Malaysia is back on track to eliminating cervical cancer

It is important that women above 30 aim to get screened at least twice in their lifetime with HPV PCR testing, which can be done at home or at the doctor's office. — Freepik

It's been 13 years since the government introduced the national school-based human papillomavirus (HPV) immunisation programme, targeting 13-year-old girls.

Malaysia was one of the first Asean countries to invest in such a comprehensive programme, and since 2010, more than 80% of girls in this age group have completed their HPV vaccination.

HPV is a common sexually-transmitted infection (STI), which usually shows no symptoms and goes away by itself, but can sometimes lead to genital warts or cancer.

Our investment in preventing females from developing cervical cancer in the future has paid off, according to a first-of-its-kind study in Malaysia and South-East Asia.

A team of researchers has been studying the different aspects of HPV infection in the Malaysian population since 2012.

Last December (2022), their results were published in the PLOS One journal under a paper titled Changes in Genital Human Papillomavirus (HPV) Prevalence Among Urban Females A Decade After The Malaysian HPV Vaccination Program.

They had assessed the frequency of a range of HPV genotypes among a sample of urban women in the age groups of 18-24 (277 subjects) and 35-45 (857 subjects between 2019 and 2020.

The frequency of the viral genotypes were then compared to that reported in an earlier, similar study carried out in an unvaccinated population from 2013 to 2015.

“In this study, we demonstrated a whopping 91% reduction in vaccine-targeted HPV subtypes among younger women in 2019–2020 (vaccine recipients), compared to 2013-2015 (pre-vaccine era).

“This indicates that if the vaccines can effectively reduce the infections that are associated with the development of cervical cancer by 90%, it should lead to a corresponding reduction in women being diagnosed with cervical cancer,” says Professor Dr Woo Yin Ling, one of the researchers.

The Universiti Malaya Medical Centre consultant gynaecological oncologist says that the results were not unexpected as the observations made in Malaysia are consistent with those in developed countries such as Sweden, which is already observing a reduction in cervical cancer cases.

“Cervical cancer is a cancer we can eliminate in our lifetime.

“This is the first cancer in human history that we have ‘ready tools’ to use.

“In 2018, the World Health Organization (WHO) director-general made a call to accelerate the elimination of cervical cancer through HPV vaccination, HPV testing and appropriate follow-up,” she points out, adding that there is no point in screening if there is no proper follow-up.

Pandemic effect

At the 2020 World Health Assembly meeting, Malaysia, along with 192 other countries, agreed to achieve the bold vision of a world without cervical cancer.

ALSO READ: A global plan to eliminate cervical cancer

One of our targets is to ensure that 90% of our adolescent girls are vaccinated against HPV by 2030.

The study noted that HPV vaccination coverage had increased from 9.3% in 2013-2015 to 75.5% in 2019-2020.

Everything was moving on track until the Covid-19 pandemic struck.

It is estimated that approximately 560,000 girls missed one or both of their HPV vaccine doses during this period.

Prof Woo says: “This is of concern, and I believe the government is trying to address it.

“However, it is also important to note that there is no longer an issue with HPV vaccine supplies.

“The Covid-19 pandemic has taught us that if we strengthen our efforts of systematically vaccinating and offering appropriate screening, we can ensure resources are used effectively towards a better health outcome.”

While there are more than 200 types of HPV, only 14 types are associated with the risk of developing cervical cancer.

The two main subtypes that account for 70% of cervical cancer are HPV types 16 and 18.

There are currently three vaccines that have been approved for use in Malaysia:

• Bivalent HPV vaccine

  It protects against HPV types 16 and 18.

• Quadrivalent HPV vaccine

  In addition to HPV types 16 and 18, this vaccine protects against HPV types six and 11, which are known to cause approximately 90% of genital warts.

• Nine-valent vaccine

  In addition to HPV types 16, 18, six and 11, this vaccine protects against five additional HPV types (31, 33, 45, 52 and 58), which cause about 20% of cervical cancers.

