Ishu Kataria 

I think being a citizen of the country like India and always seeing things working out at scale with the sheer nature of our population, to me doesn’t seem as daunting as it seems to you and I would not consider a vaccination of over 60 million girls difficult honestly. 

Lilly Matson (Host) 

Hi! Welcome to That Cancer Conversation, the podcast from Cancer Research UK that brings together the science and the stories behind cancer with me, Lily Matson. 

Around the world, cervical cancer is the fourth most common cancer in women. It’s unusual as cancers go, because 99% of cases worldwide are caused by an extremely common sexually transmitted infection known as human papilloma virus, or HPV for short. 

Now, having HPV doesn’t mean that someone will definitely go on to develop cancer. I need to be really, really clear here. You can’t catch cancer. And this is because there are hundreds of different types of HPV. Some don’t pose any major issues, and the body clears them naturally. 

Some cause things like warts and verrucas. But a few types are considered high risk and can lead to different forms of cancer. Studies from countries including Sweden and here in the UK, have shown that vaccinating people for HPV at a young age before they become sexually active and more likely to be exposed to the virus dramatically reduces the incidence of cervical cancer. Many countries around the world have open HPV vaccination programmes. But in other places like the USA, for example, it’s not as accessible for everyone across the country. So to tackle this issue in one of the largest countries in the world, brilliant experts are working out how India might be able to introduce their own programme nationwide. 

Ishu Kataria  

I am Dr. Ishu Kataria, I work as a senior public health researcher with the Centre for Global Non Communicable Diseases at a research organisation called RTI International. My work basically involves prevention and control of non communicable diseases. Specifically, a lot of it is on cancer prevention control. 

So cervical cancer is the third most common cancer in India. And the cancer really accounts for about the second highest number of cancer deaths in the country. The most common cause is the infection through HPV or human papilloma virus, as we call it. And what is, I would say, really sad is that there is a vaccine to prevent cervical cancer that a lot of people don’t know about or have access to. We usually give this vaccine to girls in the age group of 9 to 14, generally before they begin their sexual debut. 

Lilly Matson  

Okay, I see. So like right now, it’s November 2021. Could you explain a little bit about what India’s approach to cervical cancer is? 

Ishu Kataria  

What India basically has at this moment Lilly is a screening programme. That is for non communicable diseases. Sort of the key thing to note is that you don’t really have the whole population that is your target population that gets invited systematically for screening. But it really depends on how many times a patient would visit a doctor. So that’s, that’s opportunistic screening. So we are not able to screen as many people as we should be screening, but that is currently what is in the limit. 

Lilly Matson  

So if we think about India, it’s such a massive population. I suppose getting anything delivered across the whole country, vaccine or screening is quite a big task. You and your team are talking about a programme to immunise all girls between the ages of 9 and 14, so that something like 60, 70, maybe 74 million people, if not more. That’s more than the entire population of the UK and you seem so calm about doing something at such a huge scale. 

Ishu Kataria  

I think being a citizen of the country like India, and always seeing things working out at scale with the sheer nature of our population, to me doesn’t seem as daunting as it seems to you. Um, so under the universal immunisation programme, the UIP, the Government of India really provides vaccination to prevent a lot of preventable diseases. So, the malaria, pertussis, tetanus, polio, measles and and so on. So I would say that people are fairly acceptable to vaccines. As a country, we are not a country where you would see a lot of anti vaccine sentiment. And I would not consider a vaccination of over 60 million girls difficult, honestly. 

Lilly Matson  

So I guess that’s the first thing to think about as the girls. Are there any issues trying to convince them to get the vaccine? 

Ishu Kataria  

I think one of the key things is that with the way we function as a society in India, the adolescent girls do not really have an independent choice about HPV vaccination. So the choice really rests with the parents. There may be some parents who could involve the adolescent in decision making, but a lot of times it’s the parents to take decision for children. 

Lilly Matson  

Okay, I see. So what would it take to convince the parents to ensure this can go ahead? Like you said, India has a history of vaccinating infants and children for diseases? So how do you get them to say yes to the HPV vaccine? 

