Give India The HPV Vaccine!
Oncologists from Tata Memorial Centre in Mumbai recently gathered for a symposium to celebrate the facility’s 75th year and discuss cancer in India. One hot-ticket discussion focused around cervical cancer, which is one of the two most common cancers among Indian women. Of the women in India who do get cervical cancer – an almost entirely preventable disease – nearly one-half of them die. These women account for a quarter of cervical cancer deaths worldwide. So, we’re glad to see the topic – in the form of a debate over the HPV vaccine — get attention from one of the country’s premier cancer treatment and research institutions, not to mention the global experts in attendance.
A quick background on the connection between the HVP vaccine and cervical cancer: The human papilloma virus (HPV) is a sexually transmitted disease that is far and away the biggest cause of cervical cancer. (It’s also a major cause of anal, oral and penile cancers, among others.) The thing about HPV is that it’s very common – many people are infected even if they’ve only had one sexual partner, and most people who have it never know. Many find out only after the abnormal cervical cells caused by HPV or full-blown cancer cells are discovered.
The HPV vaccine has been widely used in other countries for 10 years. Interestingly, the Tata symposium coincided with the first statistically relevant reports on the success of the vaccine in the US, which shows cases of cervical cancer among the target population have reduced by an astonishing two-thirds.
But the Tata gathering seemed not to see this as a cause for learning and application. The Hindu reported doctors arguing against the HPV vaccine, saying that government-sponsored screenings and personal hygiene campaigns have accomplished the same thing here in India, bringing the incidence of cervical cancer in Indian metros almost as low as the current incidence in the US after 10 years of vaccine use there. (But they admit that incidence in other parts of the country have remained three times higher, even with screening programs underway.) Let’s ignore the reference to personal hygiene campaigns — as if hand washing has anything to do with stopping the spread of an STD – and focus on the fact that leaders of our medical community seem to think screenings and vaccines accomplish the same thing.
Screenings for cervical cancer catch the disease in its earliest ‘pre-cancerous’ stages or later. Once caught, the abnormal cells can be removed – but the vaccine keeps these cells from ever developing in the first place. In other words, screenings are a response, while the vaccine is prevention. Which means at some point in the future, with greater use of the vaccine (a one-time treatment), the US’s incidence will continue to fall, while the rate in India, relying on screenings (which are not 100% accurate and depend on human behaviour over the course of a lifetime), will plateau above that.
Despite what the doctors at the Tata conference say, in the long term, a vaccine is cheaper than screenings. The Government has just received a grant from GAVI to roll out the HPV vaccine, among others, at less than US$ 5 per injection. The full price of the vaccine would be higher without these subsidies, of course, but it is well documented that within a few years of a vaccine entering a new market, its price drops dramatically.
Screenings, on the other hand, require public service campaigns to first make women feel comfortable spreading their legs for a strange, often male, doctor – no simple or cheap feat in a conservative country. They require high-quality laboratory testing of the sample cells, equipment to incise them if they appear abnormal, and doctors to perform both screening and treatment. All of this requires immense funding — once a year for every woman (and every future woman), starting in her teens until her death – with no end in sight. With vaccines, the cost is predictable and finite. Win-win.
Screenings also require lifelong, regular access to quality medical care. That might be possible in Indian metros (hence, the improved incidence rate) but not in other parts of the country where the majority of Indian women live. Vaccination can be achieved after three (or fewer!) injections, providing lifelong protection, whether or not the woman can get to a doctor easily in the future.
Finally, let’s look at a far-too-infrequently considered factor: women’s comfort. The vaccine requires a woman to bare an arm, a thigh. Screenings are invasive. Women must lie with their legs in stirrups and speculums in their vaginas. When abnormal cells are found, women must pursue one of several expensive and uncomfortable procedures – some of which may involve general anesthesia – to remove those cells. Up to four weeks of light bleeding and in some cases, pain, can follow – perhaps mere discomfort for some, but in a country where access to sanitary menstrual products is rare, a major problem for many others.
This seems clear enough to wonder why we’re even having this debate: Screenings unduly saddle women with a lifelong and yearly onus that they may or may not be able to meet financially, logistically, or comfortably – but must, somehow, if they want to be confident about their health. When senior medical experts cling to this method so fiercely in the face of a better option, it begs the question – why?
