Australia is soon set to become the world’s first country to eliminate cervical cancer. Ten years ago, it implemented a free, school-based vaccination program to protect against HPV, a sexually transmitted virus that causes 99.9% of cervical cancers.
From 2005-2015, infection rates plummeted from 23% to just 1% among women aged 18 to 24. More than three-quarters of 15-year-olds are vaccinated, and high coverage is now creating a herd protection effect.
It sounds simple. But the rest of the world is lagging far behind, and not for want of trying.
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Globally, one woman dies every two minutes from cervical cancer, the second most common cancer for 15- to 44-year-old women after breast cancer. Most deaths are in the developing world where vaccination rates remain low and secondary prevention through screening is limited, largely due to lack of funding and organisational capacity.
But many rich countries have spent vast sums on prevention and still fail to replicate Australia’s success.
In the US, 10 years after the government recommended the HPV vaccine for all adolescent girls and five years after it did so for boys, less than half of girls and just a quarter of boys are getting immunised. That’s far short of the government’s 80% goal, and HPV infection rates among young women are more than 10 times higher than in Australia.
And, in Japan, vaccine rates in 2013 were 70% – but today have plummeted to close to zero.
Cost is not the problem. In the US, half the teen population is covered by private insurance that pays for government-recommended vaccines, and the other half is covered by the vaccines for children program. Japanese prices have not suddenly increased.
The spread of fake information
In Japan, the sudden drop has a simple – if remarkable – explanation. The results of a mouse study purportedly showed the vaccine leading to brain damage were spread by the media, alongside unconfirmed reports of videos of girls in wheelchairs having seizures after immunisation.
According to the WHO, fears of side effects are not rooted in any scientific evidence: safety checks of millions of people have shown no good data suggesting any significant concerns. But in response to the scare, the Japanese government revoked its HPV immunisation recommendation, despite finding no evidence to support the claims.
"Japan unfortunately was caught a little bit flat-footed"
A Japanese scientist has now won awards for discovering that the mouse “study” involved a sample size of just one mouse - and furthermore, even that evidence had been tampered with. Despite her findings, immunisation rates remain low.
Japan has not been alone in succumbing to a dangerous media panic. “We’ve seen it to a degree in Ireland and Latin America, too. And it even happened in Denmark, a very well-organised country with one of the world’s highest vaccination rates,” said Professor Silvia de Sanjose, President of the International Papillomavirus Society.
“Suddenly there was a crisis: there was a video on Danish TV about potential adverse effects and people just stopped vaccinating. But the government took it very seriously and slowly they are recovering the rates they had before,” she said.
Fears of girls’ sexuality
However, while scares like this explain the sudden rate drop, the persistent failure of the US government to get vaccination rates up to its targets is more complex.
HPV is a sexually transmitted disease, and so the vaccine is ideally administered to children and young adolescents at around age 11 or 12 - before they are sexually active.
"In the US, sex is a very taboo topic"
One concern that has affected policy and parental decisions in the US is fear of teenage girls’ sexuality, in particular that protecting young teens from the infection will encourage them to have sex. The concern even prompted the Texas Legislature in 2007 to overturn an order to mandate the vaccine for school girls.
“The research shows that it does not increase promiscuity, but it has been a long road in trying to quell that myth,” said Amy Pisani, the director of Every Child By Two.
Anxieties about young teens' sexuality have also led to awkwardness and discomfort in conversations between parents, teens and pediatricians, distorting the government's recommended messaging.
“There are concerns about sexual transmission, both on the side of the parents - in the US, sex is a very taboo topic - and the providers, who assume parents are concerned about sex, even if they’re not. Providers can be very hesitant to get into that conversation with parents of early adolescents, particularly as those pre-teens are sitting in the exam room,” said Dr Debbie Saslow, a Senior Director at the American Cancer Society.
Pisani agreed: “Pediatricians aren’t really accustomed to having these conversations about sex. There’s some data that shows that pediatricians don’t see the end game - when you get cervical cancer or oropharyngeal cancer, you’re no longer at the pediatric practice,” she said.
“And sometimes the front office staff or nurses aren’t on board. When I brought my kids to get their vaccines, the medical assistant said: ‘You need these two teen vaccines - and do you want the HPV vaccine?’ and then the next kid she called it ‘the voluntary HPV vaccine’. The pediatrician doesn’t know that’s happening,” she added.
What governments can do
In much of the developing world, HPV infection will decrease quickly when money and organising power are in place to offer the population the vaccine for free.
But, as new governments start to implement campaigns, there is much to be learnt from the mistakes of countries that have had these in place for years.
"The first thing governments can do is to invest in serious vaccine safety systems"
Firstly, scares have shown the importance of vaccine safety systems so governments have plans in place in case of any problems and are ready to reassure the public that they are keeping a close eye on any concerns.
“The first thing governments can do is to invest in serious vaccine safety systems, paired with independent review committees and engaging the media - being transparent that vaccines can have rare side effects. Japan, unfortunately, was caught a little bit flat-footed,” said Saad Omer, Professor of Global Health at Emory University.
Beyond safety systems, the US experience shows that messaging around the purpose and importance of the vaccine is critical to uptake. The US government is now working out how to change conversations happening in pediatricians and doctors’ offices. It wants to normalise the vaccine – to have providers presume parents want it, avoid awkward conversations, and only go into detail if parents specifically request.
This approach is called presumptive communications. “Rather than saying ‘Should we vaccinate little Johnny or Sarah on this visit?’ the provider says ‘It’s time for little Johnny or Sarah to get vaccinated on this visit.’ The idea is to assume vaccination, because the HPV vaccine has been shown to be extremely safe, and so it should be framed as a routine part of care,” said Omer.
School-based programs, like Australia’s, have generally proved even more effective – they normalise the vaccine by creating a system where parents see all other children that age getting immunised.
“Each country varies, but overall school-based programs have been more effective than some of the other modalities,” Omer said.
“On the other hand, there has to be a little bit of caution applying that same strategy in low-income countries, because if school enrolment is not universal, you risk leaving out an already underprivileged population,” he added.
A race to elimination?
The results from Australia show that robust screening and vaccination programs that don't fall into these common pitfalls can have incredibly powerful results. And several other countries also have high rates of both screening and vaccination - which has led many to start suggesting that global elimination of cervical cancer could be on the horizon.
"It would be a wonderful thing to have a global race to see who would be first to eliminate a form of cancer. That has never been done"
“Somebody mentioned to me they thought Israel would be first. It would be a wonderful thing to have a global race to see who would be first to eliminate a form of cancer. That has never been done,” said Saslow.
But, for now, hundreds of thousands of women still contract and die from the disease each year. Many in low-income countries are offered neither free vaccination nor free screenings. Until this happens, global elimination will remain a distant, if possible, goal.
"In public health, the art of the possible is a big motivator"
“Funding is, at this point, not there: we have to have broad introduction of the vaccine in multiple countries, especially in sub-Saharan Africa and South Asia, before we can talk about global elimination of HPV - so I think it’s a little bit premature to do that,” said Omer.
“At the same time, I think examples like Australia are very reassuring,” he added. “In public health, the art of the possible is a big motivator.”
(Picture credit: Getty)
Odette Chalaby
odette.chalaby@apolitical.co
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