Cervical cancer, a major public health problem in India, is under the spotlight due to the government’s recent initiative for vaccination of young adolescent girls, highlighted recently in the Union Budget. This strategic move is heralded as a potential turning point in the battle against cervical cancer, a disease that results in the death of more than 77,346 Indian women every year. By aligning with global efforts to eliminate cervical cancer, this proactive vaccination campaign marks a crucial step towards safeguarding women’s health across the nation.
Despite the availability of Human Papillomavirus (HPV) vaccines for over a decade, including the recent introduction of CERVAVAC, a cost-effective, India-made indigenous vaccine (developed and manufactured by Serum Institute of India, Pune), the burden of cervical cancer (CaCx) remains significantly high, particularly in India, including more than 35 low-and-middle-income-countries (LMICs). This situation persisted despite the availability of screening, early detection methodologies, and treatments, underscored by over four decades of global research efforts.
Image Courtesy: PIB
LEADING CAUSE OF DEATH AMONG WOMEN
Cervical cancer is the second leading cause of death in Indian women after breast cancer, though, in rural India it is still the number one killer. It is a deadly disease of women and more than 25% of all global CaCx related deaths are reported from India due to lack of availability of HPV immunization, early screening and absence of easy access to treatment. It is a huge public health concern in India and a big challenge to the society as it kills one woman every three minutes in India, and annually about 123,907 new cases. This is in-spite of the fact that CaCx is easily detectable at early precancerous stages, which spans 10-20 years, but is fully preventable, treatable and a curable cancer, if detected early. Because of a long precancerous period following HPV infection with well-recognized signs and symptoms, it provides a unique opportunity of a sufficient window period for early detection, efficient prevention and curable treatment.
In 2018, World Health Organization (WHO) proposed for a global elimination of cervical cancer as a public health problem with a coordinated triple intervention strategy by (1.) 90% vaccination of 9-19 years or above girls/women (only if not HPV infected), (2.) 70% reliable screening of women for CaCx at the age of 35-45 and (3) 90% early treatment of those found positive by screening for cervical cancer. Elimination of cervical cancer in Indian women is also feasible by these three strategies as it was successfully done for smallpox, polio and most recently, Covid-19 eradication.
HPV AND HPV VACCINE
HPV and its vaccines represent a critical area in the fight against cervical cancer. HPV, a DNA containing tumor causing virus primarily infects through sexual contact, targets the skin, genital regions, and throat, posing significant health risks. As of 2024, there are six HPV vaccines based on recombinant DNA technology using virus-like particles (VLPs) designed to prevent virus infection. These include the Cervarix® (bivalent against high risk-HPV types 16 &18), the Gardasil® (tetravalent against HPV types 6, 11, 16, 18), and the Gardasil®9 (nonavalent against HPV 6, 11, 16, 18, 31, 33,45, 52, 58), alongside India’s recent, the cost-effective, single-dose, four-valent Cervavac, targeting four HPV types 16, 18, 6, and 11. These vaccines are found to be highly immunogenic, 100% safe, develop herd immunity, and produce high antibody titre if given to adolescent girls aged between 9-19 years. These are pivotal in protecting against the two most carcinogenic HPV types 16 and 18, responsible for the majority of cervical cancer cases, and proven to be safe and effective in curbing HPV-related cancers.
The groundwork for these vaccines traces back to the pathbreaking research of Prof Harald zur Hausen (1936-2023), a renowned Gynae Oncologist and molecular biologist and Chairman of German Cancer Research Center, Heidelberg, Germany, who established the link between HPV and cervical cancer, leading to the development of cervical cancer vaccines. His groundbreaking discovery earned him the Nobel Prize in Physiology or Medicine in 2008. The first author of this article, Prof Das worked with him for several years and contributed significantly to the field since 1986 and published many papers on HPV along with him. Returning to India, Prof Das pioneered the work and showed for the first time that nearly 100% Indian women with cervical cancer are infected with HPV 16 and 18, underscoring the vital role of HPV vaccination in cancer prevention. He has also developed cost-effective, very simple and non-invasive detection of HPV infection using urine and pap smear samples and improved screening by visual inspection with magnavisualizer.
Image Courtesy: Wikimedia Commons
CHALLENGES AND OPPORTUNITIES IN ACHIEVING THE GOAL
Although initially two HPV vaccines were successfully introduced as early as 2008 for primary prevention of HPV infection and control of cervical cancer, even after more than a decade and a half, hardly 1-2% of adolescent girls are vaccinated in India. It indicates that there must be several serious challenges and difficulties that are faced by young women in India. The recent introduction of indigenously developed, highly cost-effective, single dose quadrivalent HPV vaccine, ‘CERVAVAC’ must be welcomed for effective prevention and control of cervical cancer, not only in India but also in South and Southeast Asia.
It is indeed a commendable decision by the Indian government to introduce an indigenously developed HPV vaccine to protect women from cervical cancer. This initiative not only highlights the government’s commitment to women’s health but also marks a significant step towards empowering women by ensuring they have access to vital healthcare resources in the country. By focusing on preventive healthcare, the government is setting a powerful example of prioritizing the well-being and empowerment of women, which is essential for the progress of society as a whole.
