Health and economic effects of introducing single-dose or two-dose human papillomavirus vaccination in India.

BACKGROUND: Cervical cancer is a major public health problem in India, where access to prevention programmes is low. The WHO-Strategic Advisory Group of Experts recently updated their recommendation for human papillomavirus (HPV) vaccination to include a single-dose option in addition to the two-dose option, which could make HPV vaccination programmes easier to implement and more affordable. METHODS: We combined projections from a type-specific HPV transmission model and a cancer progression model to assess the health and economic effects of HPV vaccination at national and state level in India. The models used national and state-specific Indian demographic, epidemiological and cost data, and single-dose vaccine efficacy and immunogenicity data from the International Agency for Research on Cancer India vaccine trial with 10-year follow-up. We compared single-dose and two-dose HPV vaccination for a range of plausible scenarios regarding single-dose vaccine protection, coverage and catch-up. We used a healthcare sector payer perspective with a time horizon of 100 years. RESULTS: Under the base-case scenario of lifelong protection of single-dose vaccination in 10-year-old girls with 90% coverage, the discounted incremental cost-effectiveness ratio (ICER) of nationwide vaccination relative to no vaccination was US$406 (₹INR30 000) per DALY (disability-adjusted life-years) averted. This lay below an opportunity-cost-based threshold of 30% Indian gross domestic product per capita in each Indian state (state-specific ICER range: US$67-US$593 per DALY averted). The ICER of two-dose vaccination versus no vaccination vaccination was US$1404 (₹INR104 000). The ICER of two-dose vaccination versus single-dose vaccination, assuming lower initial efficacy and waning of single-dose vaccination, was at least US$2282 (₹INR169 000) per DALY averted. CONCLUSIONS: Nationwide introduction of single-dose HPV vaccination at age 10 in India is highly likely to be cost-effective whereas extending the number of doses from one to two would have a less favourable profile.

Weight stigma among adolescents in three low- and middle-income countries.

Background: Overweight (OW) and obesity affect millions of adolescents worldwide. Evidence from high-income countries indicates widespread weight stigma that adversely affects young people's mental and physical health. However, evidence relating to low- and middle-income countries (LMICs) is sparse. We aimed to generate insight into weight stigma prevalence and experience among adolescents in three LMICs. Methods: We identified adolescents aged 15-19 from Brazil, South Africa, and Indonesia from families within market research databases. We adopted a mixed-methods design. The sample included equal numbers by country, sex, and age, and included urban and rural dwellers. Self-reported weight was recorded but was not a selection criterion. Consent (age >18) and assent/parental consent (

Evidence-based impact projections of single-dose human papillomavirus vaccination in India: a modelling study.