Ishu Kataria  

It’s really important because there’s a lot of trust and faith that people have in the healthcare system. So if a doctor recommends something, I think that has a high likelihood of being accepted than from anybody else. They could create awareness, people could go back to them ask questions, have clarifications on the vaccine, because honestly, as I told you, as a country, we are really focused on Childhood Immunisation. And we haven’t seen adolescent vaccines come up – the only other vaccine, which is the COVID-19 vaccine is where we have first time really targeted age groups other than children. So it’s, it’s a little new in that sense. 

Lilly Matson  

So this is pretty complicated. Let’s try and break it down a little bit. Ishu and a team want India to have a programme in place to vaccinate all the girls aged 9 to 14 in India, that’s about 74 million people. In comparison, the entire population of the UK is only around 67 million people. So it’s like imagining that you want to vaccinate everyone in the UK – but before you can you have to convince their families that it’s a good thing, how would you do that? Like Ishu said, get health care providers on side, but she and her team have found it’s not a simple task. 

Ishu Kataria  

So the cost of the vaccine Lilly, I would say is a major barrier. It’s available, it’s available in the sector that can be dispensed to health clinics with private providers as well. But it’s not in the sort of the public health sector in that sense. So a lot of people cannot afford the vaccine with the kind of income level that they have, as a result of which a doctor would often say to me that even if I recommend the vaccine, the person sitting in front of me would say, like, that is something that I cannot afford. That is the whole amount that I really have, where I can feed my family. So why would I spend it on a vaccine? And that is cost of just one vaccine because you have to give two doses of it. So cost is one major barrier. 

Lilly Matson  

Right? So if the vaccine were cheaper, would that mean that people would be more inclined to have their kids vaccinated? Or is there anything else that healthcare professionals have to consider? 

Ishu Kataria  

There is a fear among parents that it could lead to their daughter’s becoming sexually promiscuous. They are a little confused because HPV is a sexually transmitted infection. So they come back asking that their daughter would not really start sexual abuse that early. So their daughter does not really need the vaccine. And what also happens is that a lot of adolescents themselves, don’t really know about the vaccine. And one of the major barriers that I think a lot of physicians unanimously vocalised was that it is not part of the universal immunisation programme of the country. So if it’s not in the UIP, we don’t really want to recommend it. We’d be happy recommending it once it is in the UIP. 

Lilly Matson  

So let’s look at what it boils down to. So far, we’ve established that for adolescent girls to be able to get the vaccine you often have to convince parents or other family members and in order to convince them you first have to convince the healthcare professionals, but in order to convince the healthcare professionals to recommend vaccine, you have to get it into India’s universal immunisation programme. This is a big deal. Why? Well, it’s a matter of size. So India is a country with a population of almost 1.4 billion people, that’s about 20 times larger than that of the UK. The country is divided into 28 states. Some of them are small, like Sikkim, for example, population estimates put it at about 660,000 people. So just a little bit more than the City of Glasgow. On the other hand, some are really big like Uttar Pradesh, it’s estimated that over 200 million people live there. So that’s more than the combined population of Britain, Ireland, France, Spain, and to top it all off, Portugal. It makes sense then that unlike the UK, where the majority of healthcare services are coordinated and provided centrally through the NHS, the different states in India control that healthcare and are guided by the national government. So how do you get every single state on the same page? This is where the universal immunisation programme, or UIP, launched in 1985 comes in. It’s one of the world’s largest if not the largest immunisation programme covering groups such as newborns, children, and pregnant individuals to prevent the spread of preventable diseases across India, things like hepatitis, polio, measles, and added recently rotavirus. So this is a really important step because once a vaccine is in the UIP, it tells healthcare professionals who should be given it is provided free of charge, and perhaps most importantly, people trust it. So with more and more evidence coming out from places like the UK, that HPV vaccination programmes are effective, why isn’t the HPV vaccine part of the universal immunisation programme? 

Ishu Kataria  

With respect to the HPV vaccination, we did have a demonstration project that happened in a few sites across India. And this was I think, the year of 2009. There were some media reports that came out that actually attribute it some deaths that happened in those areas to HPV vaccine. So there was this combination of sort of what media reported. The misinformation around the deaths, actually, which was not related to the HPV programme or vaccination was really a big impediment for really introduced the vaccine. And it has been for over a years 

Lilly Matson  

I see, I guess, in the time since then, have there been any attempts to make the vaccine more widely available? 

