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HPV vaccine: high coverage could eradicate cervical cancer within decades, say researchers

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4450 (Published 27 June 2019) Cite this as: BMJ 2019;365:l4450

Rapid Response:

WHO made a global call for action towards the elimination of cervical cancer, not eradication

The recently published news article in the British Medical Journal titled ‘HPV vaccine: high coverage could eradicate cervical cancer within decades, say researchers’ has created some confusion, which is evident from the letter written to the journal by Dr. Peter English, a public health physician. [1,2] It is important to address the issue of elimination vs eradication and clear any doubts raised by the use of incorrect terminology in the news item.

The WHO Director-General made a global call for action towards elimination of cervical cancer as a public health problem at the World Health Assembly in May 2018. ‘Elimination as a public health problem’ is a term that is defined as achieving the measurable global targets set by WHO, in relation to a specific disease. The Dahlem Workshop in March 1997 discussed the hierarchy of possible public health interventions with infectious diseases. [3] Control measures are required to be continued even after elimination has been achieved. Conversely eradication is defined as a permanent reduction to zero of the worldwide incidence of infection and intervention measures no longer needed.

Dr. English has very rightly pointed out that cervical cancer eradication is not possible as the currently available vaccines against human papillomavirus (HPV) do not protect against all the oncogenic HPV genotypes. The emerging data from the national immunization programmes in several countries have consistently demonstrated the highly significant protective effect of the vaccine against cervical cancer at the population level due to the high efficacy of the vaccine against the targeted HPV types, substantial cross-protection against certain non-targeted HPV types and the herd protection offered by high coverage of the target population. [4] Still such protection cannot be 100% due to the fact that a small number of vaccinated women may get cervical cancer after being infected by the non-targeted oncogenic HPV types and cervical cancer screening is not completely failsafe.

Based on epidemiological data and modelling work, ‘elimination of cervical cancer as a public health problem’ was proposed to be defined as an incidence rate below 4 cases per 100,000 woman-years during several strategic expert group consultations convened by the WHO. [5] To reach elimination goals, the WHO emphasizes the importance of control measures, including high coverages of HPV vaccination, of screening and treatment of cervical pre-cancer lesions and of treatment and palliative care for women with cervical cancer.

The term elimination was rightly used in the statement that was made by Mr. Marc Brisson of Laval University in Quebec City at the press meeting in London. However, using the term ‘eradication’ in the title of the report of the press meeting in the BMJ was obviously an oversight.

Disclaimer
Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer / World Health Organization.

References
1. Torjesen I. HPV vaccine: high coverage could eradicate cervical cancer within decades, say researchers. BMJ 2019;365:l4450. 10.1136/bmj.l4450.
2. English PMB. Eradicating cervical cancer is unlikely. BMJ 2019;366:l4953. 10.1136/bmj.l4953.
3. Dowdle WR. The principles of disease elimination and eradication. Bull World Health Organ 1998;76 Suppl 2:22-5.
4. Drolet M, Bénard É, Pérez N, Brisson M; HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019;394(10197):497-509. 10.1016/S0140-6736(19)30298-3
5. World Health Organization. Draft global strategy towards the elimination of cervical cancer as a public health problem. 2019. WHO, Geneva. Available from https://www.who.int/docs/default-source/documents/cervical-cancer-elimin.... Accessed 28 August 2019.

Competing interests: No competing interests

03 September 2019
Partha Basu
MD, PhD
Raymond Hutubessy PhD MSc: Department of Immunization, Vaccines and Biologicals, World Health Organization; Nathalie Broutet MD, PhD: Department of Reproductive Health and Research, World Health Organization
Screening Group, International Agency for Research on Cancer, World Health Organization
Lyon, France