BACKGROUND: Despite the high burden of cervical cancer, access to preventive measures remains low in India. A single-dose immunisation schedule could facilitate the scale-up of human papillomavirus (HPV) vaccination, contributing to global elimination of cervical cancer. We projected the effect of single-dose quadrivalent HPV vaccination in India in comparison with no vaccination or to a two-dose schedule. METHODS: In this modelling study, we adapted an HPV transmission model (EpiMetHeos) to Indian data on sexual behaviour (from the Demographic and Health Survey and the Indian National AIDS Control Organisation), HPV prevalence data (from two local surveys, from the states of Tamil Nadu and West Bengal), and cervical cancer incidence data (from Cancer Incidence in Five Continents for the period 2008-12 [volume XI], and the Indian National Centre for Disease Informatics and Research for the period 2012-16). Using the model, we projected the nationwide and state-specific effect of HPV vaccination on HPV prevalence and cervical cancer incidence, and lifetime risk of cervical cancer, for 100 years after the introduction of vaccination or in the first 50 vaccinated birth cohorts. Projections were derived under a two-dose vaccination scenario assuming life-long protection and under a single-dose vaccination scenario with protection duration assumptions derived from International Agency for Research on Cancer (IARC) India vaccine trial data, in combination with different vaccination coverages and catch-up vaccination age ranges. We used two thresholds to define cervical cancer elimination: an age-standardised incidence rate of less than 4 cases per 100 000 woman-years, and standardised lifetime risk of less than 250 cases per 100 000 women born. FINDINGS: Assuming vaccination in girls aged 10 years, with 90% coverage, and life-long protection by two-dose or single-dose schedule, HPV vaccination could reduce the prevalence of HPV16 and HPV18 infection by 97% (80% UI 96-99) in 50 years, and the lifetime risk of cervical cancer by 71-78% from 1067 cases per 100 000 women born under a no vaccination scenario to 311 (80% UI 284-339) cases per 100 000 women born in the short term and 233 (219-252) cases per 100 000 women born in the long term in vaccinated cohorts. Under this scenario, we projected that the age-standardised incidence rate threshold for elimination could be met across India (range across Indian states: 1·6 cases [80% UI 1·5-1·7] to 4·0 cases [3·8-4·4] per 100 000 woman-years), while the complementary threshold based on standardised lifetime risk was attainable in 17 (68%) of 25 states, but not nationwide (range across Indian states: 207 cases [80% UI 194-223] to 477 cases [447-514] per 100 000 women born). Under the considered assumptions of waning vaccine protection, single-dose vaccination was projected to have a 21-100% higher per-dose efficiency than two-dose vaccination. Single-dose vaccination with catch-up for girls and women aged 11-20 years was more impactful than two-dose vaccination without catch-up, with reduction of 39-65% versus 38% in lifetime risk of cervical cancer across the ten catch-up birth cohorts and the first ten routine vaccination birth cohorts. INTERPRETATION: Our evidence-based projections suggest that scaling up cervical cancer prevention through single-dose HPV vaccination could substantially reduce cervical cancer burden in India. FUNDING: The Bill & Melinda Gates Foundation.

'Know-Can' gap: gap between knowledge and skills related to childhood diarrhoea and pneumonia among frontline workers in rural Uttar Pradesh, India.

OBJECTIVES: In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them. METHODS: We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills. RESULTS: FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia. CONCLUSIONS: FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.

OBJECTIFS: En Inde, les travailleurs de première ligne (TPL) - activistes de la santé sociale accrédités par le public (ASSAP) et prestataires médicaux ruraux privés (PMRP) - sont importants pour la détection et le traitement précoces de la diarrhée et de la pneumonie infantiles. Cette étude transversale vise à mesurer les connaissances et les compétences, et l'écart entre les deux (écart ''savoir-pouvoir''), en ce qui concerne l'évaluation de la diarrhée infantile avec déshydratation et la pneumonie chez les TPL et à explorer les facteurs qui leur sont associés. MÉTHODES: Nous avons mené une enquête sur 473 ASSAP et 447 PMRP dans six districts de l'Uttar Pradesh. Nous avons évalué les connaissances et les compétences à l'aide d'entretiens de face à face et de vignettes vidéo, respectivement, sur les signes clés des deux conditions. L'écart «savoir-pouvoir¼ correspond à des compétences absentes parmi les TPL ayant des connaissances correctes. Nous avons utilisé la régression logistique pour identifier les corrélats des connaissances et des compétences. RÉSULTATS: Les connaissances correctes des TPL variaient de 23% à 48% pour les signes de déshydratation, 27% à 37% pour les signes de pneumonie. Leurs compétences variaient de 3% à 42% pour la déshydratation et de 3% à 18% pour la pneumonie. Il y avait un écart important dans le «savoir-pouvoir¼ pour tous les signes, à l'exception des «yeux enfoncés¼. La formation et le soutien à la supervision étaient associés à de meilleures connaissances et compétences pour la diarrhée avec déshydratation, mais seulement à de meilleures connaissances pour la pneumonie. CONCLUSIONS: Les TPL sont cruciaux pour le système de santé indien, et des services de TPL de haute qualité sont nécessaires pour continuer à lutter contre les décès d'enfants de moins de cinq ans. L'écart entre les connaissances et les compétences des TPL mérite une attention immédiate. En particulier, nos résultats suggèrent que les formations axées sur les connaissances sont insuffisantes pour que les TPL convertissent les connaissances en compétences d'évaluation appropriées.