Universal routine HPV vaccination for young girls in Uganda: a review of opportunities and potential obstacles
Infectious Agents and Cancer
Universal routine HPV vaccination for young girls in Uganda: a review of opportunities and potential obstacles
Cecily Banura 0
Florence M Mirembe 2
Anne R Katahoire 0
Proscovia B Namujju 1 3
Edward K Mbidde 1
0 Child Health and Development Centre, Makerere University College of Health Sciences , P. O. Box 6717, Kampala , Uganda
1 Uganda Virus Research Institute , P.O. Box 49, Entebbe , Uganda
2 Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences , P.O. Box 7072, Kampala , Uganda
3 National Institute for Health and Welfare , Oulu , Finland
This article reviews the existing realities in Uganda to identify opportunities and potential obstacles of providing universal routine HPV vaccination to young adolescent girls. Cervical cancer is a public health priority in Uganda where it contributes to about 50-60% of all female malignancies. It is associated with a dismal 5-year relative survival of approximately 20%. With adequate financial resources, primary prevention through vaccination is feasible using existing education and health infrastructure. Cost-effectiveness studies show that at a cost of US$2 per dose, the current vaccines would be cost effective. With optimal (70%) coverage of the target population, the lifetime risk of cervical cancer could be reduced by >50%. Uganda fulfils 4 out of the 5 criteria set by the WHO for the introduction of routine HPV vaccination to young adolescent girls. The existing political commitment, community support for immunization and the favorable laws and policy environment all provide an opportunity that should not be missed to introduce this much needed vaccine to the young adolescent girls. However, sustainable financing by the government without external assistances remains a major obstacle. Also, the existing health delivery systems would require strengthening to cope with the delivery of HPV vaccine to a population that is normally not targeted for routine vaccination. Given the high incidence of cervical cancer and in the absence of a national screening program, universal HPV vaccination of Ugandan adolescent girls is critical for cervical cancer prevention.
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Introduction
Almost every case of cervical cancer is potentially
preventable. Yet, women in low- as opposed to those in
highincome settings have about a two fold cumulative risk of
developing cervical cancer before the age of 65 years [1].
Equally, women in low income settings have a threefold
risk of dying from cervical cancer than those in high
income settings [2]. Human papillomavirus is the primary
cause of cervical cancer (>99%) and is responsible for
8395% anal, 87% oro-pharyngeal, 60-65% vaginal and
2025% vulvar cancers in women [3]. A womans lifetime risk
of acquiring HPV infection is greater than 80% and most
infections occur within 34 years of sexual debut [4,5].
Among HIV positive women, the prevalence of HPV
infections and high grade cervical pre-cancer lesions (CIN
2/3) is several fold higher than in HIV negative women
[6,7]. Cervical cancer is the biggest single cause of years of
lost life particularly in low income settings where it affects
relatively young women at the peak of their productive
years [8].
Preventive HPV vaccines that protect against HPV 16
and 18 have been commercially available since 2006.
CervarixW made by GlaxoSmithKline (GSK) Biologicals,
Rixensart, Belgium and GardasilW made by Merck & Co.
Inc.,Whitestation, NJ, USA. The antigens in these
vaccines protect against oncogenic HPV types 16 and 18
responsible for 70% of cervical cancers, globally [9]. The
remaining 30% of cervical cancer cases are caused by
other oncogenic HPV types. Results from recent studies
have shown some level of cross protection by both
vaccines [10]. This implies that screening programs will still
be needed even after HPV vaccines are introduced.
Gardasil also prevents non oncogenic HPV 6 and 11
responsible for about 90% of genital warts but rarely cause
anogenital cancers [11].
The introduction of these two vaccines presents an
opportunity to prevent approximately 70% of cervical
cancer cases, globally [12]. Data from Sub Saharan Africa
however, seem to suggest that other oncogenic HPV
types are more prevalent and more diverse than
elsewhere in the world possibly because of prevalent HIV
infection [13,14]. This introduces uncertainty about the
proportion of cervical cancer cases that will be
potentially prevented by vaccination.
There is an urgent need for preventive HPV vaccines
in low-income settings particularly in Sub Saharan
Africa (SSA) given the elevated age standardized
incidence rates of cervical cancer [15]. However, the
demand for these vaccines so far is low. By the end of
2011, over 30 high- and middle- income settings had
introduced routine HPV vaccination in their national
vaccination programs compared to only one (Rwanda) in
SSA [16]. Past experience has shown that there is usually
a lag period of 1520 years between t (...truncated)