Very few types of cancer are preventable. Luckily, cervical cancer, the most common cancer in females, is one among them. Prevention of cervical cancer by vaccination is the new mantra!
The belief that women do not indulge in any sort of sexual activity at a young age is a myth. With every passing year, more and more teenagers are becoming sexually active at a young age. According to the National Health and Family Welfare data, the average age at first sexual activity in India is 19 years. Though there is no national body that collects data on pre-marital sexual activity among Indians, various surveys conducted by some independent bodies suggest that as high as 6 to 15 % of adolescents are involved in sexual activity. Almost one in three women admit having been involved in sexual activity before reaching the age of 18. One in ten girls has had a sexual experience of some kind before even turning 15.
With no proper sexual education in the school curriculum, easy and early access to pornography, rampant illegal child marriages, and in general, the taboo associated with sex in our culture, the situation seems to be only worsening. Other than being of a deep moral and ethical concern, the dangers are nothing less than an epidemic. Sexual activity at this tender age brings with it loads of psychological and health-related burdens. This is seen in the form of rising sexually transmitted diseases among adolescents, teenage pregnancies, and illegal abortions. Most of the sexually transmitted diseases are amenable to cure, but unfortunately, many are a lifelong affliction. One of the most disastrous consequences of early sexual activity, coupled with multiple sexual partners, is cervical cancer.
Many people are not aware that 90 % of cervical cancer cases are caused by sexually transmitted Human Papillomavirus (HPV). Although the majority of HPV infections do not cause symptoms or disease and resolve spontaneously, persistent infection with high-risk HPV strains may result in cervical cancer. Cervical cancer is responsible for the death of almost 60 to 70 thousand women every year in India. The International Agency for Research on Cancer currently defines 12 high-risk HPV types that cause cancers in humans: types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59.
In addition to cervical cancer, HPV infection is also implicated in the causation of genital warts, cancer of anus, oropharynx, vulva, vagina, and penis. It is estimated that up to 90 % of all anal cancers and 40 % of vulvar cancers are associated with HPV-16 and 18.
Fortunately, HPV infection and consequently, cervical cancer can be prevented. HPV infections decrease by abstinence, older age at first sexual activity, lifetime mutual monogamy, and barrier contraception methods like condoms. None of these methods, however, is guaranteed protection.
After years of research, in 2006-7, two vaccines were introduced in the market against HPV infection:
This started a new chapter in the primary prevention of cervical cancer. A new vaccine Gardasil 9 is also approved by the US FDA, which protects against nine strains of HPV. This is not available in India yet.
Cervical cancer vaccines should be administered, preferably before the onset of sexual activity, i.e., before first exposure to HPV infection. Given the decreasing age at first sexual activity, CDC and WHO recommend vaccination between the ages of 9 and 12.
We may think that 11 years is too early to vaccinate as many children do not become sexually active for several more years, but vaccinating preteens helps to take the guesswork out of figuring when a child will become sexually active. The vaccine also has been shown to be more effective in immunizing against HPV when it is given to younger girls. In fact, girls who are vaccinated before the age of 15 may need only two vaccine shots in contrast to older girls who need a standard three-shot vaccination.
The Indian Academy of Pediatrics Committee on Immunization (IAPCOI) recommends offering the HPV vaccine to all females who can afford the vaccine. Australia has been one of the leading countries in implementing public health programs for the prevention of HPV, being among the first to introduce a National HPV Vaccination Programme for girls and young women. More than 50 countries already have it in their national immunization schedule. The vaccine is given as a deep intramuscular injection, generally three shots at 0, 2, and 6 months. The vaccine is so far not recommended for boys in India.
Girls from ages 13 to 26 who have not received it earlier can also take the vaccination. Sexually active females may also benefit from vaccination to some extent. This is because a few sexually active young women are infected with all the HPV types prevented by the vaccines, so most young women could still get protection by getting vaccinated. For women aged more than 26 years, screening and early detection by PAP test is the key for prevention, though some studies do suggest the benefit of vaccination even up to the age of 40 years.
The vaccine has been studied in thousands of people around the world, and these studies showed no serious safety concerns. However, mild pain at the site of injection, fever, dizziness, fainting, and nausea may occur rarely.
As a care provider, doctors must emphasize that the primary goal of vaccination is to help prevent cervical cancer. It should not give a false sense of security against all sexually transmitted infections. It is also not a replacement for periodic screening with PAP smear. Hence, screening programs should continue as per recommendations to detect non-HPV related cervical cancers, which are around 10 %.
Safe sex should be taught to adolescents, and sex education made mandatory in schools. Laws against child marriage should be made more strict, and cervical cancer screening by PAP smear should be made widespread by government programs and available in all hospitals at a very low cost. These practices will help in decreasing the disease burden in our country.
All of us love our daughters, mothers, and sisters; let us give them the gift of a cervical cancer-free life. Let us pledge to vaccinate our daughters before their 13th birthday.
Last reviewed at:
10 Jun 2020 - 4 min read
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