Author: Prossy Namyalo is a Ph.D. Candidate of Health Services Research (Health Policy Specialization) and Global Health Specialization at Institute of Health Policy…
Optimizing the Preventive Power of HPV Vaccine Introduction among AGYW in India
Authors: Preetika Banerjee, Public Health Sciences Division, Fred Hutchinson Cancer Center; Ipsita Bhattacharjee, Regional Medical Advisor for Women’s Health at a leading pharmaceutical organization in India
Cervical cancer, a preventable disease, curable with early detection and treatment, is the second most common cancer among women in India. India accounts for 21% of cases in Asia, the highest in the continent. India recorded over 77,000 cervical cancer deaths in 2020 (1). An overwhelming majority of cervical cancer, over 95% is due to the human papillomavirus (HPV) (2).
Cervical cancer occurrence is linked to sexual behaviors including poor genital hygiene, early marriage, multiple sexual partners, and repeated pregnancies. These practices, coupled with low socio-economic status are widely prevalent in developing settings like India. This is exacerbated by widespread stigma and misconceptions around sexual and reproductive health (SRH). With an approximated 453 million Indian women aged 15 years and above at risk for this disease, it is crucial for cervical cancer screening strategies and HPV vaccine campaigns to reach adolescent girls and young women (AGWY) (3). The current social structure in India does not allow for vaccination of this age group without parental approval.
India is poised for a nationwide roll-out of the HPV vaccination program this year, making it critical to consider communication and implementation strategies that would ensure acceptance of HPV vaccines among both AGYW and their caregivers.
Although bivalent and quadrivalent HPV vaccines were licensed in the country in 2008; A non-valent vaccine was licensed in 2018 (4). The anticipated launch of an indigenous vaccine in 2023 may provide a much-needed boost for country wide coverage of HPV vaccination among AGYW in India (4). Cervavac, a quadrivalent vaccine will provide immunity against 4 vaccine strains- 16,18,6 and 11. Of these, types 16 and 18 exert the heaviest disease burden. The vaccine will presumably be priced at one-tenth the price (Rs 200-400/dose) of alternatives from foreign manufacturers (Rs2,000-3,500/dose). This increased affordability provides an opportunity for vaccine access to prevent cervical cancer (5).
Among prior HPV programs in India, the states of Sikkim and Punjab demonstrated the ability to attain high vaccine coverage. Factors that contributed to this success, included strong political commitment, robust vaccine preparedness and rollout and awareness initiatives for adolescents and caregivers (4).
In other low- and middle-income settings, pilots involving HPV vaccine delivery through schools were shown to be effective in reaching girls aged from 9-14 years old. Adopting similar strategies in India through the School Health & Wellness Program, would be a promising way to approach AGYW for HPV vaccination and a platform to simultaneously address concerns and misconceptions that may be raised by them or their parents (6).
India represents a massive market for social media use, making it a powerful health communication tool (7). Research among female adolescents in India, shows that exposure to social media bears potential to positively influence their SRH knowledge (8). Therefore, nuanced, age-specific messaging about HPV vaccines- their benefits and modes of access, from trustworthy sources would be pivotal to enhancing awareness in this age group. Innovative social media campaigns including app-based vaccine appointment booking and reward systems were actively used in India to combat misconceptions around COVID-19 vaccines and were successful in motivating adults across the country to get vaccinated. Using similar approaches for HPV vaccines will likely resonate with AGYW (9).
In addition to AGYW, enhancing knowledge and acceptability for HPV vaccines among caregivers is key to sustainable vaccine roll-out and for attaining of high coverage levels. In settings such as the United States, caregiver concerns have been associated with lower rates of HPV vaccination (10). In India, caregiver knowledge and attitudes about HPV differ widely by state and socio-economic level, with several studies across West Bengal, Karnataka and Andhra Pradesh citing differences in acceptance levels depending on affluence levels, urban- rural residence and religious beliefs (11) (12) (13) (14).
Given the vast difference in awareness and hesitancy with regards to HPV vaccine, using context- specific, tailored HPV communication with caregivers would be more favorable as opposed to a one-size fits all strategy. Along with AGYW, caregivers should be involved in vaccine promotion campaigns (15). Multi-pronged communication strategies including social mobilization, engaging community influencers and media- based advocacy have previously been effective in reaching the hardest to reach populations within India. These initiatives have enhanced political will, individual and community level knowledge, and have helped with overcoming gender related barriers and resistance to vaccines (16).
