Neerja Bhatla
New Delhi
In 2008, Professor Harald zur Hausen received the Nobel Prize for his discovery that persistent infection with high-risk strains of the human papillomavirus (HPV) is the necessary cause of cervical cancer, an important cause of morbidity and mortality globally, but more so in low and lower middle income countries (LMICs). His discovery paved the way for development of prophylactic vaccines as well as tests to detect the infectious agent. A decade later, in 2018, the World Health Organization (WHO) announced an initiative for the elimination of cervical cancer, and the global strategy was formally launched on November 17, 2020, endorsed by 194 countries, India among them.
Elimination of a cancer! Not just any cancer but cervical cancer. The source of extreme physical misery, emotional strife and financial hardship. The second most common cancer among women in India, with approximately one lakh new cases every year and half as many deaths, one quarter of the global burden. The years of life lost with cervical cancer are more than with other cancers as these women are relatively younger, with active family and social responsibilities. As an oncologist, I have witnessed their suffering.. women diagnosed in stage 4 who had developed urinary fistulas, where the odour would precede their entry into the consulting room, women who hesitated to mention the postmenopausal bleeding till the daughter-in-law noticed the stain on their saris, women with extreme sciatic and lumbar pain, obstruction to their ureters and renal failure… Then there were the luckier ones who got diagnosed at an earlier stage that was curable, but only with radical surgery or chemo- and radiation therapy… aggressive surgeries that take their toll, prolonged treatment schedules for radiation that deprive the caregivers of education or work, expensive chemo- and immunotherapy… And then, there were cases with recurrences despite our best efforts, requiring even more difficult exenteration procedures, stomas, etc. Yes, we could cure, we could provide symptom relief, even hormone replacement and other supportive care, but at a cost – physical, emotional, financial.
What made it even more tragic was the fact that this suffering was preventable. Since the 1940s, secondary prevention by regular Pap smear screening had been set up in the West, enabling detection of not just cancer but also its precancerous stages. The natural history of cervical cancer has been well documented for over a century. It has a long precancerous phase of 10-15 years termed cervical intraepithelial neoplasia (CIN) which can be detected by microscopic examination of cells collected on a slide by brushing the cervix. In this stage it is easily treated by simple day-care procedures that do not require removal of the uterus. In India and other LMICs we lacked the infrastructure and trained manpower to implement screening of all women over age 30 years even once in a lifetime, let alone the recommended 3-yearly intervals. Even in good tertiary centres, the laboratory placed a limit on the number of women that could be screened in a day. Outreach camps were conducted at regular intervals by gynaecologists and pathologists around the country trying to help the underprivileged, but these were merely a drop in the ocean. Even today, despite a national programme for screening with visual inspection (VIA), the screening coverage does not exceed 5%, and bringing women who test positive into the hospital for a confirmatory biopsy and treatment has extremely poor compliance.
HPV vaccination entered this scenario in 2006 like a promising superhero for primary prevention of cervical cancer. Starting off as a three-dose vaccination, progressive research showed that it could be reduced to two, and further that one dose was sufficient to provide protection against 85-90% of cancers. A simple intramuscular injection could prevent so much suffering?! It was an exciting prospect. Safety is the first priority in preventive vaccination. Over 500 million doses have been delivered worldwide and nearly 4 million in India. Cumulative data from systematic trials and post-marketing surveillance show no increase in adverse events among vaccinated women than in the general population. Transient mild reactions have been observed that are common to all vaccines. There have been no adverse effects on reproductive performance, fertility rates, congenital malformations or menstrual patterns. The efficacy of the HPV vaccines is remarkable, with nearly complete protection against the vaccine-contained types. The first generation of vaccines were directed against the two most virulent strains, HPV 16 and 18, that account for 70% of cervical cancers globally but 85% in India. Countries like Australia and UK that introduced the HPV vaccine soon after its launch in 2007-8 have already witnessed significant reductions in precancer and cancer. Similar reports have come from other countries like Sweden, Denmark, Canada and USA.
WHO’s cervical cancer elimination initiative envisions making cervical cancer a rare cancer, with an incidence rate of 4 per 100,000. To reach this goal, we must achieve certain targets by 2030: HPV vaccination of 90% girls before the age of 15 years, screening of 70% of women with an HPV test at 35 and 45 years, and treatment of 90% of those detected with lesions. We have already crossed the halfway point since the launch of the global declaration and are still far from these targets. The medical community represented by organizations like the Indian Medical Association, Federation of Obstetrics & Gynaecology of India (FOGSI) and the Indian Academy of Paediatrics (IAP) has been demanding for a long time that HPV vaccination should be included in the Universal Immunization Programme. Finally, we have hope – the nationwide launch of the National HPV Vaccination Campaign on February 28, 2026 by the Hon’ble PM himself signals the highest political commitment to ensure that women’s health and reproductive rights get the importance they deserve. Accessibility, affordability and availability, the major concerns, have been addressed fully by the government. Now all parents need to be aware of this wonderful opportunity so that their 14-year-old daughters can avail free vaccination at the nearest government health facilities. One small jab to our girls will take us in one giant leap towards cervical cancer elimination and a Viksit Bharat@2047.
Neerja Bhatla, Professor Emeritus, National Cancer Institute Jhajjar, Former Head of Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Delhi
