TechNet-21 - Forum

This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.
  1. Omesh K. Bharti
  2. Service delivery
  3. Monday, 25 June 2012

The Indian government suspended research in April 2010 on the feasibility and safety of human papillomavirus (HPV) vaccine in two Indian states (Andhra Pradesh and Gujarat) amid public concerns about its safety. This paper describes cervical cancer and cancer surveillance in India and reviews the epidemiological claims made by the Programme for Appropriate Technology in Health (PATH) in support of the vaccine in these two states. National cancer data published by the Indian National Cancer Registry Programme of state registry returns and the International Agency for Research on Cancer cover around seven percent of the population with underrepresentation of rural, northern, eastern and north-eastern areas. There is no cancer registry in the state of Andhra Pradesh and PATH does not cite data from the Gujarat cancer registries. Age-adjusted cervical cancer mortality and incidence rates vary widely across and within states. National trends in age standardized cervical cancer incidence fell from 42.3 to 22.3 per 100,000 between 1982/1983 and 2004/2005 respectively. Incidence studies report low incidence and mortality rates in Gujarat and Andhra Pradesh. Although HPV prevalence is higher in cancer patients (93.3%) than healthy patients (7.0%) and HPV types 16 and 18 are most prevalent in cancer patients, population prevelance data are poor and studies highly variable in their findings. Current data on HPV type and cervical cancer incidence do not support PATH's claim that India has a large burden of cervical cancer or its decision to roll out the vaccine programme. In the absence of comprehensive cancer surveillance, World Health Organization criteria with respect to monitoring effectiveness of the vaccine and knowledge of disease trends cannot be fulfilled.

Moderator Accepted Answer
Dr Thomas Cherian, IVB/WHO, responds to the post. Dr. Bharti has rightly highlighted the limitations of cancer surveillance in India and the need to strengthen surveillance in order to monitor the effectiveness of any public health intervention is unquestionable. However, the perfect should not be the enemy of the good and one should not wait to institute strategies to address problems till the perfect data are available. Data from the International Agency for Research on Cancer estimate the age-standardized incidence of cervical cancer in women in India to be 27/100,000 in 2008 (, which is close to the estimates cited by Dr. Bharti. But, importantly the rate of death in these women is high in India, with an estimated 72,825 deaths annually in India, making it the leading cause of cancer deaths in women in India (a bigger problem than breast cancer). Therefore, one cannot deny that cervical cancer is a public health problem in India that deserved attention, particularly since there are several effective approaches to address the problem, including screening and early treatment in addition to vaccination. It is the lack of access to screening and treatment that makes cervical cancer a bigger problem in developing countries than in the industrialized countries. Whether or not this intervention should be vaccination deserves further assessment and I agree with Dr. Bharti that such an assessment is essential prior to any decision on vaccine roll out. While cost-effectiveness of a vaccination strategy would undoubtedly be important in making any decision, an equally important factor would be the ability of the programme to deliver vaccine or any other intervention to the target populations (pre-adolescent girls for vaccine and adult women for screening and treatment programmes) in the most marginalized populations who carry the disproportionate burden of the disease. Equity considerations should be an important factor while considering any available strategy for cervical cancer control. While advocating for better surveillance and monitoring mechanisms, which are the cornerstone of public health programmes, a parallel effort to initiate action to address pressing public health needs, as evidenced by the best available information, is also required. One cannot afford to wait and watch. Dr. Thomas Cherian Department of Immunization, Vaccines and Biologicals World Health Organization
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  2. Service delivery
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