BARRIERS IN CERVICAL CANCER ELIMINATION IN INDIA
Despite the potential of vaccines like CERVAVAC, India’s battle against cervical cancer is hindered by several challenges. These include a large population, large‑scale migration, combination of urban, urbanized‑rural and slum population, diverse socio-cultural, economic, political and religious environment, faiths and beliefs, and prejudice including inadequate health infrastructure. The struggle is exacerbated by a shortage of skilled health professionals and resources. Budget announcement to promote HPV vaccination among girls aged 9-14, alongside the introduction of the U-WIN platform for vaccine management, signals a strategic move towards universal immunization. In addition, state-led programs for free HPV vaccination underscore the potential of localized interventions, setting a precedent for national rollout. These efforts highlight the critical roles of political commitment, public awareness, and robust healthcare systems in overcoming existing barriers.
THE WAY FORWARD
The Government of India is steering towards expanding the national cervical screening program, targeting women aged 30-65 years for regular screenings. This initiative, part of the broader strategy under the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke, marks a significant step forward.
In order to effectively combat cervical cancer and to tackle this problem, focused efforts and new policies are required, such as faster comprehensive cytologic screening (VIA or Pap test), high coverage of HPV immunization, recall-and-reminder system based on personal invitation by using electronic media/mobile health and artificial intelligence to eligible women, monitoring and availability of post-screening treatment to protect women and girls from this dreaded disease. These might serve as a landmark initiative which may help in drastically reducing, if not completely eradicating, cervical cancer inIndia. This will also fulfil the national vision of empowering women. The accompanying figure shows how the four key pillars can be employed to successfully prevent and control cervical and other HPV-induced cancers in India.
PUBLIC HEALTH ISSUES
It is predicted that successful elimination of cervical cancer will be possible if two major effective primary prevention methods, cervical screening and HPV vaccination coverage, are scaled-up to 80%-100% in the next 50 years. Though these two prevention approaches seem to be easily achievable in high-income developed countries, it would be a major challenging task for women in developing or less developed countries, especially in India with a population more than 1.48 billion. Therefore, with the introduction of the HPV vaccine, there is a need for improving our public health infrastructure, resources, awareness and access to universal screening and vaccination.
CHALLENGES IN IMPLEMENTATION OF HPV VACCINATION
Since HPV infection is transmitted predominantly through sexual contact, including those with promiscuous sex life, immunization of adolescent girls aged 9-19 years before marriage will raise several questions on moral, social, religious, customs/culture, lifestyle and ethics as premarital sexual exposure is not acceptable by our society, particularly in middle-income group and rural population, who need the vaccine the most. Since Indian society has misogynistic undertones, parents think HPV vaccination will make sex safe leading to liberty to promiscuity and increased teenage sex.
Therefore, vaccinating teenage girls in India has caused a serious social debate and raised questions during marriage of girls as the majority of marriages in India are arranged marriages. The disease, thus, remains a taboo leading to women being stigmatised, ostracised and not allowed to come forward even for screening; to say nothing of vaccinating young adolescent girls. Furthermore, almost 50% of the Indian population comprising Muslims (14.2%), tribals (8.6%) and those below the poverty line (BPL) (25%-30%) are inaccessible or least accessible for cervical cancer screening and HPV vaccination programs due to reasons indicated above. So, there is an urgent need for nationwide awareness campaigns about CaCx that can break these taboo, stigma, myths, fears and doubts about the gynaecological testing/examination and HPV vaccination and promote screening and vaccination in India. It is equally important to raise awareness about the virus, de-stigmatizing the HPV infection/vaccination and gaining confidence for mass vaccination of girls. While cervical screening and HPV vaccination is important in reducing/eliminating cervical cancer, implementation and scaling-up of these programmes in India would be a major challenge and it requires coordinated efforts of the government including active participation of NGOs, public health care system and the population at large.
It is also important to note that although men often do not develop this cancer, they can become hosts by getting infected with HPVs and can cause HPV-related cancers and STIs and substantial proportion of penile, anal, oral, oropharyngeal cancer in men. Therefore, vaccinating both adolescent boys and girls may be essentially important in preventing women from HPV infected diseases.
In addition, effective training of gynaecologists, cytopathologists and paediatricians in PHC (primary health centres) and CHC (community health clinics), ESIC hospitals and RCCs (Regional Cancer Centres) with focused goals is crucial for a well-coordinated public health program for elimination of cervical cancer. The training and awareness program for healthcare personnel will help significantly in the success of cancer control programs in women.
Image Courtesy: Dr Bhudev C Das
India’s journey towards the elimination of cervical cancer will certainly be fraught with challenges but also ripe with opportunities. By using the low-cost single-dose CERVAVAC, and fostering a collective response to this serious public health cause, the country can pave the way for a cervical cancer-free India. It requires concerted efforts from all stakeholders to fight against this preventable disease, ensuring a healthier tomorrow for women across the nation and beyond.
*Prof (Dr) Bhudev C Das is former Director of ICMR-NICPR, Noida, and pioneer of HPV research in India and South-East Asia. He is now Chairman, Amity Institute of Molecular Medicine and Stem Cell Research (AIMMSCR), and Dean, Health Sciences, Amity University, Noida. He is a Dr BC Roy National Award winner and formerly JC Bose National Fellow. Dr Shilpi Gupta is a Young Scientist and Assistant Professor at AIMMSCR, Amity University, Noida.
