Cervical cancer is again in the national news, this time as a result of fake news doing the rounds on social media platforms, asserting the untimely death of Indian actress Poonam Pandey due to cervical cancer. Earlier this week, during the interim budget speech of 2024-2025, the finance minister had batted for cervical cancer vaccination for girls aged between 9 to 14 years.

While there is welcome spotlight and analysis on the causes of this pernicious disease, at the same time it is also imperative to understand the nuances of the wider public debate taking place concerning the road ahead for India in eradicating this persistent public health menace. Globally, cervical cancer is the fourth most widely reported cancer, accounting for 10 per cent of all female cancers. As per statistics from GLOBOCAN 2022, cancer of the cervix uteri has a mortality rank of 9 and causes 3,48,186 deaths worldwide.

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Recent studies have indicated that low and middle-income countries (LMICs) have higher incidence and mortality rates of cervical cancer, with 90 per cent deaths of the aforementioned deaths worldwide occurring in LMICs. Closer home, as per the HPV Information Centre’s latest HPV and Related Cancers Report 2023: India, cervical cancer ranks as the second most common cancer among Indian women between ages 15 to 44, with about 5 per cent (i.e., 2,56,114) of Indian women harbouring human papillomavirus (HPV) at any given time. As per the WHO, cervical cancer is also, but not exclusively, caused by persistent infection with the HPV leading to cervical precancerous lesions, which if left untreated, cause 95 per cent of cervical cancers. Some of the contributing risk factors of cervical cancer are poor genital hygiene, multiple sexual partners resulting in increased exposure to HPV, etc..

Symptoms can range from excessive white discharge, bleeding between the periods, bleeding during sexual intercourse, postmenopausal bleeding, chronic pain in the abdomen, low backache, etc., depending on the stage of the cancer. Notably, cervical cancer can be prevented economically and effectively through the use of prophylactic HPV vaccination, timely screening, and speedy healthseeking behaviour for treatment of the virus. Nevertheless, obstacles to the fight against cervical cancer remain. Cost-related concerns make the HPV vaccine unaffordable for many if not most Indians. Even popular brands of the vaccine developed indigenously by home-grown big pharma can cost as much as Rs 2,000-4,000 per dose, when purchased privately. Moreover, currently there is no single comprehensive cervical cancer programme or policy in place at the national level requiring big pharma to supply HPV vaccines at favourable and discounted rates.

However, recently in January 2023 – interestingly also the month observed as ‘world cervical cancer awareness’ month – the Ministry of Health and Family Welfare wrote to seven state governments, from Tamil Nadu to Himachal Pradesh, requesting them to prepare for the roll-out of the HPV vaccine for girls aged 9 to 14 years in their respective states. This effort is widely understood to be the commencement of a phased introduction of HPV vaccination into routine mass immunisation programmes in the country.

This idea is not new. In 2022, the National Technical Advisory Group on Immunization (NTAGI) had endorsed introduction of indigenously developed HPV vaccine in the universal immunization programme as a two-dose regimen. In this matter, the experience of the United Kingdom, which adopted the HPV vaccination into its national health programmes more than a decade ago and has since commendably achieved an 86 per cent reduction in HPV infections, is instructive.

Lessons can also be drawn from the successful HPV vaccination rollouts in the state of Sikkim. Sikkim had initially introduced the vaccine in 2014 but the initiative faltered at the time due to social hesitancy. Leveraging the lessons learnt from 2014, the vaccine was re-introduced in 2018, backed by detailed pre-rollout preparations, aggressive media sensitization, and a strong political will, resulting in a 97 per cent coverage. The hope now is that finance minister’s clarion call on the need for HPV mass immunization will provide a fillip for capacity building and mass production by domestic drug manufacturers, thus making the vaccine available as cheaply as INR 200-400 per dose, and bring it closer to the common person’s reach. This bold step holds immense promise of success.

A related point to note is that as per the latest NFHS-5 (2019-21) data, only 1.9 per cent of Indian women (2.2 per cent urban and 1.7 per cent rural) between the ages of 30 to 49 have undergone cervical cancer screening in their lifetime. In areas of high-incidence such as Africa and Asia, cancer screening programmes have demonstrated ability to effectively help identify early-stage malignancies. It goes without saying that the utilization of cervical cancer screening as a method of early detection by health professionals and the general Indian populations alike remains woefully low despite the national programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke (NPCDCS) recommending national cervical cancer screening to be conducted at every five years’ interval for those falling in the age bracket of 30 to 65 years.

However, in India, whether such screenings are actually conducted at the ground level is anyone’s guess. Stepping up and experimenting with more proactive and robust screening strategies at the primary and secondary-levels of health care in PHCs, CHCs, and HWCs is a vital public health need of the times. Therefore, it stands to reason that regular and robust cervical cancer screening at the grassroots-level accompanied by universal vaccination under the national immunization program, especially in rural India, is a surefire way to realise the dream of a cervical cancer free India.

Only then will India have a fighting chance to expedite and realize the targets set by the WHO for elimination of cervical cancer by 2030.

(The writers are, respectively, with the KSRDPRU, Gadag (School of Public Health, and Sanitation Management, Karnataka) specializing in NCD screening of common cancers, and with the National Law School of India University, Bengaluru. The views are personal.)