Human papillomavirus vaccine for cancer cervix prevention: Rationale & recommendations for implementation in India

Factors influencing HPV vaccine implementation in South Asia: a scoping review protocol

INTRODUCTION

The HPV vaccine is characterized by its significant effectiveness in preventing the occurrence of cervical cancer. However, the South Asian countries face multiple challenges in implementing the human papillomavirus vaccine (HPV) at scale. Implementation of human papillomavirus vaccination for eliminating cervical cancer necessitates investigating the factors that impact the health system of these nations. Hence, this review will map the evidence on factors influencing the scaling up of human papillomavirus vaccination in South Asia.

METHODS

The proposed scoping review will follow the steps given by Arksey and O'Malley and Levac et al. The search approach will follow McGowan et al. (14) evidence-based manual for Peer Analysis of Electronic Search Strategies (PRESS 2015) for systematic searches. Using a comprehensive search, the literature from 2006 onward will be identified from PubMed, CINAHL, EMBASE, Web of Science, and Scopus. The search strategy will include terms relating to the HPV vaccine and implementation. A predefined criterion for the inclusion and exclusion of studies will be adopted by three review authors independently to determine the eligible studies. The results will be narratively synthesized and examined in addition to being quantitatively presented to provide an outline. The review will be presented per the "Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR)" guidelines.

CONCLUSIONS/DISCUSSION

The evaluation is anticipated to map the barriers and enablers influencing the rollout of the human papillomavirus vaccine. Lessons learned from the South Asian countries, where the vaccine has been implemented, may contribute to aiding the implementation of the vaccine in countries with similar health systems in an effective manner.

SYSTEMATIC REVIEW REGISTRATION

The protocol was prospectively registered on the "open science framework". The registration DOI is https://doi.org/10.17605/OSF.IO/T5SW9 .

Validity and reliability of a Turkish version of the human papillomavirus knowledge scale: a methodological study

Objective

The aim of the study was to test validity and reliability of the Human Papilloma Virus Knowledge Scale (HPV-KS) in Turkish.

Material and Methods

The methodological study was conducted with 920 participants at a training and research hospital in Ankara, Turkey, between February and May 2019. The data collection form consisted of descriptive characteristics of the participants and HPV-KS. Guidelines for the Process of Cross-Cultural Adaptation of Self-Reported Measures were followed for the language and cultural adaptation of the scale. Content validity, exploratory, and confirmatory factor analyses were performed to test the validity of the scale. The scale's reliability was assessed using the item-total correlation, Cronbach's alpha, and test-retest analysis.

Results

In line with the experts' suggestions, two item were excluded from the scale. The scale content validity index was found to be 0.96. The exploratory factor analysis determined the four subscales of the scale with 33-items. The explained variance was found to be 64.56%. In the confirmatory factor analysis, all the goodness of fit indexes had acceptable values. The item-total correlations determined that each item was positively correlated with the total scale ranging from 0.53 to 0.80. The Cronbach's alpha coefficient calculated for the overall scale was 0.96. It was found that there was a statistically significant positive relationship between test and retest (r=0.166; p=0.05).

Conclusion

The scale was shown to be a valid and reliable standard measurement that can be used to accurately evaluate the efficacy of health education provided by healthcare professionals.

Evidence on factors influencing HPV vaccine implementation in South Asia: A scoping review

Cervical cancer is a significant public health concern globally, with low and middle-income countries bearing the highest burden, specifically the South Asian region. Therefore, the current scoping review aimed to highlight the factors influencing the implementation of human papillomavirus (HPV) vaccination in South Asia. Adopting the 'Arksey and O'Malley and Levac et al.' methodology, multiple electronic databases were searched to identify relevant records. The results were narratively synthesised and discussed, adopting the Consolidated Framework for Implementation Research (CFIR) model. We identified 527 records, which were assessed for eligibility based on title, abstract, and full text by three reviewers, followed by data extraction of 29 studies included for analysis in the review. Implementing HPV vaccination programs in South Asia faces various challenges, such as economic, health system, financial, health literacy, and sociocultural factors that hinder their successful implementation. To successfully implement the vaccine, a tailored risk communication strategy is necessary for these countries. Knowledge gained from the experience of South Asian nations in implementing the HPV vaccine can assist in policymaking in similar healthcare for advancing the implementation of HPV vaccination.

Cervical Cancer: Formulation and Implementation of Govt of India Guidelines for Screening and Management

Purpose

Cervical cancer is the second most common cancers of women in India, despite being largely preventable. This review traces the journey of formulation of the Operational Guidelines for the management of common cancers and its implementation.

Methods

A literature review was done to document the process of formulation of the guidelines, in addition to inputs from the officials involved in the process of developing them.

Results

The review covers the pre-existing challenges in the National cancer control program and helps in providing recommendations for the future of cervical cancer screening, considering the COVID pandemic and the limitations of the public health system in India.

Conclusion

The implementation of early diagnosis of cervical cancer on a national scale as envisaged in the Operational Guidelines for the management of common cancers is a herculean task. A concerted approach for the implementation of cervical cancer control and HPV vaccination will hopefully bring fruitful results going forward.

