I have been following the research and recommendations around the human papillomavirus (HPV) vaccine for young girls. In this blog, I will provide a reality check on whether the HPV vaccine is necessary for Indian girls by examining the latest research and recommendations.
Introduction to HPV and HPV vaccines
HPV or human papillomavirus is one of the most common sexually transmitted infections globally. According to the WHO, most sexually active individuals will get infected with HPV at some point in their lives. There are over 100 types of HPV viruses, with around 13 high-risk strains that can lead to cervical and other types of cancers. HPV types 16 and 18 are responsible for 70% of all cervical cancer cases worldwide.
To prevent HPV and related cancers, three prophylactic HPV vaccines have been approved globally – a bivalent vaccine, a quadrivalent vaccine, and a 9-valent vaccine. These vaccines protect against high-risk HPV types 16 and 18, which cause the majority of HPV-driven cancers. The vaccines need to be given before potential exposure to HPV through sexual contact for maximum protection.
The key question is – with HPV being common globally, do young girls in India need the protection offered by these vaccines?
HPV disease burden in India
India accounts for about a fifth of the global burden of cervical cancer, with over 96,000 new cases and 60,000 deaths reported annually. Cervical cancer is the second most common cancer among Indian women after breast cancer. Studies have shown that about 72% of cervical cancer cases in India are attributed to HPV types 16 and 18.
Apart from cervical cancer, HPV is known to cause other anogenital cancers and oropharyngeal cancers. Though robust data is lacking, some small studies from India have shown HPV attribution rates of 18-72% for vaginal, 35-100% for vulvar, 30-88% for anal, and 21-58% for oropharyngeal cancers.
So there is clear evidence of a significant disease burden due to HPV that can likely be prevented through vaccination in our population.
Current HPV vaccine recommendations in India
Some expert groups in India, including the Federation of Obstetric & Gynaecological Societies of India (FOGSI) currently recommend giving the HPV vaccine.
- To girls aged 9-14 years – as the vaccine will have the most benefit if given before sexual debut
- Catch-up vaccination for young women aged 15-26 years – especially those who are sexually active
- Consider vaccination for boys aged 9-14 years for added protection
The Indian government included the HPV vaccine in its universal immunization program in 2016 but later deferred its inclusion citing inadequate evidence, high cost, low burden compared to other diseases, and the need for more advocacy. Union Finance Minister Nirmala Sitharaman on February 1 announced the government’s plans to focus on vaccination against cervical cancer for girls aged 9 to 14 as part of her Interim Budget 2024.
So while some leading doctors bodies acknowledge the role of the vaccine, there is still no consensus on universal mass vaccination in India.
What does the research say about HPV vaccine efficacy and safety?
Numerous international and Indian research studies have demonstrated excellent real-world effectiveness and safety of the HPV vaccines.
High efficacy against infections & precancers
- Clinical trials show close to 100% efficacy in preventing persistent infections and precancerous lesions associated with vaccine-included HPV types among previously unexposed girls and women.
- Population-level studies from countries like Australia, Sweden, and even India have shown a dramatic decline of 70-90% in vaccine-targeted HPV types and anogenital precancers like CIN2+ in young vaccinated cohorts compared to unvaccinated individuals after vaccine introduction. This indicates the real-world impact vaccination can have.
Indirect protection via herd effects
Herd immunity effects from young female vaccination are resulting in fewer infections even among unvaccinated individuals of both genders across all age groups in multiple settings. Evidence suggests strong herd effects can bring the effective vaccine coverage to over 80% for unvaccinated individuals.
Favorable safety outcomes
- After administration of over 270 million doses globally, the HPV vaccines have a very reassuring safety profile. Monitoring data indicates no increased risk of serious adverse events like autoimmune disorders or secondary cancers compared to unvaccinated girls. Mild side effects like injection site reactions, dizziness, and nausea are seen in less than 10% of recipients.
- Indian studies looking at over 10,000 girls who received HPV vaccines also found no significant differences in the frequency of adverse events among vaccinated and unvaccinated individuals.
So in summary, both international and Indian research provides robust evidence that the approved HPV vaccines are highly efficacious and safe. They can make a significant public health impact in preventing cervical and other HPV-associated cancers in our population if coverage is adequate.
Cost-effectiveness of the HPV vaccine in India
Another question is whether the HPV vaccine provides good value for money spent, especially given India’s limited health budget.
Economic analysis and Markov simulation models looking at the cost per quality-adjusted life years (QALY) estimate the HPV vaccine would be very cost-effective for India at thresholds under $200 per QALY gained. Studies show vaccinating a single cohort of Indian girls at age 12 years can be beneficial and affordable in the range of $9-76 per QALY depending upon vaccine costs and cancer care expenditures.
Research also suggests India is likely to accrue substantial savings in terms of treatment costs avoided with vaccination against the NoVaccine scenario. With the GAVI alliance recently negotiating record-low prices for HPV vaccines, cost-effectiveness is expected to improve further making the introduction appealing in the Indian context.
On the balance of clinical effectiveness, safety & cost-effectiveness data, the case for HPV vaccination of young adolescent girls seems compelling for India.
Potential concerns around the HPV vaccine in India
While the evidence around the HPV vaccine seems largely positive, some questions & concerns remain from an Indian perspective.
- Social acceptance of a vaccine against a sexually transmitted infection is still evolving gradually. Counseling of parents, along with school & community awareness is key.
- Vaccine delivery platforms focusing on young girls need further strengthening under our Universal Immunization Program.
- Effectiveness data is still limited from India as large post-marketing studies are few. We need indigenous surveillance on trends in HPV infections and cancers.
- Optimum dose schedule questions between 2 vs 3 doses need clarity. Can we sustain protection with fewer doses thereby reducing program costs?
- Prioritization is essential. Should we introduce HPV vaccines nationally when coverage against infections like measles and hepatitis B remains suboptimal?
- Do boys also need to be vaccinated for more complete protection at a population level? Evidence is emerging but implications for costs & logistics need evaluation.
While most concerns have potential solutions with concerted efforts towards community sensitization, political commitment, smart vaccine delivery, and indigenous research, they need deliberation before India fully adopts HPV vaccination nationally.
My opinion
To conclude, as a physician I believe there is enough clinical evidence today to recommend routine HPV vaccination for girls aged 9-14 years in India along with catch-up vaccination for women 15-26 years if feasible.
We have a huge disease burden that can be drastically reduced by these remarkably effective and safe vaccines. Cost-effectiveness and herd-effect benefits also make a case for prioritization. Addressing programmatic challenges around delivery platforms and generating local research evidence to confirm post-vaccination trends must be simultaneous goals. With a growing cervical cancer crisis in India, we must leverage HPV vaccines judiciously as a pivotal prevention strategy within a comprehensive screening and vaccination framework.
I hope this reality check has provided a balanced perspective on the rationale behind HPV vaccine recommendations for young girls in India by doctors. The evidence is robust from global and local research that these vaccines can save lives by preventing avoidable cancer deaths linked to HPV. While reasonable skepticism exists on the operational feasibility and lingering questions, the fundamental premise of effectiveness & safety is difficult to challenge even by naysayers. Through coordinated efforts, we can overcome hurdles around acceptance, strengthen our health systems to deliver HPV vaccines, and make progress against cervical and other HPV-linked cancers. The time to act is now to safeguard our next generation.
