Girls wait for their vaccination cards to be updated after receiving the HPV vaccine at BP Koirala Cancer Hospital in Bharatpur, Nepal, 10 July 2023. Credit: Marty Logan/IPS
CHITWAN DISTRICT, Nepal, Jul 31 2023 (IPS) – As Dipak Subedi was organizing a vaccination programme against the human papillomavirus (HPV) in the city of Bharatpur in Chitwan district of southern Nepal he was getting phone calls from neighbouring districts asking if he had extra doses available — people were willing to travel for hours to get their girls vaccinated against HPV, which causes cervical cancer, the deadliest form of cancer for women in Nepal.
Callers had heard about the campaign, which started in 2022, after the city posted the news on its Facebook page, says Subedi, senior public health officer and chief of the Bharatpur public health promotion section. Unfortunately he had no extra doses to meet the demand. “With such demand if the HPV vaccine was to be included in our regular vaccination programme we could get more than 90% coverage,” he adds in an interview in his office in Bharatpur, a city of 370,000 people best known for its location near Chitwan National Park.
The burden of the disease in Asia is high. In 2020, China and India alone accounted for 40% of global cervical deaths (17% and 23% respectively), according to The Lancet journal. In Nepal, there were an estimated 14.2 cases per 100,000 women in 2020, versus the WHO target for 2030 of less than 4.0
Most people approached for this article who were connected to the Bharatpur campaign, or to previous small-scale pilot projects in Nepal, noted similar high demand. In recent years the Nepal Government has pledged repeatedly to provide the HPV vaccine for national distribution but has yet to do so.
Awaiting GAVI response
Earlier this month a national campaign moved a step closer when the child health and immunization section of the health department submitted a request to the global vaccine alliance GAVI for 1.6 million doses. The response should be known by September; if positive, vaccination could start in 2024.
Cervical cancer is the fourth most common form of cancer among women globally and the leading cause of cancer-related deaths for women in 36 countries in Africa, Asia and Latin America. The World Health Organization (WHO) reported recently that 604,000 new cases of cervical cancer were reported globally in 2020 and that 342,000 women died from the disease – a staggering 90% of the new cases and deaths occurred in low and middle-income countries.
HPV is the virus that causes most cases of cervical cancer and is responsible for the majority of sexually transmitted infections of the reproductive system. The HPV vaccine has been shown to prevent up to 90% of HPV-related cancers and pre-cancerous injuries. WHO says that eradicating cervical cancer will require vaccinating 90% of all girls worldwide by the age of 15.
The burden of the disease in Asia is high. In 2020, China and India alone accounted for 40% of global cervical deaths (17% and 23% respectively), according to . In Nepal, there were an estimated 14.2 cases per 100,000 women in 2020, versus the WHO target for 2030 of less than 4.0. The disease kills about 1,500 women in the country each year, reports the .
In 2020, researchers predicted that without any intervention, a total of 170,600 women in Nepal would die from cervical cancer by 2070 and 318,855 by 2120. But , HPV vaccination could prevent nearly 38,737 cervical cancer deaths in Nepal by 2070, and 165,115 deaths by 2120.
About 400-500 new cases are diagnosed at the BP Koirala Cancer Hospital in Bharatpur alone every year, says Dr Asmita Rana, the head of the hospital’s department of cancer prevention control and research.
Rana is managing the vaccination campaign that includes Bharatpur and two other municipalities, distributing 12,500 doses to girls ages 11-13, two doses each. While the first phase was a big success, the second one has faltered, she says in an interview in her office. That’s mainly because phase one was implemented at the community level (schools and health facilities) by municipal staff. Phase two was centred around the hospital, meaning that caregivers (school officials and/or parents) had to take time to transport children to and from the facility.
Staff members in the hospital’s department of cancer prevention control and research discuss vaccination with a girl about to be receive her second dose of the HPV vaccine, at BP Koirala Cancer Hospital in Bharatpur, Nepal, 10 July 2023. Credit: Marty Logan/IPS
Schools the preferred site
Asked what she has learned from the campaign, Rana says she would do all phases through schools next time to ensure participation. “That would be a more appropriate way to follow up those girls… rather than at the health facilities.”
The second learning is that raising awareness ahead of time is key, says Rana. “From my experience I can say that if we do an awareness programme ahead of time — tell them something about the vaccine, about HPV, and the effectiveness of the vaccine for preventing cancer, then they will be quite positive and participating.”
Even if people are initially sceptical, “gradually when we explain to them that it’s a very good vaccine, it’s free of cost — although it’s expensive if you have to buy it — and will prevent your daughter from getting cervical cancer in the future, most of the people are convinced.”
