Protecting Women Securing Future

Cervical cancer, the second most common cancer among Indian women, claims one life every eight minutes. HPV vaccination has emerged as a proven prevention strategy, yet its adoption in India lags due to systemic barriers. The need is to scale up efforts to eliminate this scourge.
By Dr Suneela Garg, Dr K Madan Gopal, and Dr Arvind Garg

Cervical cancer, following breast cancer, remains the second most common cancer among Indian women, contributing to one-fifth of the global burden. According to WHO-GLOBOCAN 2020 estimates, India witnessed 1.2 lakh new cases and over 77,000 deaths that year. This translates to an alarming rate of 18 new cases per 100,000 women, with a five-year survival rate below 50 per cent. Tragically, in India, four out of five cervical cancer cases are diagnosed at advanced stages, leading to exceptionally high mortality rates. It is estimated that one Indian woman succumbs to cervical cancer every eight minutes.

The Role of HPV in Cervical Cancer
Cervical cancer arises predominantly due to persistent infection with high-risk types of human papillomavirus (HPV). Co-factors such as early onset of sexual activity, teenage pregnancies, multiple sexual partners, multiple pregnancies, and sexually transmitted infections (STIs) further facilitate the disease’s initiation and progression. HPV is a DNA virus with over 100 distinct types, among which HPV-16 and HPV-18 are responsible for the majority of invasive cervical cancers worldwide.
This form of cancer has a prolonged pre-invasive phase lasting 10-15 years, providing an invaluable window for prevention through vaccination, regular screening, and early detection. Globally, HPV-16 and HPV-18 cause over 70 per cent of invasive cervical cancers, a figure that climbs to over 80 per cent in India. These types are targeted by all prophylactic HPV vaccines, making vaccination a critical tool in combating cervical cancer.

Global Call for Cervical Cancer Elimination
In a landmark effort to eradicate cervical cancer, the World Health Organization (WHO) issued a call to action, emphasising widespread HPV vaccination, screening, early diagnosis, and timely treatment of pre-cancerous lesions and cancer. On November 17, 2020, the World Health Assembly (WHA) launched a comprehensive global strategy with three ambitious targets to achieve by 2030:

90 per cent of girls fully vaccinated by 15 years of age with two doses of the HPV vaccine.
70 per cent of women screened using a high-performance test at ages 35 and 45.
90 per cent of women with cervical pre-cancer and cancer receiving treatment.

These initiatives aim to reduce cervical cancer cases to less than four per 100,000 women, aligning with the United Nations’ Sustainable Development Goals (SDGs) to cut premature mortality from noncommunicable diseases by one-third by 2030. Since its introduction in 2008, HPV vaccination has proven to be a safe and effective means of primary prevention. By June 2015, over 200 million doses of the quadrivalent vaccine and 80 million doses of the bivalent vaccine had been administered globally. International monitoring agencies, including the WHO, the European Medicines Agency, and the Global Advisory Committee on Vaccine Safety, have all concluded that these vaccines are safe, with no undue safety concerns.

Challenges in India’s HPV Vaccination Rollout
Despite its introduction, HPV vaccination is yet to be included in India’s Universal Immunisation Programme. Barriers to implementation include:
Sociocultural challenges, such as myths and misinformation about the vaccine.
Health system limitations, including a lack of trained personnel.
Financial constraints, as the vaccine’s cost remains a significant hurdle.
Policy inconsistencies, exacerbated by changes in governance.

However, some Indian states have made commendable progress in introducing HPV vaccination:
Delhi: The first state to implement opportunistic HPV vaccination for schoolgirls.
Punjab: Conducted phased vaccination campaigns, demonstrating the feasibility of large-scale implementation.
Sikkim: Achieved the distinction of being the first state to vaccinate all girls aged 9-14 in 2018.

The Way Forward
WHO identifies HPV vaccination as the most cost-effective preventive strategy, particularly in resource-constrained settings like India. The Indian Academy of Paediatrics Committee on Immunisation and the Federation of Obstetricians and Gynaecologists of India recommend vaccinating all females aged 9-14 years.
India must intensify efforts to promote HPV vaccination as a preventive measure against cervical cancer. Key strategies include:
Community-based capacity-building initiatives to raise awareness about HPV vaccination.

School-based vaccination programmes to ensure higher coverage among adolescents.
Development of comprehensive Information, Education, and Communication (IEC) materials to bust myths and disseminate accurate information about HPV vaccines.
Collaborations with stakeholders, including healthcare providers and educational institutions, to create an enabling environment for vaccine uptake.

India’s commitment to eliminating cervical cancer hinges on its ability to overcome barriers to HPV vaccination and integrate it into a broader cancer prevention framework. By scaling up efforts, the country can save countless lives and move closer to achieving global health goals. By prioritising awareness, accessibility, and policy consistency, India can protect its women from this devastating illness. The time to act is now, and a concerted national effort could transform the cervical cancer landscape, bringing the country closer to the WHO’s elimination targets.

(The authors are Chair Programme Advisory Committee; Ex-Sub Dean MAMC, Professor of Excellence, Member Lancet Commission/ Senior Public Health Advisor, National Health Systems Resource Centre/ Director Child Care Clinic & Head Paediatrics Apollo Hospitals Noida, respectively)