This document outlines a strategy to eliminate cervical cancer as a global public health problem through increased HPV vaccination coverage, cervical cancer screening and treatment of pre-cancer lesions, and treatment of invasive cancer. It discusses challenges such as limited HPV vaccine supply and affordability, and the need for simple, scalable screening technologies. Key outputs include accelerating HPV vaccine introduction and delivery, increasing screening coverage through national scale-up of affordable screen-and-treat approaches, and expanding access to diagnosis, treatment and palliative care for invasive cancer. Timelines and milestones are proposed to guide progress toward global elimination of cervical cancer by 2030.

1. 1 |
Elimination of cervical cancer as
a global public health problem
12 December 2018

2. 2 |
Cervical cancer – an avoidable NCD with gross inequities
(Globocan 2018)

3. 3 |
Life course approach to cervical cancer prevention and control
Girls 9-14 years
• HPV vaccination
Girls and boys, as appropriate
•Health information and warnings about
tobacco use
•Sexuality education tailored to age & culture
•Condom promotion/provision for those
engaged in sexual activity
•Male circumcision
Women > 30 years of age
“Screen and treat” – single visit approach
• Point-of-care rapid HPV testing for high risk
HPV types
• Followed by immediate treatment
• On site treatment
All women as needed
Treatment of invasive cancer at any age and
palliative care
•Ablative surgery
•Radiotherapy
•Chemotherapy
•Palliative Care
Primary Prevention Secondary Prevention Tertiary Prevention
Global guidelines  Global Indicators  Global Cost-effectiveness recommendations 

4. 4 |
May 2018: WHO Director General’s Call to Action to eliminate
cervical cancer as a public health problem

5. 5 |
Definitions on Control, Elimination and Eradication
The Dahlem Workshop in March 1997 discussed the hierarchy of
possible public health intervention with infectious diseases
(Dowdle 1998).
Dowdle WR. The principles of disease elimination and eradication.
Bull World Health Organ 1998;76 Suppl 2:23-5.
http://www.who.int/bulletin/volumes/84/2/editorial10206html
/en/

6. 6 |
Elimination
 of disease: reduction to zero of the incidence of a specific
disease in a defined geographical area as a result of deliberated
efforts, continued intervention measures required (Example:
Measles in the Americas).
 of infection: reduction to zero of the incidence of infection
caused by a specific agent in a defined geographical area as a
result of deliberated efforts, continued intervention measures
required (Example: Chagas).
 as a public health problem: this term should only be used if
clear target definitions are commonly agreed - continued
intervention measures required (Example: Target definitions for Leprosy).

7. 7 |
Key questions that must be addressed
 What will the cervical cancer threshold to achieve
elimination as a public health problem be (4 or
10/100000)?
 What combination of screening and vaccination strategies
can lead to elimination (for different thresholds)?
 When could elimination be reached, for different
strategies and countries?
 What is the most efficient/cost-effective strategy to reach
elimination?

8. 8 |
Overview Model Comparison Work
Step 1
Use 4 models fit to few
countries
Use simplified screening
vaccination scenarios
Examine:
Consistency in model
predictions
Understand potential for
elimination
Step 2
Use 4 models fit to wider
range of countries
Use realistic screening and
vaccination scenarios
Examine:
Strategies that lead to
elimination
Time to elimination
Added benefit of strategies
Intermediate goals on the
pathway to elimination
Step 3
Use small set of
screening & Vaccination
scenarios
Global predictions:
Elimination & Pathway to
elimination
Selected countries:
Costing & Cost-
effectiveness of
elimination

9. 9 |
OVERALL CONCEPTUAL FRAMEWORK
2030 2120
2020
Elimination
Cervical
cancer
cases/100,000
Current vaccination and screening
Intensive vaccination
Very intensive screening and vaccination
2060

10. 10 |
Example of definition and 2030 targets
The 2030 targets and elimination threshold are subject to revision depending on the outcomes of the
modeling and the WHO approval process
Vision: A world without cervical cancer
Goal: below 4 cases of cervical cancer per 100,000 woman-years
90%
of girls fully vaccinated
with HPV vaccine by 15
years of age
70%
of women screened with
an HPV test at 35 and 45
years of age and all
managed appropriately
30%
reduction in mortality
from cervical cancer
2030
TARGETS

11. 11 |
Reported HPV vaccine coverage
Various ages, 2014-2016
Source: Brotherton & Bloem, 2017
%
AFR AMR EUR SEAR WPR
0
10
20
30
40
50
60
70
80
90
100
Bot
Mau
Rwa
Sey
SA
Ug
Arg
Bar
Bel
Bra
Can
Chi
Col
Ecu
Hon
Mex
Pan
Par
Per
Sur
USA
Uru
Aut
Bel
Den
Fin
Fra
Ger
Hun
Ice
Ire
Ita
Lat
Mac
Mal
Net
Nor
Por
Slo
Spa
Swe
Swi
UK
Bhu
Aus
Bru
Coo
Fij
Mal
Nzl
Pal