Non-invasive saliva-based screening of high-risk Human Papilloma Virus 16 and 18 in healthy young adults and creating awareness about its vaccination

Context:

Human Papilloma Virus (HPV) has not only been linked with cervical cancer but also a key player in other types including oral cancer. Vaccine against HPV has shown promising outcomes in protection against cervical cancer. It is suggested that the same vaccine may be a safeguard against oral cancer as well. Since prevalence of oral cancer is on rise because of various reasons besides high-risk sexual behavior, its prevention becomes equally important.

Aim:

Study aimed at screening saliva samples of healthy young adults to detect the presence of HPV with an intention to increase awareness regarding HPV and its vaccination.

Settings and Design:

The study was executed in the department of Biochemistry, AIIMS, Patna. This cross-sectional study included 100 consented healthy undergraduate medical and nursing students.

Methods and Material:

We isolated DNA from all saliva samples, amplified using multiplex PCR and gel electrophoresed to screen HPV 16 and 18. Feedback about the study in creating awareness regarding HPV and its vaccine was conducted using three-point Likert scale.

Statistical analysis:

The collected responses were entered in Microsoft excel. The results were expressed in frequency and percentages.

Results:

All saliva samples screened were found negative for HPV 16 and 18 DNA. Responses from feedback showed improved knowledge and awareness about the HPV and its vaccine among the participants.

Conclusion:

Even all the saliva samples tested were found negative for HPV DNA, the screening of high-risk HPV in saliva of young medical and nursing students generated curiosity among them to know more about HPV and its vaccine. This exercise may have helped in increasing the acceptance of HPV vaccine and the awareness of getting it at their ideal age to be benefited with dual protection, from oral and cervical (in case of females) cancers lifelong.

Current Status and Future Perspectives of Molecular Prevention Strategies for Cervical Cancers

Cervical cancer continues to be a global health problem; despite the potential for prevention through organised screening programmes that can detect and treat pre-cancerous lesions and also more recently, the availability of HPV (Human Papilloma Virus) vaccines. While routine screening with Pap smear testing has reduced the burden of cervical cancer in the high-income countries, the implementation of organised Pap-based screening programmes has not been found feasible in low-resource settings due to a lack of health care delivery infrastructure and limited health budgets. The well-established causal relationship between cervical cancer development and high-risk-HPV (HR-HPV) infection and the subsequent appreciation of the greater sensitivity of HPV testing over Pap smear cytology eventually lead to HPV testing being incorporated in the primary cervical cancer prevention programmes. An organised cervical cancer screening programme incorporating HR-HPV testing and HPV vaccine administration are currently considered to be the two major interventions for a comprehensive cervical cancer control programme worldwide. However, there are concerns that the requirement of a sophisticated infrastructure with its associated costs may make cervical cancer screening using molecular prevention by HPV testing impracticable to be implemented, especially in resource-poor, low-income countries. Visual Inspection with Acetic acid (VIA) represents one of the alternative methods for cervical cancer screening proposed for the countries with low- to middle-income resources and has gained popularity in India following the successful completion of two randomised controlled trials, but this method but has low sensitivity to detect cervical pre-cancers. More recently, the cost-effectiveness analysis of many studies including randomised controlled trials, even from the low-resource settings, has found that HPV testing is followed by treatment for HPV-positive women to be an effective and cost-effective screening strategy as compared to other screening methods including VIA. The incorporation of self-sampling and HPV testing by partial genotyping has the potential to significantly add to the effectiveness and the cost-effectiveness. The current status and future perspectives of molecular prevention strategies for cervical cancer prevention is further discussed.

Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4)

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHCs had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHCs, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Current status of human papillomavirus vaccination in India's cervical cancer prevention efforts

Efforts are being made to scale up human papillomavirus (HPV) vaccination for adolescent girls in India. Bivalent and quadrivalent HPV vaccines were licensed in the country in 2008, and a nonavalent vaccine was licensed in 2018. Demonstration projects initiated in Andhra Pradesh and Gujarat in 2009 introduced HPV vaccination in public health services in India. Following a few deaths in these projects, although subsequently deemed unrelated to vaccination, HPV vaccination in research projects was suspended. This suspension by default resulted in some participants in a trial evaluating two versus three doses receiving only one dose. Since 2016, the successful introduction of HPV vaccination in immunisation programmes in Punjab and Sikkim (with high coverage and safety), government-sponsored opportunistic vaccination in Delhi, prospects of a single dose providing protection, and future availability of an affordable Indian vaccine shows promise for future widespread implementation and evaluation of HPV vaccination in India.

Ethics of cancer care: beyond biology and medicine

Treatable cancers are on the rise due to improved early diagnosis and more innovative treatments, and preventative strategies against cancer are becoming a global concern. With the rapidly increasing complexity of cancer treatment, a clear definition of what constitutes ethical cancer care has become a matter of great debate. This situation is more complex in a developing country where healthcare resources are limited. Doctors, nurses and public health professionals engaged in the prevention, screening, diagnosis, treatment and research of cancers are often posed with ethical dilemmas while making complex choices. With a special focus on low- and middle-income countries, this paper is intended to highlight these real-world ethical concerns facing those involved in the management of cancer patients. While taking a neutral view, this paper has adopted a theme-wise approach to discuss barriers in cancer care.