Cristina Averhoff
Cervical cancer, caused by human papillomavirus (HPV), is one of few preventable cancers. In the developed world, this cancer is relatively easy to manage with preventative surgery or HPV vaccines such as Gardasil. However, in the developing world, cervical cancer is a virulent threat consistently ranking among the leading causes of death in women.1 HPV causes approximately 275,000 deaths due to cervical cancer each year, 88% of which occur in developing countries.2 If available around the world, the HPV vaccine could decrease rates of cervical cancer by 70%.2
The Global Alliance for Vaccines and Immunizations (GAVI) was launched in early 2000 to support the implementation of vaccination programs to reduce child mortality rates in 70 of the world’s poorest countries.3 GAVI gathers funds from donors worldwide, and decides which vaccines would be the most efficacious and cost-effective to introduce to these countries. Recently, GAVI has agreed to fund the HPV vaccine. This decision will likely protect two million women in nine countries from cervical cancer by 2015.2 Although GAVI has agreed to fund this vaccine, impediments to introduction of the vaccine may still exist, says Dr. Lauri Markowitz, an expert on HPV and STIs at the Center for Disease Control and Prevention (CDC).4 GAVI may cover the costs for vaccines and some operational costs, but the states are responsible for delivering them in the most effective and efficient way. Introduction of vaccine requires capacity for storage, transport, and personnel, which might be lacking in the country, adds Markowitz, further complicating the launch of the vaccine program. Due to infrastructure and capacity issues, many GAVI countries may delay the introduction of this vaccine.
Public health experts have expressed concerns about the implementation of HPV vaccine programs in GAVI countries, particularly regarding the introduction and delivery of the vaccine to preadolescent girls. Unfortunately, countries have little experience with routine vaccination in the target age group, pre-adolescents, and the required three doses makes delivery even more difficult.5 An international non-profit, the Program for Appropriate Technology in Heath (PATH), recently published a paper claiming they have acheivedachieved high rates of coverage from the HPV vaccine in low and middle income countries.5,6 This organization worked with the governments of India, Peru, and Vietnam to research and gather evidence to determine how best to introduce HPV into these countries.5,6 Their study involved 7289 families, each with a daughter in school who was eligible to receive the vaccine. This study found that school-based implementation of the vaccine resulted in high coverage for these girls. Reasons for lapses in coverage varied depending on the country. Ultimately, lack of awareness of the program and the concern of the experimental nature of the study were major factors in the parent’s decisions to not vaccinate their daughters.5,6
Many GAVI countries, however, have large rural populations in remote areas that are difficult to access, and even programs initiated in schools and health facilities will not reach many young women. According to USAID, 25% of girls in developing countries do not attend school; these millions of girls would be neglected by a school-based vaccination program.67 Markowitz remarked that alternative programs for these regions are being considered. Some have suggested additional vaccination programs for the isolated group of girls within the target age group.
Additional hurdles include developing programs for a new target age group and coordination issues within government health departments. Most routine immunization systems in GAVI countries are geared toward vaccinating children under the age of five. For HPV, the WHO has started to formulate unique policies and program guidance for the introduction of adolsecent HPV vaccinations. Introducing a routine immunization program for preadolescent girls requires innovation, novel methods, and numerous studies to determine the efficacy and feasibility of various models to have maximal coverage for this unusual target age range.
Successful introduction of HPV vaccine will also require communication and collaboration among many different groups within the Ministry of Health, a term used in many countries to describe the national health department. Unlike other immunizations, HPV requires a major collaborative effort among immunization programs, cancer prevention programs, and programs that address sexually transmitted infections. In order to have feasible policies for introduction, these stakeholders must cooperate, says Markowitz, an additional hurdle to introducing the vaccine in GAVI countries.
Although GAVI has agreed to fund the HPV vaccine as a routine vaccination, GAVI countries are far from realizing a practical, effective HPV immunization program. Not only do many of the countries lack resources and capacity for introduction, but implementing a vaccine geared towards young women also generates new infrastructural and cultural challenges. Unlike routine immunization programs, the HPV vaccination scheme has a unique set of obstacles to overcome: the additional infrastructure required to administer the vaccine to a novel and often neglected target population, and the need for increased government coordination. In spite of these challenges, some low resource countries have already introduced the HPV vaccine, which may urge other GAVI countries to overcome barriers and launch successful programs of their own.
Dr. Lauri Markowitz MD is the Team Lead for Epidemiology Research in the Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC).
1. Women”s Health. World Health Organization. Available at: http://www.who.int/mediacentre/factsheets/fs334/en/index.html. Accessed April 1, 2012.
2. GAVI Takes First Steps to Introduce Vaccines against Cervical Cancer and Rubella. Global Alliance for Vaccines and Immunizations. Available at: http://www.gavialliance.org/library/news/press-releases/2011/gavi-takes-first-steps-to-introduce-vaccines-against-cervical-cancer-and-rubella/. Accessed March 4, 2012.
3. GAVI Alliance. Available at: http://www.gavialliance.org/. Accessed March 12, 2012.
4. Winkler, JL. Determinants of Human Papillomavirus Vaccine Acceptability in Latin America and the Caribbean. Vaccine 2008;26(11):73-79.
5. LaMontagne, DS. Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries. Bulletin of the World Health Organization. 2011;89:821-830B.
6. USAID Office of Gender Equality & Women’s Empowerment: Gender Statistics. US Agency for International Development. Available at: http://www.usaid.gov/our_work/crosscutting_programs/wid/wid_stats.html.