|Year : 2021 | Volume
| Issue : 2 | Page : 114-118
HPV vaccination program: Hurdles and challenges in a tertiary care center!
Pratibha Kumari1, Satya Kumari1, Jyotsna Rani1, Kavya Abhilashi1, Setu Sinha2, Sangeeta Pankaj1, Seema Devi3
1 Department of Gynecological Oncology, SCI, IGIMS, Patna, Bihar, India
2 Department of Community Medicine, SCI, IGIMS, Patna, Bihar, India
3 Department of Radiation Oncology, SCI, IGIMS, Patna, Bihar, India
|Date of Submission||22-Mar-2021|
|Date of Decision||31-May-2021|
|Date of Acceptance||04-Oct-2021|
|Date of Web Publication||17-Aug-2021|
IGIMS, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Introduction: Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide, infecting three of four individuals at least once in their lifetime. The virus exists in more than 200 morphogenic strains, and some of these variants are oncogenic. HPV is detected in virtually all cases of cervical carcinoma. HPV vaccination against high-risk HPV types is expected to reduce the burden of cervical cancer, but for this, it has to overcome a lot of obstacles and challenges in its way.
Materials and Methods: In May 2018, HPV immunization program was started in the Department of Gynecology Oncology, IGIMS, PATNA – a tertiary care center of Bihar for daughters of hospital employees and their relatives of age group 9–26 years of age. A total of 60 girls got vaccinated under this program.
Results: About 80% of the parents who got their daughters vaccinated in the study were aware of cervical cancer, but they lacked knowledge about HPV – the causative agent of cervical cancer. About 50% of them were not aware of existence of any vaccine against it. Young adolescent girls were not aware of this vaccine either.
Conclusion: Three-dose schedule was a major barrier to the delivery and uptake of the HPV vaccine. Had a single dose of HPV vaccine been effective that would have been important logistics advancement. Lack of knowledge about vaccine is a problem that leads to low vaccination coverage.
Keywords: Cervarix, cervical cancer, Gardasil, human papillomavirus
|How to cite this article:|
Kumari P, Kumari S, Rani J, Abhilashi K, Sinha S, Pankaj S, Devi S. HPV vaccination program: Hurdles and challenges in a tertiary care center!. J Indira Gandhi Inst Med Sci 2021;7:114-8
|How to cite this URL:|
Kumari P, Kumari S, Rani J, Abhilashi K, Sinha S, Pankaj S, Devi S. HPV vaccination program: Hurdles and challenges in a tertiary care center!. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Jul 3];7:114-8. Available from: http://www.jigims.co.in/text.asp?2021/7/2/114/331743
| Introduction|| |
The human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide, infecting three out of four individuals at least once in their lifetime. More than 200 different strains of this virus exist and some of the HPV strains are oncogenic. Although most infections clear up on their own, only persistent infections lead to life-threatening consequences. There is now substantial literature documenting the presence of HPV in virtually all cases of cervical carcinoma., HPV is also found to be associated with other different types of cancers including vulvar, vaginal, penile, anal, and oropharyngeal (head and neck) cancers., Furthermore, two low-risk HPV (HPV 6 and 11) are found to be responsible for a significant proportion of genital warts.,
Considering the burden of HPV-related disease, development of the HPV vaccination has led to emergence of a new era in cancer prevention. HPV vaccination for the prevention of high-risk HPV types is expected to reduce the cervical cancer burden. As the development of cervical cancer typically takes decades to build up, this is the same time span, in which we should be expecting to confirm the impact of vaccine against cancer.