To achieve the full preventive potential for HPV vaccine introduction in India, efforts to facilitate sufficient supply of vaccine must be couple with demand creation strategies. Purposeful and proactive communication will be central to lasting acceptance of HPV vaccine.
- Singh D, Vignat J, Lorenzoni V, et al. Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Glob Heal. 2023;11(2):e197-e206. doi:10.1016/S2214-109X(22)00501-0
- Cervical cancer. https://www.who.int/news-room/fact-sheets/detail/cervical-cancer. Accessed February 26, 2023.
- Singh M, Jha RP, Shri N, Bhattacharyya K, Patel P, Dhamnetiya D. Secular trends in incidence and mortality of cervical cancer in India and its states, 1990-2019: data from the Global Burden of Disease 2019 Study. BMC Cancer. 2022 Feb 7;22(1):149. doi: 10.1186/s12885-022-09232-w. PMID: 35130853; PMCID: PMC8819855
- Sankaranarayanan R, Basu P, Kaur P, et al. Current status of human papillomavirus vaccination in
India’s cervical cancer prevention efforts. Lancet Oncol. 2019;20(11):e637-e644. doi:10.1016/S1470- 2045(19)30531-5
- Serum Institute Of India’S Cervical Cancer Vaccine Cervavac Likely To Be Available This Month. https://www.cnbctv18.com/healthcare/hpv-vaccine-serum-institute-of-india-cervical-cancer- cervavac-available-this-month-likely-15902071.htm. Accessed February 26, 2023.
- Paths to Prevention: CDC Shares HPV Vaccination Lessons. https://www.cdc.gov/globalhealth/immunization/stories/cdc-evaluates-hpv-vaccine- introduction.html. Accessed February 26, 2023.
- Dar SA, Nagrath D. The Impact that social media has had on Today’s Generation of Indian Youth: An
Analytical Study. Int J English Lit Soc Sci. 2022;7(4):048-056. doi:10.22161/IJELS.74.8
- Saha R, Paul P, Yaya S, Banke-Thomas A. Association between exposure to social media and knowledge of sexual and reproductive health among adolescent girls: evidence from the UDAYA
survey in Bihar and Uttar Pradesh, India. Reprod Health. 2020;19:178. doi:10.1186/s12978-022- 01487-7
- A look at India Inc’s PSA moment to eliminate COVID-19 vaccine hesitancy | Social Samosa. https://www.socialsamosa.com/2021/07/india-inc-brand-vaccination-campaigns/. Accessed February 26, 2023.
- Vasudevan L, Ostermann J, Wang Y, et al. Association of caregiver attitudes with adolescent HPV vaccination in 13 southern US states. Vaccine X. 2022;11:100181. doi:10.1016/J.JVACX.2022.100181
- Basu P, Mittal S. Acceptability of human papillomavirus vaccine among the urban, affluent and educated parents of young girls residing in Kolkata, Eastern India. J Obstet Gynaecol Res. 2011 May;37(5):393-401. doi: 10.1111/j.1447-0756.2010.01371.x. Epub 2011 Feb 11. PMID: 21314807.
- Madhivanan P, Li T, Srinivas V, Marlow L, Mukherjee S, Krupp K. Human papillomavirus vaccine acceptability among parents of adolescent girls: obstacles and challenges in Mysore, India. Prev Med. 2014 Jul;64:69-74. doi: 10.1016/j.ypmed.2014.04.002. Epub 2014 Apr 13. PMID: 24732716.
- Degarege A, Krupp K, Srinivas V, et al. Determinants of attitudes and beliefs toward human papillomavirus infection, cervical cancer and human papillomavirus vaccine among parents of adolescent girls in Mysore, India. J Obstet Gynaecol Res. 2018;44(11):2091-2100. doi:10.1111/JOG.13765
- Paul P, Tanner AE, Gravitt PE, Vijayaraghavan K, Shah K V., Zimet GD. Acceptability of HPV Vaccine Implementation Among Parents in India. Health Care Women Int. 2014;35(10):1148-1161. doi:10.1080/07399332.2012.740115
- Holroyd TA, Yan SD, Srivastava V, et al. Designing a Pro-Equity HPV Vaccine Delivery Program for Girls Who Have Dropped Out of School: Community Perspectives From Uttar Pradesh, India. Health Promotion Practice. 2022;23(6):1039-1049. doi:10.1177/15248399211046611
- Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M, Ogden E. Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan. Bull World Health Organ. 2009 Aug;87(8):624-30. doi: 10.2471/blt.08.060863. PMID: 19705014; PMCID: PMC2733260.