Yesterday I had two sessions, in the first session I was talking about how cervical cancer prevention interventions are scaled up in low and middle income countries across the world. I was emphasising that the human papilloma viral vaccination, which is one of the important strategies for cervical cancer prevention, is being scaled up currently in 70 countries. Compared to the pace at which human papilloma virus vaccination is being upscaled, it’s much higher than the pace at which hepatitis B vaccination was scaled up about ten or twelve years back. So this is a very encouraging sign and I was emphasising that HPV vaccination is probably one of the easiest things to scale up in national health services because of the existence of the extended programme of immunisation infrastructure. Every country with a high risk of cervical cancer should look into the possibility of scaling up HPV vaccination targeting 10-14 year old girls.
On the other hand, although screening is a very important intervention for cervical cancer prevention, it requires a very highly, well-organised health service, with a sufficient number of providers, the infrastructure and access to diagnosis and treatment and a good information system to monitor. So unless these things are in place, unless there are efficient health services are in place, screening programmes are difficult to scale up. So the countries which are planning to introduce screening programmes probably think of introducing HPV testing as the primary screening procedure and at the same time they should start improving their healthcare infrastructure so that they can implement an effective screening programme.
I was also suggesting at a pragmatic perspective the best way to control cervical cancer is to vaccinate 10 or 11 year or 12 year old girls with HPV vaccination, two doses at six months apart or twelve months apart, and provide at least a single HPV screen between 35 and 39 years. If resources permit then repeat another screen, another HPV screen, after ten years. Such a strategy will rapidly bring down cervical cancer incidence and mortality in low and middle income countries.
HPV vaccination programmes can be costly. Do they save money in the long term?
When HPV vaccines came into the market they were very expensive, like any new product comes into the market it is expensive. As time goes on when the demand increases, when the competition comes in, eventually the prices come down. There are mechanisms by which low and middle income countries can implement HPV vaccination at considerably lower cost than nominally one perceives. For example, the GAVI eligible countries can use the GAVI route, HPV vaccine is a GAVI eligible vaccine. GAVI purchases at a rate of $5 per dose and distributes to the countries, to the GAVI eligible countries. So the GAVI eligible countries can apply to GAVI, first to introduce a demonstration programme to show how HPV vaccination can be integrated into the health services and following that, with the successful demonstration of the demonstration programme, one can scale up HPV vaccination. The GAVI non-eligible low and middle income countries can negotiate a bulk purchase and negotiate.
I’ll give you a very good example. In the American region, which comprises North America, Central America, South America and the Caribbean, seven out of eight girls have access to HPV vaccination through their national immunisation programme. This is possible because the Pan-American Health Organisation, which is the regional office of the WHO in the American region, has a revolving fund. Through the revolving fund they bulk purchase HPV vaccines for the whole region. So when they bulk purchase they have a better price. They were purchasing at a rate of $15 per dose initially and very recently I hear they have renegotiated the price but I don’t have the details. So this is a mechanism by which the Latin American countries like Mexico, Argentina and many of these countries have benefitted. So the access is dramatically improved.
Access is very low in Asia because only a very few countries have implemented, like Bhutan, Malaysia, Brunei, Dar-Es-Salaam, Uzbekistan and the United Arab Emirates. Other than them nobody has introduced at a national level. In Africa also access is improved but it is still much lower than in Latin America. The country itself, enormous negotiating potential at the moment. What South Africa has done is very interesting, they have negotiated the prices so they have considerable… it’s not a GAVI eligible country, so they have considerably cheaper prices than the developed countries pay. Similarly Brazil, they have negotiated the price and they have also, I understand, the technology will be transferred so the vaccines will be locally manufactured. In future I’m sure there will be more companies which may be producing vaccines like in China and India and competition grows and demand increases the price will eventually even further go down.
Then again there are cost effectiveness studies in the context of different countries, low and middle income countries. So if they invest now they can save a lot of money in the future because it is going to prevent a minimum of 70-75% of cervical cancers, it may be even higher because nobody takes into account the herd immunity. In fact, there has been a WHO prime modelling study where they showed in 179 countries if they vaccinate the entire cohort of 11-12 year old girls now, they will prevent in this cohort something like 690,000 cervical cancers and about 425,000 cervical cancer deaths in coming years. Just imagine, this will cost around $4 billion at the current rates. Just imagine, if you vaccinate successive cohorts of girls in coming years the number of cervical cancers prevented will be quite high. So I think, by all the evidence that we have now, the way the prices are coming down with the negotiating power and things like that, HPV vaccination can be cost-effectively introduced in countries.
Could African countries buy in bulk in a similar way to South American countries?
Yes, that would be a fantastic mechanism, whenever you bulk buy things. It is very good that PAHO has this revolving fund. The UNICEF procurement office which purchases the vaccines for the HPV vaccines as well as for the GAVI, the HPV vaccine, how do they negotiate? Because they buy it for several countries so it’s a bulk purchase. So I’m sure in Africa if these countries find a solution by a consortium or something that will be an interesting approach for HPV vaccination.
Are there plans to vaccinate boys also?
No. At the moment I would say if you vaccinate girls and achieve a good coverage, and with herd immunity, I think that is sufficient. I think I would like to give a dogmatic answer. I also forgot to add another thing: now WHO recommends two doses at six months apart or one year apart for girls between 10 and 14 years. So this also brings down the cost. The cost with vaccinations is not only the cost of the vaccine but the delivery costs. So this is another thing which is now improving the feasibility and the cost effectiveness of HPV vaccination.
