Indonesia's Readiness to Implement the HPV Vaccine Mandatory for School Age

Background: According to WHO, two out of 10,000 women in Indonesia live with cervical cancer and an estimated 26 women die each day from cervical cancer. Indonesian government is planning to add the HPV vaccine into the national immunization program. The objective is to assess the possibility of Indonesia’s readiness to implement the HPV vaccine mandatory for school age and factors that may affect it. Methods: The method was a systematic review through articles related to HPV vaccine which have been published in accredited and scopus-indexed journals for the last 10 years. With keywords “Implementation for HPV Immunization”, founded 17,000 search results. Afterwards, a critical appraisal on the selected articles is conducted using PRISMA method. Results: It is found that the awareness of community, especially parents, about HPV vaccine is still lacking, but their acceptance of this vaccine is quite positive. There are other factors into their objection to vaccines, such as the high price, fear of the side effects, sexuality, gender, and healthcare systems. Currently in Indonesia HPV vaccine must be purchased on their own initiative and is not a mandatory program of the central government. Neither has it been given free of charge through JKN program. Nevertheless, The Ministry of Health has begun a pilot project to provide free HPV vaccination in some areas within Immunization Month for School Age program using a combination of central and regional resources. Conclusion: Although there have been regulations and technical guidelines for the implementation of the pilot project of free HPV vaccination, it still needs adjustment and support from the Government if it will be implemented nationally and adapted to conditions in areas with limited facilities and access. The role of the government is needed in providing good knowledge about the HPV vaccine for the community. (Health Science Journal of Indonesia 2018;9(2):107-18) Keyword: HPV Vaccine, Implementation Readiness, National Immunization Program Health Science Journal of Indonesia Ayuningtyas and Sutrisnawati 108 Cervical cancer is the second most common type of cancer in women worldwide, with all cases linked to a sexually transmitted genital infection with the human papillomavirus (HPV). Due to poor access to screening and treatment services, more than 90% of deaths occur in women living in low and middle-income countries.1 Cervical cancer is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases in 2012.2 According to the WHO (2012), two out of 10,000 women in Indonesia live with cervical cancer and an estimated 26 women die each day from cervical cancer. The total number of women with cervical cancer in Indonesia has reached 21 thousand cases. Current estimates in 2017 indicate that every year, 20928 women are diagnosed with cervical cancer and 9498 die from the disease2. Cervical cancer ranks as the 2nd most frequent cancer among women in Indonesia and the 2nd most frequent cancer among women between 15 and 44 years of age.3 It was known that cervical cancer is caused by an oncogenic human papillomavirus (HPV) infection. The oncogenic HPV types are of 16, 18, 45, 31, 33, 52, 58, 35, 59, 56, 51, 39, 68, 73, and 82. HPV types 16 and 18 are the main causes of 70% cases of cervical cancer.4 In cases of cervical cancer in Indonesia the HPV types with the highest prevalence are HPV 16, 18, and 52. This virus infects the cervix through sexual contact.5 HPV virus infection can affect anyone, which ranges from women aged 20 years to women who are no longer in productive age. Some of the risk factors of HPV infection include early age of marriage and sexual intercourse at the age of less than 18, and women with high frequency of sexual activity and multiple partners, smokers, have a history of sexually transmitted diseases, parity (the number of births), and long-term use of oral contraceptives. These groups face a 5 time greater risk to be infected with the HPV virus (human papillomavirus).6,7 In developing countries, the number of children and poverty is a main factor that makes the incident of cervical cancer so high.6,7 High risk for women from the age of 20 years indicates that adolescence women or women who already experienced menstruation should start paying attention to her reproductive health. WHO recommends a comprehensive approach to cervical cancer prevention. The recommended set of actions includes interventions across the life course. It should be multidisciplinary, including components from community education, social mobilization, vaccination, screening, treatment and palliative care.8 Primary prevention begins with HPV vaccination of girls aged 9-13 years, before they become sexually active. Other recommended preventive interventions for boys and girls as appropriate are education about safe sexual practices, including delayed start of sexual activity; promotion and provision of condoms for those already engaged in sexual activity; warnings about tobacco use, which often starts during adolescence, and which is an important risk factor for cervical and other cancers; and male circumcision.8 WHO recommends vaccination for girls aged 9-13 years as this is the most cost-effective public health measure against cervical cancer.8 Immunization is estimated to be able to prevent 2.5 million cases of child deaths per year worldwide.9 In Indonesia, immunization is regulated by national policy through immunization program. According to Minister of Health Regulation No.42 of 2013 on immunization implementation, it is mentioned that immunization which applied in Indonesia consists of 2 types that is mandatory immunization and preference immunization. Mandatory immunization is an immunization given by the government for a person in accordance with his / her needs in order to protect the concerned and the surrounding community from certain infectious diseases, whereas the preference immunization is an immunization that can be provided to a person in accordance with his/her needs in order to protect the affected person from a particular infectious disease. Mandatory immunizations consist of routine immunization, supplemental immunization, and special immunization.10 Categories of preference immunization are Haemophilus influenza type b (Hib), Pneumococcal, Rotavirus, Influenza, Varicella, Measles Mumps Rubella, Typhoid Fever, Hepatitis A, Human Papilloma Virus (HPV), and Japanese Encephalitis.10 Until now HPV vaccine is included in the preference immunization category that may not be applied by all Indonesians to their children. Although several districts/ municipalities in Bali have used APBD for free HPV vaccination since a few years ago and so did Surabaya using APBD funds, unfortunately, it did not take place in all regions in Indonesia.11 Under these conditions, the current Indonesian government is planning to add the HPV vaccine into the national immunization program. The HPV immunization program through the Bulan Imunisasi Anak Sekolah (BIAS)/Immunization Month for School Age program begins with the provision of immunization at a pilot site that has a high prevalence rate of cervical cancer and is considered to have readiness in carrying out HPV immunization. The first place to begin the project is DKI Jakarta province starting in October 2016 and will be continued a year after in two districts Vol. 9, No.2, December 2018 Indonesia’s readiness to implement the HPV vaccine mandatory 109 in DIY provinces: Kulonprogo and Gunung Kidul regencies. DKI Jakarta and DI Yogyakarta provinces are the two cities that are considered the most ready for the pilot study, and if the project was successful then immunization program can be proposed to the National Parliament in order to become a national program.11 However, although the HPV vaccine will be incorporated into the national immunization program, the characteristics and culture of the population in Indonesia may not support the ongoing system. This study would review the possibility of Indonesia’s readiness to implement the HPV vaccine mandatory for school age and the factors that may affect it.