Three commercially prophylactic vaccines are available and approved for use; these are Cervarix (a bivalent vaccine against HPV16 and HPV18), Gardasil (a tetravalent vaccine against HPV6, 11, 16, and 18), and Gardasil 9 (nanovalent vaccine against HPV6, 11, 16, 18, 31, 33, 45, 52, and 58) as means for primary prevention of cervical cancer and ineffective reduction of the disease burden. They are noninfectious subunit vaccines containing viral-like particles derived from the assembly of the recombinant expression of L1 major capsid protein of the HPV in yeast (Gardasil) and in insect cells (Cervarix). The majority of all HPV-associated cancers are caused by HPV 16 or 18 types, targeted by 2 vHPV, 4 vHPV, and 9 v HPV. To date, protection against the targeted HPV types has been found to last for at least 10 years with Gardasil, at least 9 years with Cervarix, and at least 6 years with Gardasil 9.,,
Cervarix and Gardasil vaccines have been evaluated in extensive randomized controlled trials and are nearly 100% effective in preventing new HPV infections (caused by the leading strains) and in turn have an efficacy of >90% in preventing cervical intraepithelial neoplasia (CIN2/3)., The Cervarix vaccine has also been found to provide partial protection against some additional HPV types that are not included in the vaccine, which can cause cancer, a phenomenon called cross-protection.
HPV vaccine is recommended for routine vaccination of all adolescents at the age of 11–12 years and is given in the form of 2 or 3 shots of prime/boost injection over a 6-month period. The Advisory Committee on Immunization Practices (ACIP) specifies different dosing schedules depending on the age of the individual. An individual who starts the vaccine series before 15th birthday needs only two doses to be fully protected. Adolescents who start the series at age 15 years or older and those who have certain conditions compromising their immune system need three doses to be fully protected. ACIP recommends catchup vaccination for females through 26 years of age, males through 21 years, and for certain special population through age 26. As HPV is sexually transmitted, the vaccine has maximum benefit owing to high immunogenicity titer when given before the initiation of sexual activity.,
HPV vaccination programs have been successfully implemented in many countries all over the world., Statistical data from the recent years show that utilization of HPV vaccines is very effective for preventing infection and disease related to the specific HPV genotypes.
In developing countries like India, cervical cancer incidence and mortality reduction can be achieved only with strict supervision through government agencies by implementing a sustainable, affordable, and effective screening and vaccination programs. However, making this HPV vaccination program successful, enough hurdles have to be overcome in its pathway. There are several barriers to vaccination – a lack of research work done on long-term efficacy of vaccine, high cost, fear of promoting early indulgence in sexual activity due to the development of false belief of protection of cervical cancer, and lack of knowledge about vaccine to parents and general people. Henceforth, the purpose of this study was to explore the reasons behind acceptance of HPV vaccine among parents who came for HPV vaccination in a tertiary care hospital. This information can help in guiding educational institutions and hospital administration for increasing acceptance of HPV vaccination among general people.
| Materials and Methods|| |
In May 2018, HPV immunization program was started in the OPD of Gynecology Oncology Department, SCI, IGIMS, Patna, specifically for daughters of medical staffs and their relatives of 9–26 years of age. A total of 60 girls got vaccinated over a period of 12 months. The Cervarix vaccine was used for vaccination and was administered free of cost to the recipients. The vaccines were procured by the institute utilizing a part of fund provided to IGIMS, Patna by Bihar Health Society under NCD flexi pool focusing on prevention and control of oral, breast, and cervical cancer.
The study was conducted following approval from local institutional body and after obtaining informed consent from the participants. Questionnaire including reason for the acceptance for the vaccine and from where they got knowledge of HPV vaccination was enquired both to parents and daughters. Parents were enquired in the regional language and had to answer in their own words:
- Why have they decided to vaccinate their daughter?
- What is their knowledge about HPV vaccination and cervical cancer?
- From where did they get information about HPV vaccination?
Girls were enquired:
- Why have they come for vaccination against HPV?
- What is their knowledge about cervical cancer and HPV?
| Results|| |
Sixty girls received vaccines under the aegis of this program. Their demographic characteristics included age, marital status, and their education [Table 1]. The parents of the vaccine recipients were mostly health workers [Table 2]. They had received information about HPV vaccination for cervical cancer from their peer groups and the Internet. Only 13 girls were vaccinated under the age of 15 years and two out of them received only one dose as their parents got transferred to another city [Table 3].
