HPV Vaccination in the Western Pacific and South-East Asia Regions:

Overview, Challenges and Opportunities

James Heffelfinger, MD, MPHExpanded Programme on Immunization

WHO Regional Office for the Western Pacific

10 April 2018

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HPV and cervical cancer

• HPV is sexually transmitted– Most sexually active women and men will become infected– Peak time for infection: shortly after becoming sexually active

• >100 types of HPV – ≥12 are cancer causing– Most (90%) HPV infections clear up without any intervention

• Nearly all cervical cancer attributable to HPV infection– Infection may become chronic and lead to pre-cancerous lesions– Persistent infection with specific types of HPV (most frequently

types 16 and 18) may lead to precancerous lesions, which may progress to invasive cervical cancer

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HPV vaccination

• 3 licensed vaccines (2 WHO-prequalified or PQ) which protect against HPV 16 and 18 (cause ~70% cervical cancers)

– Bivalent vaccine or Cervarix (HPV 16, 18) – WHO PQ– Quadrivalent vaccine or Gardasil (HPV 6, 11, 16, 18) – WHO PQ– 9-valent vaccine (HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58)

• All three licensed HPV vaccines have excellent safety, efficacy and effectiveness profiles*

• Some countries have started to vaccinate boys as HPV vaccination prevents genital cancers in males and females

Source: WHO. HPV vaccines position paper. 2017.

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Estimated age-standardized incidence and mortality rates of cancer in women globally, in the Western Pacific Region

(WPR) and in the South-East Asia Region (SEAR)

Source: GLOBOCAN 2012

SEAR

20.511.3

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Age-standardized cervical cancer incidence and mortality rates in 21 WPR countries and areas

Source: GLOBOCAN 2012

0 5 10 15 20 25 30 35 40

New ZealandAustralia

ChinaSingapore

French PolynesiaWHO Western Pacific Region

GuamRepublic of Korea

Viet NamJapan

Lao PDRWorld

New CaledoniaMalaysia

PhilippinesBrunei Darussalam

SamoaVanuatu

CambodiaMongolia

Solomon IslandsPapua New Guinea

Fiji

Incidence (ASR, per 100,000)Mortality (ASR, per 100,000)

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20 countries in Asia with the highest age-standardized cervical cancer incidence

Source: GLOBOCAN 2012

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WHO HPV vaccine position paper: Main Recommendations (2017)

HPV vaccines should be included in national immunization programs

– All countries should proceed with nationwide introduction of HPV vaccination

HPV vaccines should be introduced as part of a coordinated & comprehensive strategy to prevent cervical cancer and other diseases caused by HPV

Primary target population: Girls 9-14 years, prior to becoming sexually active

Vaccination targeting multiple age cohorts of girls 9-18 years would result in faster and greater population impact than vaccination of single age cohorts

Source: WHO. HPV vaccines position paper. 2017.

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Countries with HPV vaccine in the national immunization programme, January 2018

Data source: WHO/IVB Database, as of January 2018.

Regional no. (%) introduced to date:- 13 (48%) of WPR countries- 3 (27%) of SEAR countries

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Year of HPV vaccine introduction in WPR countries and areas

Timeline for introduction of HPV vaccine in 13 WPR countries

Timeline for introduction of HPV vaccine in 6 WPR areas

2007

Guam (USA)

2008

N. Mariana Isl. (USA)

2009

AmericanSamoa (USA)

2011

New Caledonia(France)

2013

Wallis and Futuna (France)

2014

Macao(China)

2007

AustraliaPalau

2008

NewZealand

2009

FSMMarshall Isl.

2010

SingaporeMalaysia

2011

BruneiJapan

Cook Isl.

2013

Fiji

2015

Philippines

2016

Korea

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Experiences of select WPR countries with introduction: Malaysia

• Introduced in school-based approach in 2010– School-based approach– Target: Girls 9-13 years

• Lessons learned– Challenges: reaching out-of-school girls, linking HPV vaccination

data to women’s health program, emerging anti-vaccine groups– Facilitators: Political will and commitment, public trust in

Malaysian EPI programme, availability of existing school health service, existing partnership with Ministry of Education, competitive procurement process, effective risk communication strategy to address religious issues

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Experiences of select WPR countries with introduction: Fiji

• Fiji introduced bivalent HPV vaccine in 2013– School-based approach– Target: Grade 8 girls (12-13 years)

• Lessons learned– Challenges

o Community concerns about HPV vaccination from 2008-2009 campaign when there was negative publicity saying that Fijian girls should not be used as guinea pigs

o Inadequacy of cold chaino Delays in vaccine delivery and increases in shipping costo Need for donor assistance to sustain programme

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Experiences of select WPR countries with introduction: Fiji (cont.)

• Lessons learned– Facilitators

o Donor support for vaccine procuremento High acceptance by MOH, Ministry of Education, communityo Existing structure of and funding for EPI, cold chain and vaccine distributiono Strong school health programo Good community health nursing program, through which hard-to-reach girls

can be reachedo Effective communication strategy and targeted awareness and advocacy

generated support from public

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Experiences of Cambodia with HPV vaccine demonstration project

• Demonstration project– Introduction in six operational districts of two provinces in 2017– Target: Girls 9 years– School- and health center-based delivery– Funded by Gavi

• Lessons learned– Challenges:

o Shortage of time for identifying and enumerating the target girlso Limited involvement from province and district education departmentso Limited health education given to girls prior to school-based vaccination

sessions

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Experiences of Cambodia with HPV vaccine demonstration project (cont.)

• Lessons learned– Facilitators:

o The vaccine delivery strategy, which combined the school-based, and health centre based strategies to deliver vaccines to a targeted age group of girls

o Teachers conducted extensive follow-up of missed girlso First doses coverage was high – 94% of the target girls vaccinatedo Cold chain equipment was available and sufficient at all levelso The overall wastage rate of HPV vaccine was low (<10%)

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HPV vaccine introductions on the horizon in WPR

• Lao People’s Democratic Republic successfully applied for Gavi funds introduction of vaccine – will likely introduce in 2020

• Solomon Islands successfully applied for Gavi funds introduction of vaccine –will likely introduce in 2020

• Cambodia is considering applying for Gavi funds in 2019 to support HPV vaccine introduction in ~2020

• Mongolia and Singapore are both discussing introduction of HPV vaccine in near future (2019 or 2020)

• Asia Development Bank has initiated project to support introduction of introduction of HPV vaccine, PCV and rotavirus vaccine in Samoa, Tonga, Tuvalu and Vanuatu – possibly in 2019 or 2020

• Rotary Clubs of Australia and New Zealand are planning to support 4 Pacific Island countries (Cook Islands, Nauru, Niue and Tokelau) to introduce or maintain vaccination with HPV vaccine, PCV and rotavirus vaccine

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HPV vaccine introductions on the horizon in SEAR

• Bangladesh and Nepal each successfully completed HPV vaccine demonstration project in one district with Gavi support – expected they may apply for Gavi funds for HPV vaccine introduction in near future

• National immunization technical advisory groups (NITAGs) in India and Maldives have approved HPV vaccine introduction in national programmes

• India has introduced HPV vaccine in two districts of Punjab state, is planning statewide introduction in Sikkim in 2018

• Indonesia initiated HPV vaccine demonstration projects in 3 provinces• Bangladesh, Myanmar and Indonesia are planning to submit

applications to Gavi in September 2018 for support for national introduction