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Media summary
The ICO monograph series on HPV and cervical cancer:
general overview, the Latin American and the Asia Pacific Reports
“Experts say that the world is presented with an unprecedented opportunity to use the emerging
technologies targeting HPV, as well as recent advances in cheap and effective screening
alternatives, to finally help developing countries find success in combating cervical cancer”
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Introduction
A major shift in the paradigm of cancer prevention including vaccination of millions of adolescents in
public health programs requires a massive effort in education of the health professionals involved
and of the families and adolescents worldwide.
The need for unbiased information, adapted to the regional circumstances and needs is of critical
importance.
The ICO monograph series on HPV and cervical cancer published in the journal Vaccine is in
response to this need. It is an independent report which offers unparalleled information and insights
about Human Papillmavirus (HPV) vaccine and screening.
It represents the best global thinking in screening and vaccination and includes contributions from
more than 180 authors worldwide. It provides regional and national data, scientifically sound models
and recommendations to help enable informed, financially sustainable decisions.
It addresses in detail the key challenges to HPV screening and vaccination programs including:
 Vaccine price and acceptability – it includes models to guide decisions as to the level of
prices and general costs that can be acceptable for both manufacturers and users
 Advances in screening
 Advances in vaccination
 Policy requirements towards eradication
 Perspectives from developing countries.
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Key highlights
The experts say that recent advances in cervical cancer screening and HPV vaccination
means that controlling the disease in developing countries is feasible for the first time.
The experts estimated that in the 22 poorest countries in Asia and the Pacific region, nearly
3 million deaths would be prevented if countries vaccinated 70% of their 11-year-old girls for
10 consecutive years.
In that region, vaccination would achieve a reduction in lifetime cervical cancer risk of
between 44% in India and 51% in Vietnam, the experts estimated. Adding screening three
times during a woman’s lifetime reduced the risk by 61% in India and 76% in Vietnam.
The experts predicted that in Latin America and the Caribbean, vaccinating 10 consecutive
birth cohorts of girls could avert more than 1 million cases of cervical cancer.
The researchers estimated that in Latin American and the Caribbean, the reduction in
lifetime risk of cervical cancer achievable by vaccinating 70% of adolescent girls ranged from
40% in Mexico to 55% in Argentina.
Recent estimates by Dr M. Parkin’s group at the International Agency for research on
Cancer (IARC) indicate that if trends continue the way they are, developing countries will
face a 60 to 75% increase in the number of cervical cancer cases because of growth and
aging of the population in the next two decades.
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Trends in Asia-Pacific
India, Bangladesh and Nepal have the highest reported incidence and death rates in the
region. This is attributed to lack of widespread screening and treatment and particularly high
rates of HPV infection in older women.
Some attempts at screening have been made in Thailand, Indonesia, the Philippines,
Vietnam and Malaysia, but coverage is low. Organized programs are being developed using
either pap smears or VIA/Visual Inspection with Acetic Acid (this involves painting the cervix
with vinegar. It is an attractive option because it is cheap and seems to be very effective in
detecting pre-cancerous lesions), but only as pilot projects, with little chance of reducing
deaths in their current form.
No screening programs exist in India, Bangladesh or China. But VIA pilot projects are
ongoing in India, and have been successful. Research in India indicates that screening
women once in their lifetime at the age of 35, involving VIA or HPV DNA testing reduced the
lifetime risk of cervical cancer by up to 36%, at a cost of less than $500 per life saved.
Trends in Latin America and the Caribbean
Cervical cancer is the second most common cancer among women in the region, after
breast cancer, with an estimated 72,000 cases and 33,000 deaths a year. It is the number
one cancer priority in many countries.
The highest incidence rates are seen in Haiti, Bolivia, Paraguay, Peru, Nicaragua and El
Salvador.
The lowest are in Puerto Rico, Bahamas, Uruguay, Cuba and Costa Rica.
Pap smear screening programs were introduced in the region in the early 1960s. Successes
seen in most developed countries have not been observed in Latin America and the
Caribbean. Experts suspect this may be because too much emphasis has been placed on
reaching high coverage in taking pap smear samples, without enough attention to the
subsequent components of a screening program, such as quality control, follow-up of
positive tests and treatment.
Pap smear introduction in developing countries has also been subject to socioeconomic
biases, resulting in widening health inequalities.
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What is HPV?
HPV is not a single virus, but a family of closely related viruses. There are more than 100 known
types of HPV and many women in the world will be infected at some point in their lives. The virus is
sexually transmitted. The body often clears the virus without harm, but more than a dozen of the
HPVs cause cervical cancer. Two of them, type 16 and type 18, are responsible for about 70% of all
cervical cancer cases.
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About HPV vaccination
HPV vaccination is considered one of the most important advances in women’s health in recent
years. HPV vaccination prevents infection with key types of the virus. It provides no protection once
infection has occurred, which is why the strategy is to vaccinate girls before they commence sexual
activity.