About 80% of the parents were aware of cervical cancer, but most of them lacked knowledge of HPV as the causative agent of cervical cancer and about existence or availability of any vaccine against it. Young adolescent girls were also not aware of the vaccine [Table 4] and [Table 5].
|Table 4: Reasons given by parents for opting vaccination of their daughters|
Click here to view
|Table 5: Percentage of parents and girls aware of cervical cancer, human papillomavirus, human papillomavirus vaccine|
Click here to view
| Discussion|| |
In our study, we found that majority of girls who got vaccinated had parents working as health-care workers [Table 2]. At the time of vaccination, many girls had not heard about HPV or HPV Vaccine earlier. Hence, it is a matter of concern how to educate the girls about cervical cancer, and the need of vaccination of adolescents mainly below 15 years of age by either introducing about sexual health more vigorously in their curriculum or educating parents for how to deliver information about sexual health to their children for proper execution of certain health practices.
Three-dose schedule was a major hurdle to the delivery and acceptability of the HPV vaccine. Completing the HPV vaccine schedule was reported as an issue in another study because it was found difficult to follow-up patients and asking them to return to the clinic to receive the second and/or third dose of vaccine. If a single dose of HPV vaccine was effective that would be an important advancement. Early analysis shows that even a single dose can reduce infection and is effective in preventing the persistent incidence of infection and premalignant neoplasia. An analysis of data from a community-based clinical trial of CERVARIX in Costa Rica, where cervical cancer rates are high, it was found that even one dose of the vaccine produces around nine times more antibodies against HPV than the body produces in response to a natural HPV infection and those antibody levels persisted for at least 7 years and the rates of HPV infection also keep on low for at least 7 years.,
A large study using national data from women across Australia, where vaccination rates are high, found that one dose of HPV vaccine was as effective as two or three doses in preventing high-grade cervical lesions. A previous study also reported that women who had not completed the vaccine schedule were unlikely to do so because they simply forgot about vaccination and had no time to return to the clinic. Potential facilitators to the uptake of the HPV vaccine that were identified included the availability of the vaccine on site, the availability of information related to the vaccine either on-site or online, and positive opinions from experts in the field. The availability of the vaccine on-site would undoubtedly be more suitable for patients, but they would still be required to attend further consultations to complete the vaccine schedule. Improving the availability of and access to information about HPV vaccination is very important as many women think that they do not have enough information to allow them to make an informed decision about whether or not to receive vaccine. This information, together with positive and encouraging opinions from experts, may facilitate the adoption of the HPV vaccine because of the strong association between high HPV-related knowledge and greater intentions to vaccinate against HPV., Considering the background of the Indian population, another major barrier to the delivery and uptake of HPV vaccination is the cost of the HPV vaccines.
| Conclusion|| |
Three-dose schedule is a major obstacle to the delivery and uptake of the HPV vaccine. If a single dose of HPV vaccine becomes effective, that will be an important advancement. Young adolescent girls are not aware of HPV vaccine. It is a matter of concern to educate these girls about cervical cancer vaccination mainly below 15 years of age group either by introducing about sexual health more vigorously in their curriculum or educating parents about how to deliver information about sexual health to their children. Lack of knowledge about vaccine is a problem that leads to low vaccination coverage. The Government of India should introduce chapters related to cervical cancer and its vaccination in curriculum of high schools so that both parents and their children become aware of this deadly entity and its preventive measures in the form of Cervarix/Gardasil.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kjaer SK, van den Brule AJ, Paull G, Svare EI, Sherman ME, Thomsen BL, et al
. Type specific persistence of high risk human papillomavirus (HPV) as indicator of high grade cervical squamous intraepithelial lesions in young women: Population based prospective follow up study. BMJ 2002;325:572.
Myers ER. The economic impact of HPV vaccines: Not just cervical cancer. Am J Obstet Gynecol 2008;198:487-8.
De Martel C, Ferlay J, Franceschi S, Vignat J, Bray F, Forman D, et al
. Global burden of cancers attributable to infections in 2008: A review and synthetic analysis. Lancet Oncol 2012;13:607-15.
Muñoz N, Castellsagué X, Berrington de González A, Gissmann L. Chapter 1: HPV in the etiology of human cancer. Vaccine 2006;24 Suppl 3:S1-10.
Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis 2013;13:39.
Cubie HA. Diseases associated with human papillomavirus infection. Virology 2013;445:21-34.
Drolet M, Bénard É, Boily MC, Ali H, Baandrup L, Bauer H, et al.