Ishu Kataria  

So gradually, I think as we started to recover as a country, there were a few states that really thought that they would try and do it in the country. So in 2016, HPV vaccination was initiated by the Delhi state government. In 2017, Punjab, another state in the northern part of India actually initiated HPV vaccination in two districts, where the cervical cancer burden was high. And finally, in 2018, Sikkim, which is a state in the northeast part of India, started a statewide HPV vaccination programme, targeting girls who were between the age of nine to 14 years in schools. 

Lilly Matson  

So right now, three different regions in India have an HPV vaccination programme in place. And a key part of issues work is finding out how this was done, and what can be applied to other states in the country. So how did they do it? Well, let’s start in Sikkim, that northeastern state whose population is just a little bit less than that of Glasgow’s, a lot of it came from as Ishu puts it, sheer political will. A senior minister was introduced to HPV vaccination while visiting another country. When he came back to Sikkim, which has a high rate of cervical cancer, he was determined to introduce something similar and they worked heavily with education and health departments to make it happen. In Punjab, state officials consulted an expert group which agreed that a programme should be in place in the 28 million person state, they use data to target 11 and 12 year old school girls in the two districts with the highest burden of cervical cancer. But Delhi was a bit different. Their programme was more opportunistic. So if the girls came to their health care provider, they would be offered the vaccine and would have a choice on whether or not to take it. But which method to Ishu and her team think works best and could help roll out a programme across the country? 

Ishu Kataria  

So I would say really that between the three states that I spoke about two of them actually captured school going adolescents used school as a vehicle. Both Sikkim and Punjab did it and are doing it. And they have found this strategy very successful, because there is an opportunity to not only get teachers involved, but also get parents involved, because there’s a lot of trust the students also placed in teachers so both these states have actually seen very high uptake with regards to school being utilised as a medium for vaccination. So I would say that is is one of the good learnings. And I think the other things that the states can learn from each other, even those states that are intending to actually start. The vaccination programme is basically learnings in terms of procurement of vaccines, because states have to then procure themselves if they are really wanting to start, how the UN agencies can help them like UNICEF or who in terms of the technical implementation. So states often reach out to each other in understanding how one state did it and how the other states can then adapt. 

Lilly Matson  

So ultimately, I guess it doesn’t matter who’s paying: the family, the state or the government, it still has a price tag, right? How can these vaccines been made cheaper and more widely accessible? 

Ishu Kataria  

India is really focusing on indigenous vaccines. We’ve seen that with COVID, where a vaccine has developed indigenously in the country and is being administered successfully. It is safe and effective. And I think a similar thing is happening with the HPV vaccine, where it is also being manufactured indigenously, and hopefully with that vaccine launch, there will be more motivation with the Government of India. 

Lilly Matson  

So let’s fast forward to a decade from now. Do you think things will be different in India? 

Ishu Kataria  

I will be very hopeful Lily and I’m a very optimistic person. So I feel that India will definitely start HPV vaccination through its universal immunisation programme. And we will have the girls who are in the eligible age category get vaccinated. That is what I hope. And that is what I dream and I’m quite quite optimistic that that will eventually happen. 

Lilly Matson  

So this is my very last question. And it’s quite a big one. If you had someone in front of you with the power to change things, someone like a government official, what would you say to them? 

Ishu Kataria  

They’re quite busy people. So I think I would just tell them that you have a real opportunity to prevent the women of your country dying from a cancer that is preventable. So it is time for you to act now. 

Lilly Matson  

That’s it for this episode of That Cancer Conversation. We were produced in the Cancer Research UK Digital News team. If you’ve come this far and would like to learn more about Dr Ishu Kataria’s work, HPV, or any of the other topics featured in this episode – links are available in the show notes. To be the first to listen to our next episode, be sure to subscribe on Apple podcasts, Spotify, or wherever you get your podcasts. I’ve been Lilly Matson, thanks so much for listening and bye for now.