The first vaccine was licensed in 2006. It prevents infection with the two most important types for
cervical cancer (16 and 18), as well as two other HPV types that cause genital warts. A second
vaccine protects against the HPV types 16 and 18. Both vaccinations are given as a course of three
shots. HPV vaccines are licensed in more than 100 countries worldwide and many are including
them in the regular program of immunisation with public support.
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Facts about HPV and cervical cancer
Cervical cancer is the most common cancer among women in the developing world.
About 510,000 women are diagnosed with the disease every year. Nearly 80% of cases are
in developing countries.
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Cervical cancer kills more than 250,000 women a year, about 80% of whom live in
developing countries.
Latin America and the Asia-Pacific region account for about 60% of the cervical cancer
cases worldwide.
Evidence suggests that if the current vaccines against HPV -16 and 18 oncogenic types
were introduced into developing countries and combined effectively with appropriate cervical
screening strategies the life time risk of developing cervical cancer could be reduced as
much as 60%.
Males transmit HPV and only occasionally develop cancer of the penis, anus and oral cavity.
These tissues seem to be more resistant to the infection and progression of the cancer than
cervical tissues.
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Primary prevention
HPV vaccines are a major breakthrough in medical history. Vaccine trials have shown a 100%
protection rates among non-exposed women against the types included in the vaccine.
Vaccines are showing efficacy irrespective of age, although efficiency will decrease with age
because an increasing fraction of women will have acquired the status of persistent HPV carriers at
the time of vaccination. These vaccines are not therapeutic.
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Secondary prevention
Conventional screening (regularly performed pap smears) has been useful in developed countries,
but largely inefficient in developing countries.
HPV screening has proven in over 17 controlled trials and all metanalysis to be significantly superior
in sensitivity and close to in specificity to the conventional pap smear. Use of HPV tests as the
primary screening test should result in a reduction in the required visits by women (from annual
visits to every five years or so).
Novel technologies are adapting HPV tests to make them sustainable in developing environments.
Such tests should provide quality results within a working day and allow for screen and treat
protocols to be used. The cost of these tests should also reduce the costs of the programs
significantly.
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The future in cervical cancer prevention
The future of cervical cancer prevention is likely to include HPV vaccination in the preadolescent
age groups with ‘catch up’ as enlarged as possible in the range of 9 to 26 eventually extending
above this age.
It is anticipated that screening programs will largely shift to HPV-based screening methods. In the
parts of the world where HPV screening cannot be implemented, low technology visual methods are
being intensively investigated and will be potentially implemented.
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Background on the Vaccine Monograph
The Vaccine Monograph project started in 2005. The titles of previous Vaccine supplements are:
Vaccine 26, Supplement 10, Prevention of Cervical Cancer: Progress and Challenges on HPV
Vaccination and Screening; Vaccine 26, Supplement 11, Prevention of Cervical Cancer in the Latin
America and Caribbean Region: Progress and Challenges on HPV Vaccination and Screening;
Vaccine 26, Supplement 12, Prevention of Cervical Cancer in the Asia Pacific Region: Progress and
Challenges on HPV Vaccination and Screening.
As part of the project, general chapters describing scientific progress will be updated every two to
three years and it is intended that the regional reports will eventually cover every region in the
world. The Vaccine Monograph is a result of collaboration among the international HPV scientific
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community, including scientists, public health and medical professionals. The program involves
some of the leading education institutions in the world, including the University of Harvard, Laval
University Canada, The University of Cambridge, The J Hopkins/Blumberg School of Public Health,
the National Cancer Institute in the US, the University of London and the Economic and Modelling
Unit at the Health Protection Agency in London. Strong expertise and support is provided by WHO,
the UICC, PATH, GAVI, AOGIN and others.
Public Grants have been provided by the ICO, The Spanish Network of Medical Research (RETTIC
and CIBERESP) and the Bill & Melinda Gates Foundation.
Unrestricted educational grants have been provided by sponsors of the monograph including
GlaxoSmithKline, Merck, MSD, Quiagen/Digene, Roche and Sanofi Pasteur.
Two additional monographs are being prepared for 2010 with a focus on Eastern Europe and Africa.
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Access to information
The Vaccine Monograph will be made available via the The HINARI (Health InterNetwork Access to
Research Initiative program), set up by WHO together with major publishers, enabling developing
countries to gain access to one of the world’s largest collections of biomedical and health literature.
Over 3,750 journal titles are now available to health institutions in 113 countries, benefiting many
thousands of health workers and researchers, and in turn, contributing to improved world health. In
2006, 1.45 million downloads were made from Elsevier journals, representing 35% of the over 4
million downloads made through the entire HINARI collection
The Vaccine Monograph will be made available in an educational distant learning platform (eoncologia) to be used in small tutorial groups at the local level in several languages.
For a copy of the The ICO monograph series on HPV and cervical cancer:
general overview, the Latin American and the Asia Pacific Reports please contact:
Darryl Freeman, Elsevier Ltd.
Tel: +44 (0) 1392 285 827 or email: [email protected]
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