Population-level impact and herd effects following human papillomavirus vaccination programmes: A systematic review and meta-analysis. Lancet Infect Dis 2015;15:565-80.
Kjaer SK, Nygård M, Dillner J, Brooke Marshall J, Radley D, Li M, et al
. A 12-year follow-up on the long-term effectiveness of the quadrivalent human papillomavirus vaccine in 4 Nordic countries. Clin Infect Dis 2018;66:339-45.
Naud PS, Roteli-Martins CM, De Carvalho NS, Teixeira JC, de Borba PC, Sanchez N, et al.
Sustained efficacy, immunogenicity, and safety of the HPV-16/18 AS04-adjuvanted vaccine: Final analysis of a long-term follow-up study up to 9.4 years post-vaccination. Hum Vaccin Immunother 2014;10:2147-62.
Huh WK, Joura EA, Giuliano AR, Iversen OE, de Andrade RP, Ault KA, et al.
Final efficacy, immunogenicity, and safety analyses of a nine-valent human papillomavirus vaccine in women aged 16-26 years: A randomised, double-blind trial. Lancet 2017;390:2143-59.
Schiller JT, Castellsagué X, Garland SM. A review of clinical trials of human papillomavirus prophylactic vaccines. Vaccine 2012;30 Suppl 5:F123-38.
Kavanagh K, Pollock KG, Cuschieri K, Palmer T, Cameron RL, Watt C, et al.
Changes in the prevalence of human papillomavirus following a national bivalent human papillomavirus vaccination programme in Scotland: A 7-year cross-sectional study. Lancet Infect Dis 2017;17:1293-302.
Markowitz LE, Dunne EF, Saraiya M, Chesson HW, Curtis CR, Gee J, et al.
Human papillomavirus vaccination: Recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2014;63:1-30.
Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination – Updated recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2016;65:1405-8.
Crosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. Lancet 2013;382:889-99.
National Advisory Committee on Immunization. Statement on human papillomavirus vaccine. Can Commun Dis Rep 2007;33:1-32.
Brotherton JM. Impact of HPV vaccination: Achievements and future challenges. Papillomavirus Res 2019;7:138-40.
Tanaka H, Shirasawa H, Shimizu D, Sato N, Ooyama N, Takahashi O, et al.
Preventive effect of human papillomavirus vaccination on the development of uterine cervical lesions in young Japanese women. J Obstet Gynaecol Res 2017;43:1597-601.
Leask J, Jackson C, Trevena L, McCaffery K, Brotherton J. Implementation of the Australian HPV vaccination program for adult women: Qualitative key informant interviews. Vaccine 2009;27:5505-12.
Schiller J, Lowy D. Explanations for the high potency of HPV prophylactic vaccines. Vaccine 2018;36:4768-73.
Kreimer AR, Herrero R, Sampson JN, Porras C, Lowy DR, Schiller JT, et al.
Evidence for single-dose protection by the bivalent HPV vaccine-review of the costa rica HPV vaccine trial and future research studies. Vaccine 2018;36:4774-82.
Safaeian M, Sampson JN, Pan Y, Porras C, Kemp TJ, Herrero R, et al.
Durability of protection afforded by fewer doses of the HPV16/18 vaccine: The CVT trial. J Natl Cancer Inst 2018;110:205-12.
Brotherton JM, Budd A, Rompotis C, Bartlett N, Malloy MJ, Andersen RL, et al.
Is one dose of human papillomavirus vaccine as effective as three? A national cohort analysis. Papillomavirus Res 2019;8:100177.
Weisberg E, Bateson D, McCaffery K, Skinner SR. HPV vaccination catch up program – Utilisation by young Australian women. Aust Fam Physician 2009;38:72-6.
Chan SS, Cheung TH, Lo WK, Chung TK. Women's attitudes on human papillomavirus vaccination to their daughters. J Adolesc Health 2007;41:204-7.
Kahn JA, Rosenthal SL, Jin Y, Huang B, Namakydoust A, Zimet GD. Rates of human papillomavirus vaccination, attitudes about vaccination, and human papillomavirus prevalence in young women. Obstet Gynecol 2008;111:1103-10.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]