Human papillomavirus vaccine: a welcome addition to the national immunisation schedule in Nepal

Summary box.

• Nepal has successfully included the human papillomavirus (HPV) vaccine in its national immunisation schedule.

• The introduction of the HPV vaccine aims to protect adolescent girls and contribute to the global cervical cancer elimination target.

• The programme’s success will depend on widespread coverage, public awareness and future innovations.

Introduction

Nepal has introduced the human papillomavirus (HPV) vaccine into its national immunisation schedule, becoming the 145th country to do so.¹ This significant public health milestone was achieved by the Immunisation Section at the Family Welfare Division (FWD), Department of Health Services, Ministry of Health and Population (MoHP), Nepal, on the recommendation of the National Immunisation Advisory Committee.² The committee, during its 23rd meeting in 2081 BS (Nepali calendar), endorsed the HPV Vaccination Service Operational Guidelines,³ facilitating the vaccine rollout. The HPV vaccination campaign is scheduled from 4 February 2025 to 18 February 2025. Supported by Gavi, the Vaccine Alliance, World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), this campaign aims to immunise over 1.6 million adolescent school girls (grades 6–10) and out-of-school girls aged 10–14, followed by its subsequent integration into the routine immunisation programme.⁴ To ensure widespread coverage among age-eligible adolescent girls, the HPV vaccine will be administered through school-based health initiatives.³ As of 2024, 144 countries have already included the HPV vaccine in their national routine immunisation schedules.¹

HPV vaccine in Nepal

The 14th antigen to be included in Nepal’s national immunisation schedule is a recombinant HPV bivalent (types 16, 18) vaccine (Escherichia coli) delivered as a single 0.5 mL intramuscular dose in the outer upper left arm (deltoid muscle). With reported efficacy of 98%–100%, it is available as a ready-to-use 0.5 mL vial containing recombinant HPV type-16 and type-18 L1 proteins, aluminium hydroxide adjuvant, excipients for injection. The vaccine must be stored and transported at +2°C to +8°C. It should be kept in a vial holder within an Ice Lined Refrigerator (ILR) at storage sites and transported in a polio carrier to prevent temperature fluctuations.³ This vaccine is the fourth WHO-prequalified HPV vaccine to be confirmed for use in a single-dose schedule, as outlined in the second edition of WHO’s technical document on considerations for HPV vaccine product selection.⁵

Prevalence and impact of HPV

HPV is the most common sexually transmitted infection and the primary causative agent of cervical cancer.⁶ Persistent infection with high-risk HPV (HR-HPV) types is responsible for virtually all cases of cervical cancer,⁷ with HPV-16 and HPV-18 accounting for approximately 70% of cases globally.⁸ HPV is implicated in a range of anogenital and oropharyngeal cancers. For instance, around 90% of squamous anal cancers are attributable to HPV infection, predominantly high-risk types.^{8 9} Additionally, HPV is associated with approximately 40% of vulvar cancers¹⁰ and 70% of vaginal cancers.⁸ Among men, HPV DNA has been detected in 47% of penile cancer cases, underscoring its significance in male cancers.¹⁰ The association of HPV with head and neck cancers, particularly oropharyngeal cancers, varies geographically, with higher prevalence in more developed regions due to differences in sexual behaviours and diagnostic practices.¹¹ Beyond cancer, HPV infection is the leading cause of genital warts, with HPV-6 and HPV-11 responsible for approximately 90% of these cases.¹²

Nepalese studies report an HPV prevalence of 8.6%–19.7%,13,16 with HR-HPV at 6.1%–9.6%.1314 16,18 The three most common HPV genotypes associated with cervical cancer in Nepal are HPV-16, HPV-18 and HPV-45, collectively contributing to 92%–96.3% of cervical cancer cases.^{16 19} The global prevalence is estimated to be around 11.7% among women with normal cytological findings, with significant regional variations.²⁰

