Should the ideal be the enemy of the good?

Abstract

In Mattheij et al.1, the authors claim that HPV vaccine is not warranted in India due to supposedly low rates of cervical cancer and poor data. While we agree that the quality of registry data on cancer is far from ideal, that is true for many global health problems (including diabetes, which has no disease registry at all). Fortunately, lack of registries has not prevented governments from tackling pressing health problems. We believe the authors have misinterpreted the Indian registry data. For example, they do not acknowledge that the decline in rates was an urban phenomenon, and that it was not reflected in the one rural registry (Barshi)2. To understand disease burden PATH relied upon the WHO's GLOBOCAN database3, which estimates that India has the highest absolute number of cervical cancer cases in the world. The study sites in Andhra Pradesh and Gujarat were selected in consultation with a national project advisory committee and were based on multiple criteria, not only regional disease incidence; these included immunization coverage, experience with new vaccine introduction, and commitment to adolescent health and cervical cancer prevention4. The authors cite the WHO document on new vaccine introduction5 as requiring that disease burden data and national surveillance be in place before any new vaccine can be used. While these guidelines set out a worthy ideal to strive for, they did not hold up the introduction of polio or measles vaccines, neither of which has the kind of comprehensive surveillance system the authors call for. Finally, the study was not an effort to introduce or rollout HPV vaccine either nationally or in the two Indian states. Its purpose was to generate evidence on feasible, acceptable, and affordable strategies for delivering the vaccines, should the Indian government decide one day that such a service belongs in their cervical cancer control program. Should that day come, the data generated by the HPV vaccine study will prove useful to immunization planners.