misconceptions, and poor understanding of the vaccine through cancer awareness camps is important to successfully vaccinate people with the new indigenous vaccine.
It is important to foresee that HPV vaccination might affect cancer screening. It has been seen in other places that vaccination can create a false sense of security from cancer and reduce screening. Screening for cervical cancer is already low in India which is highlighted by the fact that only one in three women in India gets diagnosed with localized disease while the rest present only once the disease has reached a more advanced stage. It has been shown that twice-lifetime screening accompanying vaccination can help in identifying and managing abnormal lesions early and thus reduce cancer occurrence in the community. Therefore, it becomes imperative to strengthen screening services before launching widespread vaccination drives to use those drives as an opportunity to promote screening as well.
The public health system could also draw inspiration from the previous successful methods of promoting HPV vaccination in India. Vaccination drives carried out in schools in Sikkim are a great example to follow. Moreover, adding the vaccine to the Universal Immunisation Programme will increase its accessibility, and boost its uptake. The HPV vaccine has previously been successfully introduced in India as a part of the immunisation schedule in Punjab and through opportunistic vaccination in Delhi. It is known that government-supported vaccination has better acceptance. Therefore, efforts should be made to introduce the HPV vaccine in the national immunisation schedule as soon as possible.
A blooming private health sector could also be leveraged to promote vaccination. Collaborating with professional bodies like the Federation of Obstetric and Gynaecological Societies of India (FOGSI) and other professional bodies and private corporations could play an integral role in promoting vaccine uptake. Like in the case of tuberculosis, public-private partnerships and the establishment of a referral system could help in guiding eligible people to the nearest designated facilities for vaccination, thus improving awareness and accessibility of the vaccine.
Lastly, cervical cancer should be made a notifiable disease under the National Programme for Prevention and Control of Non-Communicable Diseases (NPNCD). India’s cancer registries need to be strengthened to adequately gauge the extent of the problem of cervical cancer among other cancers. Only then it will be possible to monitor the impact of vaccination on reducing the cervical cancer burden.
Time is running out and we are losing countless lives to preventable cancer every hour. A cheaper vaccine, however, is not the ultimate solution to this problem. A problem as complex as this requires a multipronged assessment and approach for a successful and long-lasting solution.
This article is authored by Parth Sharma, public health physician, Anoushka Arora, medical student and research intern and Siddhesh Zadey, co-founding director, Association for Socially Applicable Research (ASAR).