NJOG 2011 Nov-Dec; 6 (2): 56-57
BRIEF COMMUNICATION
Cervical Cancer and HPV Vaccine in Nepal: Issues and Challenges Dangal G Department of Obs/Gyn, Kathmandu Model Hospitals, Exhibition Road, Kathmandu
Cervical cancer is a major public health problem of ĚĞǀĞůŽƉŝŶŐ ĐŽƵŶƚƌŝĞƐ ůŝŬĞ EĞƉĂů͘ /ƚ ŝƐ ƚŚĞ ƐĞĐŽŶĚ ŵŽƐƚ common cancer and a leading killer among women worldwide and is the principal cancer of women in most developing countries, ǁŚĞƌĞ ϴϬ ƉĞƌĐĞŶƚ ŽĨ ĐĂƐĞƐ ŽĐĐƵƌ1͘ dŚĞƉƌŝŵĂƌLJĐĂƵƐĞŽĨĐĂƌĐŝŶŽŵĂĐĞƌǀŝdžŝƐ,ƵŵĂŶWĂƉŝůůŽŵĂ sŝƌƵƐ ;,WsͿ ŝŶĨĞĐƟŽŶ͕ ƚŚĞ ŵŽƐƚ ĐŽŵŵŽŶ ƐĞdžƵĂůůLJ ƚƌĂŶƐŵŝƩĞĚŝŶĨĞĐƟŽŶǁŽƌůĚǁŝĚĞ͘ /ƚŝƐĂůƐŽĂŵĂũŽƌĐĂƵƐĞŽĨŵŽƌďŝĚŝƚLJĂŶĚŵŽƌƚĂůŝƚLJŝŶEĞƉĂů͕ ĂƐ ŝŶ ŽƚŚĞƌ ĐŽƵŶƚƌŝĞƐ ǁŝƚŚŝŶ ^ŽƵƚŚ ƐŝĂ ĂŶĚ ĚĞǀĞůŽƉŝŶŐ countries worldwide, where some suggest it causing as high as 34% of all cancers in women2͘WĂƉƚĞƐƚŝƐƚŚĞďĞƐƚ way to detect cell changes that may be an early sign of preĐĂŶĐĞƌŽĨƚŚĞĐĞƌǀŝdž͘dŚĞƌĞĂƌĞŶŽǁŽƚŚĞƌƐĐƌĞĞŶŝŶŐƚŽŽůƐ ĂǀĂŝůĂďůĞĞ͘Ő͘ǀŝƐƵĂůŝŶƐƉĞĐƟŽŶŽĨĐĞƌǀŝdžǁŝƚŚĂĐĞƟĐĂĐŝĚĨŽƌ ƌĞƐŽƵƌĐĞ ƉŽŽƌ ƐĞƫŶŐƐ͕ ĂŶĚ ,Ws E ƚĞƐƚ ĨŽƌ ƚŚŽƐĞ ǁŚŽ ĐĂŶĂīŽƌĚ͘ dŚĞ ƵƐĞ ŽĨ ,Ws ƉƌŽƉŚLJůĂĐƟĐ ǀĂĐĐŝŶĞ ĂŵŽŶŐ LJŽƵŶŐ ĂĚŽůĞƐĐĞŶƚƐ;ĂŐĞŽĨϵͲϭϯͿ͕ǁŚŽŚĂǀĞŶŽƚďĞĞŶƉƌĞǀŝŽƵƐůLJ ĞdžƉŽƐĞĚ ƚŽ ƚŚĞ ŝŶĨĞĐƟŽŶ͕ ĂƐ ƉƌŝŵĂƌLJ ƉƌĞǀĞŶƟŽŶ ŚŽůĚƐ ŵŽƐƚƉƌŽŵŝƐĞĨŽƌƚŚĞƉƌĞǀĞŶƟŽŶŽĨĐĞƌǀŝĐĂůĐĂŶĐĞƌ3͘Ƶƚ͕ the unfortunate reality of this disease is that in spite of its ďĞŝŶŐ ĐŽŵƉůĞƚĞůLJ ƉƌĞǀĞŶƚĂďůĞ͕ ǁĞ ŝŶ EĞƉĂů͕ ƵŶůŝŬĞ ŝŶ ƚŚĞ west, have not yet been able to prevent it4͘ sĂĐĐŝŶĂƟŽŶƐĂƌĞŽŶĞŽĨƚŚĞŵŽƐƚƐƵĐĐĞƐƐĨƵůƉƵďůŝĐŚĞĂůƚŚ ĂƉƉƌŽĂĐŚĞƐƚŽƉƌĞǀĞŶƟŶŐĂŶĚĐŽŶƚƌŽůůŝŶŐŵĂŶLJŝŶĨĞĐƟŽƵƐ ĚŝƐĞĂƐĞƐ͘ EĞǁ ǀĂĐĐŝŶĞƐ ;'ĂƌĚĂƐŝů ĂŶĚ ĞƌǀŝƌĂdžͿ͕ Ă ŐƌĞĂƚ breakthrough of the 21st century, are available which ƉƌŽƚĞĐƚ ĂŐĂŝŶƐƚ ƚŚĞ ŵĂũŽƌ ƚLJƉĞƐ ŽĨ ,Ws ƚŚĂƚ ĐĂƵƐĞ ƚŚĞ ŵŽƐƚĐĂƐĞƐŽĨĐĞƌǀŝĐĂůĐĂŶĐĞƌ͘dŚĞLJĂƌĞŚŝŐŚůLJĞīĞĐƟǀĞŝŶ ƉƌĞǀĞŶƟŶŐƚŚĞ,WsŝŶĨĞĐƟŽŶĂŶĚĂƌĞĂůƌĞĂĚLJĂǀĂŝůĂďůĞŝŶ ƚŚĞ ĚĞǀĞůŽƉĞĚ ǁŽƌůĚ͘ /ƚ ĐŽƐƚƐ h^ ΨϯϲϬ ĨŽƌ Ă ƐĞƚ ŽĨ ƚŚƌĞĞ ĚŽƐĞƐ͘dŚĞƐĞĐŽŶĚĂŶĚƚŚŝƌĚĚŽƐĞƐƐŚŽƵůĚďĞŐŝǀĞŶĂƚƚǁŽ ĂŶĚ Ɛŝdž ŵŽŶƚŚƐ ĂŌĞƌ ƚŚĞ ĮƌƐƚ ĚŽƐĞ͘ Ɛ ƚŚĞ ǀĂĐĐŝŶĞ ĚŽĞƐ ŶŽƚƉƌŽƚĞĐƚĂŐĂŝŶƐƚĂůůƚLJƉĞƐŽĨ,WsĂŶĚǁŝůůŶŽƚƉƌĞǀĞŶƚĂůů
CORRESPONDENCE Dr. Ganesh Dangal, MD, FICS Department of Obstetrics and Gynaecology Kathmandu Model Hospital GPO Box 12887, Kathmandu, Nepal Phone: 00977-1-5250802 Cell: 00977-9851055036 E-mail:
[email protected]
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cases of cervical cancer or genital warts, women who are ǀĂĐĐŝŶĂƚĞĚƐŚŽƵůĚƐƟůůŚĂǀĞƌĞŐƵůĂƌWĂƉƚĞƐƚƐ͘dŚĞǀĂĐĐŝŶĞ ǁŚŝĐŚŝƐǀĞƌLJƐĂĨĞƚŽƵƐĞ͕ŝƐĂƉƌĞǀĞŶƟǀĞƚŽŽůĂŶĚŝƐŶŽƚĂ ƐƵďƐƟƚƵƚĞĨŽƌĐĂŶĐĞƌƐĐƌĞĞŶŝŶŐ͘ dŚŽƵŐŚƚŚĞǀĂĐĐŝŶĞǁŝůůďĞŵŽƐƚĞīĞĐƟǀĞŝĨƌĞĐĞŝǀĞĚďĞĨŽƌĞ ƚŚĞŽŶƐĞƚŽĨƐĞdžƵĂůĂĐƟǀŝƚLJ;ϵͲϭϯLJĞĂƌƐŽĨĂŐĞͿ͕ǀĂĐĐŝŶĂƟŽŶ ĐĂŶďĞŽīĞƌĞĚƚŽƚŚŽƐĞǁŚŽĂƌĞĂůƌĞĂĚLJƐĞdžƵĂůůLJĂĐƟǀĞĂƐ ǁĞůů͕ƌĞŐĂƌĚůĞƐƐŽĨĂƉƌĞǀŝŽƵƐŚŝƐƚŽƌLJŽĨ,WsŝŶĨĞĐƟŽŶŽƌĂŶ ĂďŶŽƌŵĂůWĂƉƚĞƐƚ͘ ŶĞīĞĐƟǀĞ,WsǀĂĐĐŝŶĞ͕ĂŶĚŽŶĞƚŚĂƚŝƐĂĐĐĞƉƚĞĚ͕ĐŽƵůĚ ŚĂǀĞ ĞŶŽƌŵŽƵƐ ƉƵďůŝĐ ŚĞĂůƚŚ ďĞŶĞĮƚƐ ĨŽƌ ďŽƚŚ ŵĞŶ and women by decreasing the morbidity and mortality ĂƐƐŽĐŝĂƚĞĚǁŝƚŚ,WsƌĞůĂƚĞĚĐĂŶĐĞƌ͘dŚĞŵĂƐƐĂĚŵŝŶŝƐƚƌĂƟŽŶ ŽĨĂŶ,WsǀĂĐĐŝŶĞƉƌŽǀŝĚĞƐŐƌĞĂƚƉŽƚĞŶƟĂůĨŽƌŝŵƉƌŽǀŝŶŐ the health of millions of women, as well as men and it has ƚŚĞƉŽƚĞŶƟĂůƚŽƌĞĚƵĐĞĐĞƌǀŝĐĂůĐĂŶĐĞƌĚĞĂƚŚƐĂƌŽƵŶĚƚŚĞ world by as much as two-thirds, if all women were to take ǀĂĐĐŝŶĞ ĂŶĚ ŝĨ ƉƌŽƚĞĐƟŽŶ ƚƵƌŶƐ ŽƵƚ ƚŽ ďĞ ůŽŶŐ ƚĞƌŵ͘ dŚĞ ĂƉƉƌŽǀĂůŽĨƚŚĞǀĂĐĐŝŶĞĂŐĂŝŶƐƚĐĂŶĐĞƌͲĐĂƵƐŝŶŐ,WsƐƚƌĂŝŶƐ ŝƐ ƐŝŐŶŝĮĐĂŶƚ ŝŶ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ǁŽƌůĚ͕ ďƵƚ ŵŽƌĞ ƐŽ ŝŶ ĚĞǀĞůŽƉŝŶŐĐŽƵŶƚƌŝĞƐůŝŬĞEĞƉĂůǁŚŝĐŚůĂĐŬƚŚĞŚĞĂůƚŚĐĂƌĞ ƌĞƐŽƵƌĐĞƐĨŽƌƌŽƵƟŶĞĐĞƌǀŝĐĂůĐĂŶĐĞƌƐĐƌĞĞŶŝŶŐ͕ƚŚĞƌĞĨŽƌĞ ƐĂǀŝŶŐŵŝůůŝŽŶƐŽĨůŝǀĞƐ͘ The society generally perceives that cervical cancer is the problem of women, and believes there is minimum or no ƌŽůĞŽĨŵĞŶŝŶƚƌĂŶƐŵŝƫŶŐƚŚĞǀŝƌƵƐƚŽǁŽŵĞŶ͘,ŽǁĞǀĞƌ͕ ƚŚĞĐŽŶƚƌĂƌLJŝƐƚƌƵĞĂŶĚƚŽƉƌĞǀĞŶƚŝŶĨĞĐƟŽŶĨƌŽŵ,WsƚŽ ĨĞŵĂůĞƐ͕ ŵĂůĞƐ ƐŚŽƵůĚ ďĞ ǀĂĐĐŝŶĂƚĞĚ ĂƐ ǁĞůů͘ DŽƌĞŽǀĞƌ͕ there are disputes over whom to vaccinate and whether ŝƚƐŚŽƵůĚďĞĐŽŵĞŶĂƟŽŶĂůƉƌŽŐƌĂŵƌƵŶďLJŐŽǀĞƌŶŵĞŶƚŽƌ ƉĂŝĚďLJĂĚŽůĞƐĐĞŶƚ͛ƐƉĂƌĞŶƚƐ͘ ǀĞŶ ƚŚŽƵŐŚ ƚŚĞ ǀĂĐĐŝŶĞ ƉƌŽǀŝĚĞƐ ƉƌŽƚĞĐƟŽŶ ĨƌŽŵ ĚĞǀĞůŽƉŝŶŐ ,Ws ĂƐƐŽĐŝĂƚĞĚ ĐĞƌǀŝĐĂů ĐĂŶĐĞƌ͕ ŵĂŶLJ adolescents are reluctant and their parents are not
Dangal. Cervical Cancer and HPV Vaccine in Nepal: Issues and Challenges
ĞŶĚŽƌƐŝŶŐ ƚŚĞ ǀĂĐĐŝŶĂƟŽŶ ĚƵĞ ƚŽ ƚŚĞ ďĂƌƌŝĞƌƐ ƐƵĐŚ ĂƐ parental acceptability, fear of promiscuity in the teenagers, ŵLJƚŚƐ ĂŶĚ ŚŝŐŚ ĐŽƐƚ͘ dŚĞƌĞ ŝƐ ƐƟůů ƵŶĐĞƌƚĂŝŶƚLJ ĂďŽƵƚ whether the vaccine can last its immunogenicity for long Žƌ ũƵƐƚ Ă ĨĞǁ LJĞĂƌƐ͘ dŚĞ ƉƌŽƚĞĐƟǀĞ ĞīĞĐƚƐ ŽĨ ƚŚĞ ǀĂĐĐŝŶĞ ĂƌĞ ƉƌŽǀĞŶ ƚŽ ůĂƐƚ Ă ŵŝŶŝŵƵŵ ŽĨ ϱ LJĞĂƌƐ ĂŌĞƌ ƚŚĞ ŝŶŝƟĂů ǀĂĐĐŝŶĂƟŽŶ͘ KƚŚĞƌ ƵŶƌĞƐŽůǀĞĚ ŝƐƐƵĞƐ ŝŶĐůƵĚĞ ůŽŶŐͲƚĞƌŵ ƉƌŽƚĞĐƟŽŶ͕ĐƌŽƐƐͲƉƌŽƚĞĐƟŽŶĂŐĂŝŶƐƚ,WsƚLJƉĞƐŶŽƚŝŶĐůƵĚĞĚ ŝŶƚŚĞǀĂĐĐŝŶĞĂŶĚǁŚĞƚŚĞƌƐƚĞƌĚŽƐĞƐǁŝůůďĞŶĞĞĚĞĚ͘ Another issue of concern is the high cost associated with ƚŚĞ ǀĂĐĐŝŶĂƟŽŶ͖ ǁŝƚŚ ƚŚĞ ƉƌĞƐĞŶƚ ĐŽƐƚ ŝƚ ŝƐ ƉƌĂĐƟĐĂůůLJ ŝŵƉŽƐƐŝďůĞ ƚŽ ŝŵƉůĞŵĞŶƚ ŵĂƐƐ ǀĂĐĐŝŶĂƟŽŶ ŝŶ EĞƉĂů͘ ŶŽƚŚĞƌ ĐŽŶĐĞƌŶ ŝƐ ĂďŽƵƚ ƚŚĞ ĂƌŐƵŵĞŶƚ ƚŚĂƚ ǀĂĐĐŝŶĂƟŽŶ could “promote promiscuity” but there is no evidence ƐƵŐŐĞƐƟŶŐ Ă ĐŽŶŶĞĐƟŽŶ ďĞƚǁĞĞŶ Ă ĚĞĐƌĞĂƐĞ ŝŶ ,Ws ĂŶĚ ĂŶ ŝŶĐƌĞĂƐĞ ŝŶ ƐĞdžƵĂů ĂĐƟǀŝƚLJ͘ >ĂĐŬ ŽĨ ĂǁĂƌĞŶĞƐƐ͕ ƉƵďůŝĐ ĚĞŵĂŶĚ ĂŶĚ ƉŽůŝƟĐĂů ǁŝůů͕ ůĂĐŬ ŽĨ ĐŽŽƌĚŝŶĂƟŽŶ ďĞƚǁĞĞŶ ĐĂŶĐĞƌĐŽŶƚƌŽů͕ƐĞdžƵĂůĂŶĚƌĞƉƌŽĚƵĐƟǀĞŚĞĂůƚŚĂŶĚǀĂĐĐŝŶĞ ĚĞůŝǀĞƌLJƐĞƌǀŝĐĞƐĂƌĞĂĚĚŝƟŽŶĂůĐŚĂůůĞŶŐĞƐ͘ dŚĞƐŝŶŐůĞͲŵŽƐƚďĂƌƌŝĞƌƚŽƚŚĞŝŶƚƌŽĚƵĐƟŽŶŽĨƚŚĞǀĂĐĐŝŶĞ ĨŽƌ ƚŚĞ ĂĚŽůĞƐĐĞŶƚƐ ŝŶ EĞƉĂů ŝƐ ƚŚĞ ƵŶĂīŽƌĚĂďůĞ ŚŝŐŚ ƉƌŝĐĞ͘ &ƌŽŵ Ă ƉƵďůŝĐ ŚĞĂůƚŚ ƉĞƌƐƉĞĐƟǀĞ͕ ƚŚĞ ĮƌƐƚ ƉƌŝŽƌŝƚLJ ŝŶ ƌĞƐŽƵƌĐĞͲƉŽŽƌ ƐĞƫŶŐƐ ǁŽƵůĚ ďĞ ƚŽ ǀĂĐĐŝŶĂƚĞ LJŽƵŶŐ adolescent girls by school-based or community based ǀĂĐĐŝŶĂƟŽŶƉƌŽŐƌĂŵƐ͘
ŶĚƚŚĞƌĞĂƌĞƌĂLJƐŽĨŚŽƉĞ͕ƚŚĞŶŽďůĞǁŽƌŬŽĨǀĂĐĐŝŶĂƟŶŐ ŽƵƌ ƐĐŚŽŽů ŐŝƌůƐ ŚĂƐ ďĞĞŶ ŝŶŝƟĂƚĞĚ ŝŶ EĞƉĂů ĂŶĚ 's/͛Ɛ announcement of providing the vaccines to developing ĐŽƵŶƚƌŝĞƐŝŶŚŝŐŚůLJƐƵďƐŝĚŝnjĞĚƉƌŝĐĞ;h^ΨϱƉĞƌĚŽƐĞͿŝƐĂůƐŽ ĂƉŽƐŝƟǀĞƐƚĞƉ͘ dŚŝƐ ŝƐ ŶŽǁ ŚŝŐŚ ƟŵĞ ƚŚĂƚ Ă ƐĞƌŝŽƵƐ ĐŽŶƐŝĚĞƌĂƟŽŶ ĨŽƌ ǁŝĚĞƐƉƌĞĂĚ ƵƐĞ ŽĨ ,Ws ǀĂĐĐŝŶĞ ŝŶ ƚŚŝƐ ĐŽƵŶƚƌLJ ŶĞĞĚƐ ƚŽƉŵŽƐƚƉƌŝŽƌŝƚLJ͘dŚŝƐǁŝůůŽŶůLJďĞƉŽƐƐŝďůĞƚŚƌŽƵŐŚƉƵďůŝĐ ĂǁĂƌĞŶĞƐƐ͕ ĐƵůƚƵƌĂů ĂĐĐĞƉƚĂďŝůŝƚLJ͕ ƉŽůŝƟĐĂů ǁŝůů͕ ƉŽůŝĐLJ ĨŽƌŵƵůĂƟŽŶĂŶĚƉƵďůŝĐƐƵƉƉŽƌƚ͘
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WƌĂƐĂŝ ^͘ ,ƵŵĂŶ ƉĂƉŝůůŽŵĂ ǀŝƌƵƐ ǀĂĐĐŝŶĂƟŽŶ͗ ^ŚŽƵůĚ ŝƚ ďĞ ŵĂŶĚĂƚŽƌLJ͍:EĞƉĂůDĞĚƐƐŽĐ͘ϮϬϬϴ͖ϰϳ;ϭϳϭͿ͗ϭϲϳͲϳϭ͘
ϰ͘
^ŝŶŐŚD͘dŚĞŵĂũŽƌďƌĞĂŬƚŚƌŽƵŐŚŽĨƚŚĞϮϭƐƚĐĞŶƚƵƌLJͲ,WsǀĂĐĐŝŶĞ͘ E:KďƐƚĞƚ'LJŶĂĞĐŽů͘ϮϬϬϳEŽǀͲĞĐ͖Ϯ;ϮͿ͗ϭͲϮ͘
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