Closing the Gap: Single-dose HPV Vaccination | Leeya F. Pinder, MD, MPH
Leeya F. Pinder, MD, MPH
The burden of cervical cancer (CC) disproportionately impacts persons living in marginalized communities, whether in sub-Saharan Africa (SSA) or low-income, rural or migrant communities in the U.S. Worldwide, almost 350,000 women die every year from this disease.1 Our view of CC has been framed by the statistic that CC deaths in the U.S. have declined by more than 50% over the last five decades.2-6 What is hidden within this documented success, is the additional truth that CC continues to kill thousands of women every year in this country.2 Rates of CC in a population expose vulnerabilities in healthcare systems, including failing infrastructure, limited access to health resources, poor health literacy of the catchment population, implicit biases of healthcare providers and staff, and social and environmental determinants of health, which disproportionately affect members of racial and ethnic minority subgroups, and people affected by poverty.2, 7 According to the Center to Reduce Cancer Health Disparities (CRCHD)2, the populations of women who suffer the most from these factors and the subsequent higher rates of CC include African American women primarily residing in the South, Latina women along the Texas-Mexico border, women from Appalachia, American Indians of the Northern Plains, Vietnamese American women, and Alaska Natives.
It is widely accepted that CC is preventable through screening, treatment of pre-invasive disease, and vaccination against human papillomaviruses (HPV). We continue to approach cervical cancer prevention in the same way we have for decades, which only serves populations with access, and deepens disparities for groups that continue to bear the burden of inequity in healthcare. This is true both here in the U.S. and across the globe. We can begin to effect change by radically disrupting the status quo and tailoring our interventions to the local context.
This process has begun for HPV vaccination. Primary prevention with HPV vaccination is critical to the elimination of CC and is a key strategic pillar in the WHO’s Global Strategy to Eliminate Cervical Cancer as a public health problem. Although HPV vaccination has been available since 2006, coverage worldwide among adolescents is abysmal at 15%. We fair better in the U.S. with approximately 60% of adolescents being up to date,8 but states like Mississippi have significantly lower rates (38%).9 Reasons for low vaccination rates worldwide include vaccine costs, supply shortages, hesitancy and dosing schedule. The two- or three-dose schedule for vaccination often leads to an incomplete series. Evidence now suggests that in immunocompetent individuals, one dose of an HPV vaccine provides sufficient protection against the HPV types most associated with cervical cancer. Observational studies from Fiji, Costa Rica, and India and randomized controlled trials from Tanzania and Kenya10-13 have demonstrated that a single dose of the HPV vaccine has comparable efficacy to the two- or three-dose schedules. In the KEN-SHE study, 2275 participants were tested for HPV over a 36-month trial period, and both bivalent and nonavalent HPV vaccines were highly efficacious in preventing type-specific infection, with a vaccine efficacy of 98%, and 96%, respectively, after only one dose. Based on available evidence, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) has recommended updating vaccine schedules to include one dose for girls and young women aged 9-20. The two-dose schedule, six-months apart, is still recommended for those 21 years of age and older by the WHO and three doses for those aged 15 to 45 years by the CDC. While the U.S. has not yet signed on to single-dose HPV vaccination, at least 24 countries, including the UK, Mexico, and Australia have shifted to the one-dose strategy.
Single-dose HPV vaccination has the potential to close disparity gaps both globally and domestically. This strategy can alleviate major financial and logistical burdens to national vaccination programs. In remote or underserved areas with limited healthcare facilities, a single-dose regimen can strengthen the overall effectiveness of vaccination campaigns, increase vaccination coverage and limit missed opportunities for individuals to receive protection against HPV. If widely implemented, this approach could serve to close the gap between the WHO’s goal of 90% HPV vaccination coverage by 2030 and the 15% of girls presently vaccinated worldwide.
Leeya F. Pinder, MD, MPH is an Associate Professor and Director of the Center for Global Cancer Control at the University of Cincinnati. Additionally, she supports research, education, and clinical care at Women and Newborn Hospital in Lusaka, Zambia.
References
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