Universal routine HPV vaccination for young girls in Uganda: a review of opportunities and potential obstacles

Infectious Agents and Cancer, Sep 2012

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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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. - 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)


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Cecily Banura, Florence M Mirembe, Anne R Katahoire, Proscovia B Namujju, Edward K Mbidde. Universal routine HPV vaccination for young girls in Uganda: a review of opportunities and potential obstacles, Infectious Agents and Cancer, 2012, pp. 24, 7, DOI: 10.1186/1750-9378-7-24