SEATTLE, Washington — Cervical cancer is the fourth most common cancer in women worldwide, representing 7.5 percent of all female cancer-related deaths in 2012. The leading cause of this cancer is two strains of Human Papillomavirus (HPV), type 16 and 18, which account for 70 percent of precancerous lesions and can cause not just cervical cancer but also “anal cancer, penile, vaginal, vulvar, head and neck cancers.” The World Health Organization believes that cervical cancer can be eliminated in 180 countries with improved HPV vaccine coverage.

Vaccinations for HPV

Although HPV is a dangerous virus, there are three prophylactic HPV vaccines available: Cervarix, Gardasil and Gardisil 9. These vaccines have proven to be not only safe but wildly effective. It’s been so effective, in fact, that a study found that, by increasing HPV vaccine coverage around the world, cervical cancer could be eliminated in 181 countries by the end of the century.

While this is fantastic news, HPV vaccine coverage is not distributed equally. Women living in low and middle-income countries make up nearly 90 percent of all cervical cancer deaths. These women often lack access to vaccines along with cancer screenings and palliative care. Often, prevention is a girl’s best line of defense against complications from HPV, but there are barriers specific to this vaccine, such as social stigma, inadequate health systems and competing health priorities.

With all these barriers, how can these countries convince parents to vaccinate their children? As it turns out, all they have to do is look to Rwanda. The nation of Rwanda is poised to be “the first country to wipe out cervical cancer” through effective education and implementation of HPV vaccine coverage programs.

Social Stigma

One of the biggest barriers to full HPV vaccine coverage is the social taboo around sex. Because of its nature, most parents had not heard of the vaccine. Many parents that had were concerned that vaccinating their daughter against a sexually transmitted infection could lead to earlier sexual activity or that the rumors that the vaccine caused infertility were true.

To combat these rumors and the potential stigma, Rwanda implemented an education program that focused on the vaccine’s cancer prevention benefits. They raised awareness about cervical cancer and its effects through education in schools, on billboards and on the radio. While the rumors were difficult to overcome, the community has, for the most part, accepted the vaccine as a health necessity.

The Healthcare System

Insufficient healthcare system infrastructure is another barrier to full HPV vaccine coverage. The vaccine is not cheap, and a lack of medical infrastructure can make it difficult to distribute it. There is also no HPV vaccine that is safe for children under nine. Girls between the ages of nine and 13 are the main focus for the vaccine, which is an awkward age for immunization. Most get their vaccines through school, but rampant absenteeism makes it difficult for them to get the full three doses.

Rwanda was able to roll out the vaccine so effectively because it partnered with one of the companies that make it, Merck. The pharmaceutical company supplied the country with the HPV vaccine for three years in the hopes of showing Gavi, a global vaccine alliance, that distributing this vaccine in low and middle-income countries is feasible. Gavi did take note, and, when the three years were up, it agreed to pay for the majority of each dose of the vaccine.

To ensure that absentee girls did not slip through the cracks, Rwanda used the community to figure out which girls were not in school. That, along with the “national sensitization campaign” provided prior to the first dose, allowed for more than 93 percent HPV vaccine coverage for all rounds of vaccination.

Health Priorities

When it comes to health priorities, the HPV vaccine has three strikes against it. The first is that, although the vaccine prevents forms of cancer in all genders, the illness that countries emphasize is cervical cancer, “a woman’s disease.” The second is that it’s preventing an STI, and discussions of sex are often taboo. The third is that the benefits are not immediate. Full measles vaccine coverage, for example, has an immediate effect. The HPV vaccine is an investment. They vaccinate the girls now to prevent potential cancer in the future.

The rollout of the HPV vaccine in Rwanda was not without criticism. Some argued that, although the burden of cervical cancer was substantial, this decision was not good “for the people” because the country should focus on coverage for other vaccines like tetanus and measles. The Minister of Health at that time, Agnes Binagwaho countered that the nation already had high rates of immunization for tetanus and measles. She asked in a public letter, “Are the 330,000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this program not regarded as ‘the people’?”

The nation of Rwanda has been a model in cervical cancer prevention through HPV vaccine coverage. Should other nations follow in its footsteps and ramp up immunizations for HPV, it is possible that cervical cancer could be eliminated by the end of this century.

– Katharine Hanifen

Photo: Flickr