Cancer Moonshot's Low Hanging Fruit: Cervical Cancer

Cervical cancer kills one woman every two minutes.

It has killed 342,000 women in 2020, 90% of whom live in low- and middle-income countries.

Let that sink in for a minute….

And yet there is an effective vaccine available. HPV vaccination has been available since the mid-2000s on a 2- or 3-dose schedule which has limited its reach in the countries with the highest rates of cervical cancer.

Over the last decade, I have worked on cervical cancer projects, from HPV vaccine policy and implementation to cervical cancer screening and treatment. One of the biggest challenges we face right now is moving from policy decision to implementation. We are now on the verge of one of these transitions.

The World Health Organization (WHO) established a goal of eliminating cervical cancer worldwide by 2030 by fully vaccinating 90% of all girls by the age of 15. HPV vaccines have been introduced in nearly 100 countries.  The WHO’s recommendation of administering 2 or 3 doses has slowed uptake in many parts of the world. Recently, the WHO’s Strategic Advisory Group of Experts (SAGE) on Immunization made the recommendation to the WHO to change its dosing schedule to 1-dose for HPV vaccination based on immunogenicity and effectiveness studies. We are now waiting for the WHO’s formal position paper expected in December 2022 before many countries decide to take this next step.

One dose will increase coverage, improve herd immunity in unvaccinated men and women, and provide catch-up doses for older adolescents and young women. It will remove the logistical challenge and cost associated with multiple-dose regimens. This 1-dose schedule will have an overall net positive result in low- and middle-income countries hardest hit by cervical cancer cases and deaths.

This 1-dose schedule is a true public health approach in action. It would seem that this should be easy to implement – reducing the number of doses in an established vaccination schedule. The policies, vaccine supply chain, trained providers, and other health system supports are already in place in many countries.  

But, let's look further.

First, each country needs to decide if they will change their current vaccination schedule or will postpone the change until sufficient data from randomized control trials have been obtained. To make the 1-dose change to implementation requires updates in costing, timelines, and program evaluation to be successful in increasing population coverage to decrease cervical cancer. While it may appear intuitive, switching to a 1-dose schedule presents implementation challenges. The switch will be predicated on analyzing budget allocations to identify where the potential cost savings from the dose reduction can be, then allocating the surplus to the costs of changing the implementation strategy.

And switching to a 1-dose schedule presents implementation challenges that need to be addressed:

·        Planning and scheduling for vaccinations and revising procurement

·        Revising training for new vaccination deliverers being trained and updating vaccinators already providing HPV

·        Updating health educators and others doing social mobilization and communications as well as updating all print and virtual materials and resources

·        Updating record-keeping forms and electronic systems

·        Initiating revised guidance for collecting and reporting for surveillance, monitoring, and supervision

I’ve used the implementation components from the Pan American Health Organization’s Introduction and Implementation of new Vaccines: Field Guide (https://iris.paho.org/handle/10665.2/49176) to describe key changes that can help ensure successful HPV vaccination programs moving to the 1-dose schedule.

Planning, Scheduling Activities, and Coordination

Countries may decide to broaden vaccine delivery strategies from school- and clinic-based to other platforms such as conducting national immunization days or combining HPV vaccination with other vaccines targeted to this age group, such as influenza, measles, or meningococcal conjugate.

Standardization

Countries will need to update and disseminate all policy, training, operational standards for implementation, and communication documents to reflect the change from 2-dose to a 1-dose schedule.

Procurement

Initially, forecasting, procurement, and distribution of vaccine and supplies will need to be adjusted to accommodate the inventory on hand. And then ensuring new procurement plans and implementation strategies work with the new schedule.

Storage and Cold Chain

Covering a larger geographic scope means existing storage and cold chain capacity and supplies may be insufficient. Newly added vaccination sites and the workers at them will need training and updating on handling and delivering the HPV vaccine and ensuring surveillance for potential adverse and unanticipated events.

Training

Policy implementation is a large task since all involved in vaccine distribution and delivery will need update training including pre-service and in-service education for healthcare providers and ancillaries on the new schedule and delivery mechanisms.

Social Mobilization and Communication

The variety of communication channels will need reframed messaging for communications to the community on reasons for the changed schedule, especially reassurance that 1-dose is not inferior to 2-doses. Senior experts and government officials along with local health care providers need to advocate for the change to garner support for the new schedule and reduce vaccine hesitancy.

Vaccination Strategies and Implementation

Vaccine distribution will change with a 1-dose schedule if there are changes in target populations and geographic coverage.

Record-keeping

Countries will have to update immunization program forms and electronic systems to reflect the new schedule and then those working with the systems (front-end and back-end users) will need to be updated.

Monitoring and Supervision

Monitoring and surveillance reports and reporters will also need updating. And supervision for data collection and reporting will begin before the change is made and continue during implementation. These systems will signal alerts if problems arise. Supervisors for the delivery side also will also need to be updated so they can effectively supervise implementation.

By ensuring that all the components above and others are well-thought-out, successful implementation is possible, and the cervical cancer elimination agenda is one step closer! 

Photo credit: UNICEF