HPV vaccination in the world and in Colombia. Why so difficult?
Carlos Jose Castro E.
Liga Colombiana contra el Cáncer
“Recovering confidence in the safety and efficacy of the HPV vaccine is of paramount importance to prevent and eliminate cervical cancer that kills almost 300.000 women yearly around the world. It’s a moral obligation to promote HPV vaccination. It will prevent thousands of premature deaths worldwide.”
Human Papilloma Virus (HPV) affects millions of human beings around the world and is the cause of many diseases, some of them lethal like cancer of the cervix, vulva, penis, anus, oropharynx, and some clinical situations, such as genital warts that are costly and uncomfortable to deal with. Most of these cancers appear in developing countries where the death toll is quite above 300.000 per year, especially due to cervical cancer.
At the beginning of the XXI century, researchers discovered that HPV was the cause of this malignant disease, and Professor Harald sus Haussen was awarded the 2008 Nobel Prize in Medicine for his work. Shortly after, as expected, a vaccine was developed which has been the subject of many -and well-designed- clinical trials around the world, proving the efficacy and safety of it. At present, the vaccine has been approved in more than 120 countries, and more than 250 million doses have been applied, most of them in girls between ages 9 to 18. Many countries have incorporated HPV vaccination as part of their National Immunization Programs, and I wish to mention proudly that Colombia is one of them, although in the last couple of years our beautiful dream turned to be a nightmare.
We have robust evidence regarding the safety and efficacy of the three vaccines that are available, but still, the goals of having at least 80% of the target population vaccinated in order to eliminate the disease, have not been reached. Australia has done an admirable job in this regard and has announced that by the year 2030 Cervical cancer, as well as other conditions associated with the HPV, will be eliminated. Developed countries are heading in that direction with few exceptions. But developing countries, or as the new language describe them, low- and middle-income countries, are behind the expected goals in vaccination coverage.
One wonders why… One reason could be the cost. Each dose is around 30 US dollars, and the schema calls for 2 doses, six months apart. But in Colombia, it is given for free to girls between age 9-18. So, price is not the issue. One needs to mention that when the HPV vaccination program was launched, we reached almost 95% of the target population for the first dose and almost 90% for the second dose. Colombia was an example to the world. And I do believe that the key to success was that the program was school based.
Unfortunately, in May 2014, an event happened in a small town of the northern part of the country that utterly harmed the HPV vaccination program. One morning, some students of the same school and grade were admitted to the emergency room of the local hospital of “Carmen de Bolivar”, with bizarre symptoms such as abdominal pain, nausea, vomiting, headaches, and some fainted-on admission. Most of the girls were discharged after some hours in good clinical condition. Carmen de Bolivar is a small town of approximately 70.000 inhabitants, most of them displaced by the violence and the armed conflict that affected Colombia for more than fifty years, and with a large amount of unsatisfied social needs.
Who and why decided to blame the HPV vaccine as the culprit of these clinical symptoms? Why was this crazy story taken as true? Why no one took the time to verify it, and listen to the experts, and not the local politicians (that know nothing about the vaccine) and lawyers that immediately saw an opportunity to sue the pharmaceutical company and the government?
The official report of the National Institute of Health of Colombia proved beyond any doubt that the vaccine had nothing to do with the clinical manifestations, that was later described by the Colombian Society of Psychiatry as a “Massive psychogenic reaction”. Many of the girls admitted, and some boys had never been vaccinated, or they had been vaccinated many months before the event.
When the TV crews and journalist came to the town, and the Minister of Health did so too, the number of episodes and girls visiting the local hospital with fainting episodes, and peculiar muscle movements increased dramatically. And the scene of parents and girls in the emergency room became national news!
As one can imagine, the whole anti HPV vaccination program turned into a complete failure. From a 95% vaccination rate in 2013, it dropped to less than 10%. Despite the strong evidence in favor of the efficacy and safety of the vaccine and the efforts of the Ministry of Health and many NGOs that support the program, it has been very difficult to recover the effective rate of vaccination needed to eliminate the disease. There still exists a lack of confidence regarding the safety of the vaccine amongst the community and- believe it or not- in some medical doctors and nurses. Some politicians and lawyers have taken advantage of the situation and have fueled misinformation looking for some kind of benefit in a country that is prone to hear, believe and proceed without questioning the sources.
Plus, the fact that the health authorities have been very cautious (may I say, shy.?) in backing the HPV Vaccination program again. I am sure that we need to work decisively in recovering the confidence in the safety and efficacy of the vaccine by educating the health providers, parents, and adolescents. And we need to go back to a school-based program in order to facilitate the vaccinator’s work. That is one of the reasons why both Ministries of Health and Education need to work hand in hand to recover the time lost. We owe this to our women.
1. Kane MA, Sherris J, Coursaget P, Aguado T, Cutts F. Chapter 15: HPV vaccine use in the developing world. Vaccine. 2006;24 Suppl 3:S3/132-9.
2. WHO | HPV Vaccines and Safety. WHO [Internet]. 2019 [cited 2019 Jun 5]
3. Martínez M, Estévez A, Quijada H, Walteros D, Tolosa N, Paredes A, et al. Brote de evento de etiología desconocida en el municipio de El Carmen de Bolívar, Bolívar, 2014. Informe Quincenal Epidemiológico Nacional. 2015;20(3-4):41-77.
4. Organización Panamericana de la Salud (OPS). Vacunación VPH en la Región de las Américas: Lecciones aprendidas en la introducción y estrategias de comunicación. La Antigua Guatemala, Guatemala 2017