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The fact that an STD causes cervical cancer forces us to confront the idea that Indian girls and women are having sex – in and outside of marriage, with one or multiple partners in their lifetimes. The brute strength of cultural norms makes it easy to deny this, but stats on cervical cancer mean we have to acknowledge it at some point: HPV is an everywoman problem, not one limited to a particular class, age or profession. Luckily (and a bit surprisingly) Delhi is at the forefront of accepting this. The country’s first HPV vaccine program is afoot there, and in its first phase, 1 to 1.5 lakh schoolgirls will be protected against the disease, and consequently, against cervical cancer. We applaud this progress.
But it’s not enough.
At the heart of the debate, like the one at Tata Medical Centre, is always a subtext around medical colonialism, and that’s a valid concern. But this isn’t about taking a Western solution and imposing it on India — it’s about learning from the West’s mistakes. The Western world has done themselves and the rest of the world a disservice by framing the HPV vaccine as a women’s health issue. It mired the US and other countries in conflating public health progress with moral transgression for years, and we would be stupid to follow suit.
India’s medical community has an opportunity to address HPV exactly as it is: A public health issue, one that affects men as well as women, one for which boys are inoculated against as well as girls. (Boys can get the HPV vaccine, too!) This is what makes for a healthier India. Shoot us up, doctors.
The European Medicines Agency stated ‘reviews of the reports did not show a consistent pattern regarding time-to-onset following vaccination, they appear to have totally ignored the evidence provided by the UK Association of HPV Injured Daughters (AHVID) which reported that a questionnaire completed by 94 member families indicated that:
• 27 girls (31% ) had adverse reactions on the same day as the vaccination, many of them suffrering immediately, within minutes.
• 12 girls (14%) had adverse reactions after just 1 dose
• 19 girls (22%) had adverse reactions after just 2 doses (some of these had reactions also to the 1st dose
• 14 girls had adverse reactions after the 3rd dose (and some of these had earlier reactions)
• At least 4 girls (4%) had adverse reactions after each of 3 doses. Health professionals had indicated that the vaccine is safe and the adverse reactions suffered were not recognised as side effects of the vaccine. Initial symptoms were often ‘generally unwell, flu-like, tired, aches and pains’. With each dose the severity increased and day-by-day the severity increased. With some it was eventually several weeks before these symptoms developed into collapse with total fatigue and sleeping up to 23 hours each day.
This vaccine has never been proven to prevent a single case of cancer and it will be decades before we find out. Cases of cervical cancer in developed countries using Pap screening are 9/100,000. Deaths have come down from 8 to just 2/100,000 over the last 40 years with no vaccine and current uptake of screening of just 80%. Screening is still necessary even after vaccination. There are over 100 strains of HPV and some scientists expect other strains to replace those that are targeted by the vaccine.
In the meantime thousands of girls are being seriously disabled and their lives ruined by the adverse reactions. In the UK 20,503 adverse reactions have been reported by Yellow Card, including 5 with fatal outcome (data obtained by FOIA request to MHRA). Even the manufacturers admit huge numbers of serious adverse reactions during the clinical trials.
Great article, thanks. (One correction: “cases of cervical cancer among the target population have reduced by an astonishing two-thirds” should read “cases of vaccine-type HPV among the target population have reduced by an astonishing two-thirds”. Actual reduction in cancer won’t be visible for a few years yet. Or you could point to figure 5.2 of http://www.vccr.org/site/VCCR/filesystem/documents/dataandresearch/StatisticalReports/VCCR_StatisticsReport_2014_Digital_FinalApproved.pdf which shows high-grade cervical lesions have fallen by half in the under-25 age group and by 25% in the 25-29 age group. )
Evidence and science couldn’t be clearer: the vaccine is going to save a lot of lives.
You will of course get angry letters from people who deny that 99% of cervical cancer is caused by HPV, and claim that the vaccine is dangerous. These people are relaying concerns from the antivaccine echo chamber. Their standards of evidence are very low, and they completely ignore evidence far more solid than theirs. Evidently unverified personal stories are highly convincing to some people. We shouldn’t let them get in the way of preventing cancer.