Friday, December 2, 2011

HPV Vaccine in Rwanda: Different Disease, Same Double Standard

On December 2, a Correspondence letter that I co-authored was published in The Lancet regarding debates about using and paying for the Human Papillomavirus vaccine in low-income countries: “HPV Vaccine in Rwanda: Different Disease, Same Double Standard.” The text of the letter is copied below, and you can click here to read it on The Lancet website. This Youtube Video was recorded to complement the Letter in the Lancet.

We respond to a group of public health researchers who wrote a piece in July that was critical of Rwanda's program and made several claims which have been echoed in other corners of the international community. We draw parallel between this resistance and that of many debates about providing antiretroviral therapy in Africa last decade.

We have detailed articles on strategy, delivery, and outcomes of Rwanda’s program underway, and will post on my blog once they are published.

Published in The Lancet on 2 Dec 2011

HPV vaccine in Rwanda: different disease, same double standard

Agnes Binagwaho, Claire M Wagner, Cameron T Nutt

In a Correspondence letter (July 23, p 315) [1] regarding Rwanda's human papillomavirus (HPV) vaccine roll-out, Nobila Ouedraogo and colleagues express “serious doubts that [a national HPV immunisation programme] is in the best interest of the people”. Are the 330 000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this programme not regarded as “the people”?

Ouedraogo and colleagues argue that cervical cancer ranks behind other vaccine-preventable diseases in resource-constrained settings. But for the diseases cited (measles and tetanus), Rwanda has 95% and 96·8% vaccination coverage rates, respectively [2]. Second, Ouedraogo and colleagues state that HPV vaccine effectiveness is unknown. Many studies say otherwise [3]. Third, the cost-effectiveness analysis cited does not account for vaccine market dynamics by presenting assumptions as immutable facts. The initial price of the pneumococcal vaccine provides a helpful lesson, and Merck announced a two-thirds reduction in the price of Gardasil for GAVI-eligible countries (to US$5 per dose) [4] more than a month before Ouedraogo and colleagues published their Correspondence letter. Finally, Ouedraogo and colleagues accuse Merck and Rwanda of conflicts of interest regarding connections to the GAVI Alliance. Actually, Merck representatives are non-voting GAVI observers, and GAVI's website clearly shows Rwanda's board membership terminating on Dec 31, 2011 [5]. GAVI will have no role in the HPV vaccine programme before 2014.

Ouedraogo and colleagues' argument reminds us of nihilistic claims against provision of antiretroviral therapy in Africa. Their argument constitutes but the latest backlash against progressive health policies by African countries. When the possibility of prevention exists, writing off women to die of cancer solely because of where they are born is a violation of human rights.

The opinions expressed in this Correspondence are entirely those of the authors and should not be attributed to Harvard Medical School or Dartmouth College. We declare that we have no conflicts of interest.


1) Ouedraogo N, Müller O, Jahn A, Gerhardus A. Human papillomavirus vaccination in Africa. Lancet 2011; 377: 315-316. PubMed
2) Ministry of Health of Rwanda. Demographic and health survey 2010: preliminary report. Kigali: National Institute of Statistics of Rwanda, 2011.
3) Schiffman M, Wacholder S. Success of HPV vaccination is now a matter of coverage. Lancet Oncol 201110.1016/S1470-2045(11)70324-2. published online Nov 9. PubMed
4) Merck . Merck offers further commitment to sustainable vaccine access. (accessed Aug 9, 2011).
5) GAVI Alliance. Board members. (accessed Aug 9, 2011).