The vaccine is available at private health facilities in Nepal but two doses costs around 10,000 rupees (US$76). The country’s per capita income was about $1,300 in 2022. Neighbouring India started producing its own vaccine, Cervavac, in 2022. Its price is $4.88-$9.76 for two doses. South Asian neighbours Bhutan, Sri Lanka and the Maldives have launched national vaccination programmes while Bangladesh has done pilot projects.
It s surprising to hear that vaccine hesitancy hasn’t been a minor issue in the campaign. One school did refuse to participate, says Rana, after they were told that parents had to sign consent forms. “They were thinking ‘it’s like a new Covid vaccine and it’s being tested via our girls’; they were not aware that the vaccine had been approved years before. I tried so hard to convince them but they would not come.”
School nurse Sudeepa Poudel also faced some resistance, but says she overcame it after talking to doubting parents. “They say ‘we were never vaccinated but we are fine till now — why do our kids need to be vaccinated’? Some parents are easy to convince but many are not because they’re illiterate, so I have to take time to explain carefully to them; sometimes it takes two sessions. After that explanation they easily accept it.”
Poudel works at a secondary school in Bharatpur from where 25 girls were vaccinated earlier this year. Beforehand she spent one hour explaining the process to students. “I conducted classes for those students who were going to be vaccinated as well as those younger students (9-11) who might receive the vaccine in the future, explaining the purpose of the vaccine, where it comes from, how it’s managed, possible side-effects, etc.”
Just down the hall from Rana’s office at the hospital is the room where the vaccine is given. During one recent morning girls arrive in small groups and take turns sitting in a chair and rolling up their sleeves, while caregivers look on.
Later outside the room, three girls from a high school in Bharatpur shake their heads when asked if their shoulders hurt where they got the injection. They had no hesitation getting the vaccine, they add through an interpreter. “We got information from the school nurse and teachers so we are confident,” says one.
3 reasons for support
“We’re doing this for three reasons,” adds another: to prevent genital problems, or issues having children, and because getting cervical cancer would interfere with menstruation.”
The father of one of the girls says he learned about the vaccine from his daughter, via news reports and social media before being contacted by the school. “I talked to the school nurse… Yes, I’m positive — both my wife and I are positive — because there is news about this vaccine being very good. I don’t know much about the technical part,” he adds, “but I feel good doing this for my child.”
HPV is spread through sexual contact, but Rana says that most Nepalis don’t interpret that to mean their daughters should be vaccinated before they become sexually active, which might be one reason there is little resistance to campaigns. “Their understanding is that it’s early marriage that would expose girls to HPV rather than premarital sex, because that was the experience of women who are now developing cervical cancer, who are around 40-45 years of age,” she says.
“Sometimes people do ask explicitly about the impact of premarital sex, but they do not resist having their girls vaccinated when we explain,” she adds.
At Bharatpur municipality Subedi says his team easily overcame hesitancy they encountered from parents during recent campaigns for Covid-19 and routine immunization for children under 2 years. “There are some rumours and misconceptions, but we can tackle that — I don’t think it’s a big deal. We can convince them. In every vaccination campaign we do the coverage rate is very high.”
Nepal’s health department has prepared an awareness module in preparation for HPV vaccination being added to the national vaccination programme, says Dr Abhiyan Gautam, head of the child health and immunization section. It will be part of what he calls a demonstration campaign ahead of the programme, which will distribute 20,000 doses in various parts of Nepal, still to be identified.
1st time under federal system
A trial phase is needed, adds Gautam, because the health system was reorganized after Nepal enacted federalism in 2017. “We haven’t conducted such a campaign at the local area… so this is a new concept for us,” he says. “The district recording and reporting system is also quite different now… at the operational level we have to be sure that the system will work, so we’ll be piloting first.”
The same system will be used for the national programme, if GAVI approves the request. “We are hopeful that we’ll get the vaccines,” says Gautam. “What we do know is that whenever we operate a vaccine programme GAVI provides some vaccines to Nepal. We submitted our application – now the ball is in their court.”
In response to a query, GAVI said that it does not comment on current applications.
The planned programme will include girls ages 10-14, in classes 6-10, rather than the 9-14 age group recommended by WHO. Gautam says this is to conserve limited resources. “Our national immunization advisory committee recommended 10-14 based on the country situation: if we go to 9-14 our operational costs will almost double.”
If Nepal launches the national programme, the immunization chief anticipates the same results as a previous government-run pilot project in 2016. “The vaccination coverage was very good (97%) because people demand the vaccine when they know about it… Poor people may not go to private settings to get vaccinations but even rich people are waiting for the national programme.”
This feature was supported by the Sabine Vaccine Institute and Internews.