Burden of cervical cancer

Cervical cancer remains a significant public health challenge both globally and in Nepal. According to the Global Cancer Observatory,²¹ cervical cancer was the second most common cancer among Nepalese females in 2022, accounting for 17.8% of all cancer cases in this group. Nationally, it ranks third, causing 9.9% of all cancer cases and deaths.²¹ Globally, cervical cancer ranks as the fourth most common cancer among women, with an estimated 660 000 new cases and 350 000 deaths in 2022.²¹ The burden is disproportionately higher in low-income and middle-income countries, which face the highest rates of incidence and mortality. This disparity is largely driven by inequities in access to HPV vaccination, cervical cancer screening and timely treatment services, as well as broader social and economic factors.⁶

HPV vaccination efforts

Given the substantial burden of HPV-related diseases, particularly cervical cancer, the importance of effective intervention strategies cannot be overstated. HPV infections are primarily confined to the epithelial layer of the mucosa and typically do not elicit a robust immune response, which contributes to the persistence of the infection.²² With no cure, prevention is key to HPV control.²³The WHO recommends the integration of HPV vaccination into national immunisation programmes as part of a broader effort to combat HPV-related diseases.⁶ Evidence from countries that have implemented widespread HPV vaccination programmes demonstrates a marked decrease in the incidence of HPV-related cancers and other diseases, highlighting the vaccine’s effectiveness.^{23 24}

In the years 2017/2018 MoHP, through its FWD, initiated an HPV vaccination demonstration programme targeting adolescent girls in the districts of Chitwan and Kaski. The two-phase programme had 100% first-dose and 95.3% second-dose coverage. Based on these promising results, the National Immunisation Advisory Committee recommended the inclusion of the HPV vaccine in Nepal’s national immunisation schedule. This initiative is part of a strategic framework aimed at reducing the incidence of cervical cancer and other HPV-related conditions.³

Global insights

The global endeavour to eliminate cervical cancer has been significantly bolstered by the implementation of HPV vaccination programmes. The WHO has delineated clear targets to achieve this goal, emphasising that by 2030, 90% of girls should be fully vaccinated with the HPV vaccine by the age of 15, 70% of women should be screened using a high-performance test by the ages of 35 and 45, and 90% of women identified with cervical disease should receive appropriate treatment.²⁵ Various countries have embarked on HPV vaccination campaigns, yielding valuable insights.²⁶ In Africa, nations such as Zimbabwe, Senegal and Tanzania have demonstrated that increasing HPV vaccine demand and coverage, coupled with building sustainable programmes, effectively protects women from cervical cancer.²⁷ In Asia, neighbouring countries such as Bhutan, Sri Lanka, Thailand and the Maldives have already implemented the vaccine nationwide. In contrast, India and Indonesia have introduced the HPV vaccine in selected districts only,²⁸ facing challenges related to regional disparities and resource allocation. Countries such as Australia²⁹ and the UK³⁰ have adopted gender-neutral vaccination strategies, aiming to enhance herd immunity and provide direct protection to males against HPV-related diseases. Model-based predictions suggest that such an approach could increase the feasibility of attaining the WHO elimination threshold.³¹

Conclusions

The successful integration of the HPV vaccine into the national immunisation schedule is a commendable step. However, challenges persist, including logistical constraints, vaccine hesitancy and the need for sustained public education.^{32 33} Lessons from other countries underscore the importance of comprehensive strategies encompassing public awareness, healthcare worker training and robust monitoring systems.³⁴ Innovative solutions, such as school-based vaccination programmes, community-led initiatives and gender-neutral vaccines, may enhance coverage and acceptance. Future directions should focus on sustaining political commitment, securing financial resources, leveraging innovations and technological advancements to streamline vaccination efforts. A call to action is imperative for stakeholders at all levels to collaborate, ensuring that Nepal not only meets but exceeds the targets set forth by the WHO, ultimately safeguarding future generations from HPV-related diseases.

Data availability statement

No data are available.