According to the study, there was an 87% reduction in HPV types six, 11, 16 and 18 among women in the 18-24 age group.

Meanwhile, type 52 was the most common HPV genotype detected among women in the 35-42 age group in both studies.

“The safety profile of all three vaccines has been clearly demonstrated.

“The major difference between the three different vaccines, besides the number of HPV types it covers, is the cost.

“Ideally, Malaysia should take advantage of the nine-valent vaccine, which provides additional protection against more HPV strains.

“Utilising the latest vaccines can address an increasing burden in the HPV subtypes in Malaysia that are not protected by the current national immunisation programme, such as HPV 52 and 58,” says Prof Woo.

Malaysia currently uses both the bivalent and quadrivalent vaccines.

Is there a ‘right’ age?

Although adults can also be vaccinated against HPV, the vaccine works best when taken during early adolescence, before the girl or boy becomes sexually active. — TNS

The HPV vaccine can be given to children as young as nine years old and adults up to age 45, although the optimal time for vaccination is during early adolescence, before being sexually active.

Prof Woo shares: “I often ask medical students or doctors what their definition of ‘sexually active’ is.

“You won’t believe the variety of answers I get!

“Even among them, there are so many myths and misconceptions about cervical cancer and HPV.

“Yet, the greatest risk of developing cervical cancer is not having regular screening – it has nothing to do with how sexually active one is; even those who are widowed or not in any current relationship should be screened.

She adds: “We now understand a bit more about HPV infection and the immune system – there are no major side effects in women above 30 being vaccinated.

“Adults who receive the HPV vaccine still benefit from it, but may produce lesser protective antibodies compared to adolescents, thus three doses of HPV vaccine are required for adults as a preventive vaccine compared to the two doses given to adolescents.”

There has also been emerging evidence to suggest that one dose of HPV vaccination will afford the same protection as two doses among healthy adolescents.

This evidence came about due to the disruptions in HPV vaccination coverage globally during the Covid-19 pandemic.

“The WHO issued an updated recommendation in 2022, suggesting that one dose of HPV vaccination is comparable in preventing cervical cancer.

“While the early evidence is extremely compelling, with some countries considering the alternative vaccine schedule, some others like us are waiting for longer-term outcomes,” says Prof Woo.

ALSO READ: Only one HPV shot needed to prevent cervical cancer

Whatever the dose number, it is important that women above 30 get screened at least twice in their lifetime with HPV PCR (polymerase chain reaction) testing, which is now the recommended screening modality, she says.

Quick and accurate test

Previously, doctors relied on Pap smears to identify any abnormal cells in the cervix.

This required women to undergo a pelvic examination and screening every one to three years – for some, an uncomfortable or painful experience.

Prof Woo explains: “The HPV test can identify women at risk of developing cervical cancer more effectively.

“Due to its sensitivity, women only require as few as two tests per lifetime.

“They can perform their own self-test using a vaginal swab, which is not too different from a Covid-19 swab test.

“This really is the game-changer in the cervical cancer elimination strategy set by WHO.

“We are already seeing high-income countries like Australia that have totally moved to HPV testing since 2017, and the country is on track in its commitment to eliminate cervical cancer by 2035.”

ALSO READ: Now you can screen for cervical cancer at home

The only caveat about HPV tests is that it needs to be done on machines that are approved and suitable for population screening.

“There are more than 400 HPV tests in the market, but only a dozen are suitable for cervical screening.

“Using the wrong HPV test can lead to misleading results and unnecessary follow-up tests,” she notes.

Cervical cancer took the lives of 342,000 women around the world in 2020.

“We must remember that screening itself does not save lives; it is the appropriate follow-up and treatment that saves lives.

“No woman or girl should fall prey to cervical cancer because it is one of the most preventable and treatable cancers.

“No child should have their mothers taken from them,” Prof Woo emphasises.