According to the World Bank, Pakistan has a population of 230 million, with women constituting 50pc of the population.

Over the years, there has been a rise in cancer among women, with breast and cervical cancer the most common.

Breast cancer is the second most common cancer in Pakistan, affecting one out of every nine women, while cervical cancer is the third most common cancer among women in Pakistan, and the second most common among those aged 15 to 44. Both these cancers can be prevented and treated if detected early.

Cervical HPV-16/18 infection affects approximately 0.5pc of the women and accounts for 88.1pc of invasive cervical cancer cases.

According to the worldwide cervical cancer prevention strategy, the best way to avoid cervical cancer is to get screened and vaccinated.

Cervical cancer develops in a woman’s cervix, which is the entrance to the uterus from the vagina. Almost all (99pc) cervical cancer cases are linked to infection with high-risk human papillomavirus (HPV) – an extremely common virus transmitted through sexual contact.

The signs and symptoms of cervical cancer are irregular or postmenopausal bleeding, increased vaginal discharge, with more severe symptoms arising at the advanced stage.

This is the first cancer for which there is a vaccine. HPV is a non-enveloped DNA virus from the Papillomaviridae family, with over a hundred distinct serotypes.

Of these, 15 to 20 are oncogenic, with 16 and 18 being the most prevalent.

HPV is transmitted through sexual activity, and it is estimated that 75pc of all sexually active people have at least one HPV serotype. However, the majority of these infections resolve spontaneously, with less than 1pc developing to malignancy.

Regular pap smear screenings can help slow this progression. Cervical cancer mortality has decreased significantly in developed countries following the introduction of pap screenings.

Unfortunately, in underdeveloped countries such as Pakistan, pap smear uptake is quite low, with one estimate putting it as low as 2pc. In such instances, where pap smears are already difficult to perform and uptake is poor, HPV vaccinations become even more important for cervical cancer prevention.

Two globally licensed HPV vaccinations have been introduced in Pakistan: the quadrivalent Gardasil and the bivalent Cervarix. Gardasil protects against HPV serotypes 6, 11, 16 and 18, preventing cervical cancer and genital warts.

Cervarix, on the other hand, is exclusively effective against serotypes 16 and 18, limiting its protection to cervical cancer. It is important to remember that both of these vaccines are preventive and have no effect on pre-existing illnesses.

There are some challenges that need to be addressed which include limited awareness especially in rural areas, inadequate access to healthcare facilities, particularly in remote regions, screening limitation, insufficient financial resources, weak health system, cancer registries, limited number of trained providers and no national guidelines/ protocols for treatment of cervical cancer.

Despite their introduction in Pakistan, there is a lack of awareness about these vaccinations and limited adoption in public. It was reported that HPV vaccine awareness is as low as 20pc and uptake to be less than 10pc.

Cervical cancers affect over 6,000 women in Pakistan each year, with approximately 3,000 dying from the disease. So we are looking into 3,000 deaths each year, which may seem insignificant when you consider the population of 230 million.

Let’s not forget, there are preventive measures available, including vaccination. Pakistan does not have a national HPV vaccination programme, does not manufacture vaccines and does not have government-backed programmes to subsidise the available HPV vaccines.

Furthermore, despite their launch three to four years ago, Cervarix and Gardasil are still difficult to obtain in most regions of the country. Another challenge to HPV vaccination is a lack of awareness and education on the subject.

This stems from cultural taboos around discussions about sexual health, practices, and diseases.

Therefore, careful measures should be taken to increase public awareness of cervical cancer and HPV vaccination.

The government should conduct nationwide awareness programmes to educate the public about cervical cancer and how to prevent it. This should be aimed at parents, carers, local stakeholders, religious leaders and civil society members.

The ministry has both an Ulema forum and a media forum.

We can also take them onboard by explaining that if we do these things, it will help our country and the 50pc female population.

According to the country’s report, we have only four radiotherapy centres, and only one brachy therapy centre, which is an ideal treatment for cervical cancer. We do not have any national recommendations or protocols for the treatment of cervical cancer.

Cancer registry is also highly significant, however, it is still not available in Pakistan despite all efforts.

There should be reference channels and standard operating procedures in place to reduce system delays. We lack capacity building; we do not have skilled healthcare providers or lady health workers to advise someone through any challenge.

Therefore there is a need to introduce capacity-building programmes to impart training on the subject. There are also different international organisations like JICA that want to help Pakistan. Besides, every private hospital has its own specific policy, and these policies are not monitored centrally by the Pakistan Medical and Dental Council (PMDC) or any other institution that holds them accountable.

Considering the cultural stigma surrounding this topic, it may be more useful to present the vaccination as a preventative measure for cervical cancer rather than sexual disease transmission.

This technique is critical because immunisation is recommended for young females.

Parents of these girls should be counselled and educated on the necessity of administering this vaccine early.

Since the recommended age for HPV vaccine administration is nine to 26 years, and it is preferable to provide it as early as possible with two doses, these national efforts should include school settings.

There is also a need to address the shortage of HPV vaccines by making them accessible and inexpensive.

HPV vaccinations can be integrated into the Expanded Programme of Immunisation, which operates at the district level in partnership with civil society organisations. To reduce burden, we need to create awareness and reach out to rural and marginalised communities.— The writer is a nutritionist

Published in Dawn, April 14th, 2024