The importance of periodic testing for Human Pappilomavirus

The New Year brings a whole host of resolutions. If wellness and self-care were on your list, this is the right time to equip yourself with knowledge about cervical cancer: January is Cervical Cancer Awareness Month.

(For top health news of the day, subscribe to our newsletter Health Matters)

The facts first

Cervical cancer, which develops in a woman’s cervix (the entrance to the uterus from the vagina) is the second-most common cancer among women in India. It is caused by persistent infection by the human papillomavirus (HPV). Almost all sexually active people are infected by HPV at some point in their lives, but usually without symptoms, the World Health Organisation (WHO) states. In most people, the immune system clears up the virus. In some cases, certain high-risk strains of the virus persist in the body and could lead to cancer. India accounts for nearly a quarter of all cervical cancer deaths in the world. It is estimated that every year around 1.25 lakh women are diagnosed with cervical cancer, and nearly 75,000 of them die. 

In 2022, the WHO adopted a strategy aimed at eliminating cervical cancer as a public health problem, worldwide. The strategy had three pillars – 90% of girls fully vaccinated by 2030 with the HPV vaccine, this to be done by age 15; 70% of women screened with a high-performance test between 35 and 45 for early treatment of pre-cancerous lesions, and 90% of women identified with cervical disease, to receive treatment.

Though India is unlikely to meet the 2030 goals, the silver lining, says Arvind Krishnamurthy, professor and head, surgical oncology, Cancer Institute, WIA, is a decline in incidence. “Despite not having a robust national screening or vaccination programme as yet, the number of cases are decreasing. This could be attributable to a number of factors including sexual hygiene, age of pregnancy and number of children, use of contraception and the immune status of individuals,” he said.

However, Dr Krishnamoorthy stressed the need for a combination of awareness programmes, a vaccination programme and regular screening to effectively prevent new cases and deaths. He also pointed to the need to eradicate stigma through education programmes .“The goal should be to detect cases at the precancerous stage so that they do not progress to full-blown cancer. At that stage, it is 100% curable,” he said.

Cervical cancer screening

Up until some years ago, the gold standard, world over, to screen for cervical cancer, used to be the pap smear, says Jaishree Gajaraj, former president of The Obstetric & Gynaecological Society of Southern India. The pap smear involves the scraping and brushing of cells from the cervix. These cells are then examined. The smear is recommended every three years, for women between the ages of 25 and 65, barring high-risk groups, for whom the recommendation is once a year, says Dr. Gajaraj.

“The problem with the pap smear however is that it requires a cytologist to study the smear, and many places, especially in rural India, may not have access to the test itself, or to cytologists to study the samples. The second issue is that awareness continues to remain low, and even in urban areas where women come forward to do the test, it is difficult to get them to come back for follow-up screenings. Many women believe that if they’ve taken the pap smear once, it is enough for a lifetime, but this is not the case,” she says.  

As of 2019, the WHO says, fewer than one in 10 women in India had been screened for cervical cancer in the previous five years.

Now, says Dr. Gajaraj, HPV DNA testing is the recommended method for screening for cervical cancer: this involves testing cells from the cervix for infections with any of the HPV types that could cause cancer. The WHO, too, recommends that HPV DNA testing be the first-choice screening method for cervical cancer prevention – these tests are less prone to quality problems and human errors, it says. 

Dr. Krishanmoorthy added that self sampling could offer an additional option for cervical cancer screening: “Studies have shown that in the yield of results, samples taken by patients seem to be equivalent to physician-collected samples. Not all women may be able to do it or want to, but it would be useful for them to be given this option,” he says. 

The vaccine

There is some history to the HPV vaccine rollout in India: in 2010, a U.S.-based international non-profit PATH, which began a trial of the vaccine in Gujarat and Andhra Pradesh, faced major backlash after the deaths of seven girls. A Parliamentary Standing Committee that looked into the issue in 2013 strongly criticised both PATH and the Indian Council of Medical Research and the Department of Health Research, stating: “The choice of countries and population groups; the monopolistic nature, at that point of time of the product being pushed; the unlimited market potential and opportunities in the universal immunization progammes of the respective countries are all pointers to a well planned scheme to commercially exploit a situation.”

However, cervical cancer is one of the most preventable and treatable forms of cancer if detected early and managed effectively. The WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) says that the HPV vaccine is highly effective for the prevention of HPV serotypes 16&18, which cause 70% of cervical cancers. 

In a recommendation in April 2022, SAGE stated that its review concluded that even a single-dose of HPV vaccine delivers solid protection against HPV that is comparable to two-dose schedules. “The new SAGE recommendation is underpinned by concerns over the slow introduction of the HPV vaccine into immunisation programs and overall low population coverage, especially in poorer countries,” it stated. 

Also Read | Health Ministry yet to take a call on beginning HPV vaccination campaign for adolescent girls 

What are the government’s plans?

There are currently two vaccines available in India that protect against the disease: Merck’s Gardasil and Serum Institute of India’s Cervavac, which was launched last year. 

A Serum Institute of India spokesperson, in an email, said its vaccine, Cervavac, was priced at Rs. 2,000 per dose. The Institute has a production capacity of around 2-3 million doses of the vaccine, but it plans to expand this capacity, with a target of reaching 60 to 70 million doses. 

In 2018 Sikkim became the first State in the country to introduce the vaccine. The vaccine (Gardasil) was provided free, under the State budget. All girls aged between 9 and 14 years were given two doses, separated by six months. Coverage of the first and second rounds was reported at over 95%. 

In 2022, India’s National Technical Advisory Group on Immunisation (NTAGI) had recommended introducing the HPV vaccine in the country’s Universal Immunisation Programme (UIP). A one-time catch-up vaccine was to be provided for 9 to 14-year-old adolescent girls, and subsequently, with a routine introduction at nine years.

Initially, reports had indicated that the Central government would roll out a vaccination programme in six states in June 2023, targeting girls between the ages of nine and 14, covering 2.55 crore girls. However, this did not materialise. This month, media reports suggested that the drive may be rolled out in the second quarter of this year, to be executed in three phases over three years. Despite these reports though, the Union Health Ministry, as of last week, has maintained that it is yet to take a decision on starting the HPV campaign.

Globally, 100 countries have introduced the HPV vaccine into their national schedule, but significantly, this covers only 30% of the global target population, as per the WHO. 

Paediatricians are now recommending the vaccine routinely for girls from the ages of nine to 15, says R. Somasekar, a member of the Indian Academy of Paediatrics. “Giving the dose early ensures the best efficacy and maximum protection,” he says, pointing out that the vaccine can be given to adults as well, as it protects from ano-genital warts. “The ideal age is about 10 to 12 as the vaccine offers the best and longest protection when taken early, but it can be given any time up to the age of 45,” says Dr. Gajaraj.

On combating hesitation, doctors point out that communication is the key: explaining to patients how and why the vaccine is important goes a long way towards erasing anxieties and misinformation. 

The International Agency for Research on Cancer, in a statement on its website, said it marked Cervical Cancer Awareness Month this year “by highlighting the work that remains to be done for the world to eliminate this disease by the end of this century, and by promoting the tools that are available to achieve this goal.” It further said recent research by scientists from IARC and partner institutions suggests that the WHO’s 2030 targets will be missed “unless countries scale up screening programmes, improve coverage of HPV vaccination, and expand access to affordable treatment.”

What can you do this month?

The WHO’s message is clear: first, get informed – read up about HPV and cervical cancer, and help educate other women in your life as well. Next, get screened – if you haven’t done it before, talk to your healthcare provider about a cervical cancer screening. And finally, get vaccinated, of course.