Introduction of HPV Vaccine in UIP: Issue and Current Status

National Technical Advisory Group on Immunisation has proposed the introduction of a new vaccine against HPV virus under universal immunization Programme (UIP). However the move has faced opposition from the medical community in India.

What is UIP?

Universal Immunization Programme was launched in 1985 and is currently one of the key areas under National Rural Health Mission (NRHM) since 2005. The aim of the programme is to protect children from life threatening diseases. It currently cover vaccinations for 12 diseases.

What is HPV?

HPV stands for Human papilloma viruses and is group of 200 viruses. It causes following cancers in women: Cervical, Anal, vaginal and vulvar cancer. It also causes penile cancer in men. It can also cause Throat and rectum cancer in both men and women.

Transmission

It is transmitted through intimate contacts like-sexual intercourse, oral or anal sex. Also individuals with HIV infections, smokers and who are highly dependent on hormonal contraceptives are more prone to the risk of HPV virus.

Vaccinations

Globally, three vaccines available against HPV namely- Gardasil, Gardasil 9, and Cervarix. In India, two vaccines are available- Gardasil and cervarix. The vaccines are given to girls in the age group of 9-13 years-before they become sexually active.

How effective are HPV vaccines?

Highly effective in preventing infection with the types of HPV they target when given before initial exposure to the virus—which means before individuals begin to engage in sexual activity.

Why are these vaccines important?

Could prevent incidences of cervical cancer by two third.

Why there is an opposition for its introduction in UIP?

• Each shot of Gardasil costs approx Rs 3000 and Cervarix about Rs 2000.The vaccine is given thrice within six months so the burden of vaccinating around 62 crore girls would amount to 56k crore annually, which is huge.
• These vaccines provides protection against HPV virus but are not effective in treating
  • established HPV infections
  • HPV caused diseases.
  • Many Sub types of HPV
• Vaccines show some side effects such as regional pain syndrome. Even Japan has suspended HPV vaccine on temporary basis due to its side effects.
• Every HPV infection does not necessarily leads to cervical cancer. Other cofactors are necessary for progression of infection into a cancer like-multiple sex partners, use of hormonal contraceptives, poor hygiene etc. So the most important step for its prevention is early diagonosis i.e routine screening(pap smear tests) which helps find cellular abnormalities in cervical tissue, aiding early detection and hence prevention of turning a HPV infection into a cancer.
• The long term prevention after the vaccination are 8 years which is too less to spend a huge amount on it.
• India is showing a declining trend in cervical cancer due to better hygiene, changing reproductive patterns etc. So there is no need to introduce at universal level.

What are main factors cited in favour of its introduction?

• Increasing number of cases: Globally, cervical cancer is the fourth most frequent cancer in women. In India, it is the second most frequent. Worst part is 1.32 lakh cases are diagnosed annually and most of them are in their advanced stages. (WHO report).India stands at number three globally in cervical cancer deaths.
• No safety issues: According to WHO- There are no grave safety concerns regarding the use of vaccine. Currently around 71 countries have introduced it its National immunization programme.
• Cost: Prevention cost is much lower than the treatment cost. Moreover, India recently received $500 million aid from GAVI, an international vaccine alliance, for rolling out a range of vaccines, including HPV vaccine. Also the opponents of the vaccination derive are stating the market cost of the vaccine i.e Rs3000 whereas the vaccine will be available at subsidized prices once it comes under UIP.
• Global results: Australia was the first country to introduce HPV vaccination in its school programme today witness’s lowest cases of cervical cancer in the world.

In India, low level of sexual awareness and difficulties in achieving large-scale routine screening are the important factors which favours the introduction of HPV vaccine. Moreover, there is no clear evidence that barrier methods of contraception, most notably use of condoms, confer a protection against HPV infection.

What is the way forward?

As per some studies India might be showing a declining trend in the number of cervical cancer cases, however still India stands second in the frequency of its occurrence. Although Vaccines are not 100% protective against cervical cancer but it is highly effective if given before the sexual debut.

So it is clear that due to cost considerations and its lack of efficacy to fight certain sub types should not been seen as strong reasons for its introduction in UIP programme. Further, till the decision for its introduction in UIP arrives, the government should launch a pilot project in some of the areas and also

Strengthen its screening derive for the early detection of the Virus. Delhi has become the first state in the country to launch the Human Papillomavirus (HPV) vaccine as a public health programme for school girls of VIth class. Punjab and Delhi has also followed suit by starting the vaccination for girls.  Other steps like encouraging Indian companies to manufacture vaccine for a drop in cost should also be taken.