12. Cervical cancer screening:
proportion of women between 30 – 49 screened for cervical cancer at least once
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
Benin (2015)
Pakistan (2013)
Timor-Leste (2014)
Egypt (2017)
Sudan (2016)
Ethiopia (2015)
Myanmar (2014)
Burkina Faso (2013)
Iraq (2015)
Uganda (2014)
Senegal (2015)
Azerbaijan (2017)
Tajikistan (2016)
Morocco (2017)
Uzbekistan (2014)
Solomon Islands (2015)
Algeria (2016)
Kenya (2015)
Malawi (2017)
Kuwait (2014)
Lebanon (2017)
Zambia (2017)
Swaziland (2014)
Georgia (2016)
Tuvalu (2015)
Jordan (2007)
Viet Nam (2015)
Armenia (2016)
Kyrgyzstan (2013)
Turkey (2017)
Trinidad and Tobago (2012)
Mongolia (2013)
Thailand (2007)
Nauru (2016)
Turkmenistan (2014)
Bhutan (2014)
Dominica (2008)
Brunei Darussalam (2015)
Republic of Moldova (2014)
Anguilla (2016)
Tokelau (2014)
Bermuda (2014)
Saint Kitts and Nevis (2008)
Saint Lucia (2012)
Belarus (2016)
Bahamas (2013)
% of women aged 30-49
Source: WHO STEPS

13. 13 |
Estimated age-standardized mortality rates

14. 14 |
Strategy towards the elimination of cervical cancer as a
global public health problem: key outputs
Guiding principles: life course and public health approach, social justice and
equity, integrated people-centered health services
Increased
coverage of HPV
vaccination
Increased
coverage of
screening &
treatment of pre-
cancer lesions
Increased
coverage of
diagnosis &
treatment for
invasive cancer
and palliative care
Accelerators
1
2
3
KEY OUTPUTS

15. 15 |
KEY OUTPUT 1: Increased Coverage of HPV Vaccination
WHO recommendations
• 2 doses to girls 9-14 , minimum 6 months apart
• Introduce to multi-age cohort, 9-14 yrs ( 15-18 if feasible) in first year
• 3 doses for: girls 15 y and older; and for immuno-compromised individuals
Challenges
• Limited supply of the HPV vaccine
• Vaccine not affordable and high delivery cost
• After introduction vaccination coverage low in many countries due to factors like choice of
delivery strategy, insufficient communication and hesitancy related factors
Accelerators
Sufficient, affordable supply of HPV vaccine
• Concerted effort between partners and private sector to overcome vaccine supply constraints
Introduction of HPV vaccine
• Coordinated initiative to identify and leverage sustainable resources from countries and from
donors/financing agencies to introduce vaccines in more countries
Increased quality and coverage of service delivery
• Develop and implement high quality, multi-sectoral introduction plans
• Use or develop sustainable and equitable delivery platforms
• Develop high quality and sustained communication and mobilization approaches

16. 16 |
KEY OUTPUT 2: Increased coverage of screening & treatment
of pre-cancer lesions
WHO recommendations
• Women aged 30-49 be screeened at least once in their lifetime for cervical cancer, and
rescreened every 5 years.
• HIV positive women should be screened every 3 years
• Immediate treatment where possible
Challenges
• Expensive and complex screen and treat technologies complicate scaling-up
• New or optimized service delivery methods required for LMIC contexts
Accelerators
• Sufficient, affordable supply of screen and treat technologies & products
• Prompt certification of new products
• Price reductions
• National scale-up of screen & treat
• Simple algorithms need to be introduced for different settings
• Increased quality and coverage of service delivery
• Countries detailed implementation plans to introduce and scale-up products and delivery
models
• Strengthen patient retention and linkage to treatment

17. 17 |
KEY OUTPUT 3: Increased coverage of diagnosis, treatment
and palliative care for invasive cancer
WHO recommendations
• Women diagnosed with early invasive cervical cancer can be cured with effective quality treatment
• Cervical cancer diagnosis must be confirmed by histopathological examination
• Cancer surgery and radiotherapy are major primary treatment modalities
• Palliative care is an essential element of cervical cancer control
• Reducing delays in access to diagnosis and treatment can improve survival of women with cervical cancer
Challenges
• About 80% of cervical cancer in LMICs is detected in late stages
• Quality pathology and treatment is often not accessible
• Treatment is often associated with catastrophic health expenditure
• Access to palliative care is almost non-existent
Accelerators
• Access to quality pathology, cancer surgery and radiotherapy
• Reducing cost of equipment and cancer medicines
• Sufficiently trained health workforce
• Implemented protocols and care pathways
• Timely diagnosis, staging, treatment, and referral of patients
• Increased access to palliative care
• Ensured financial access to treatment
• Integrated into UHC or other social support programs

18. 18 |
Timeline
NOW 2019

19. 19 |
Consign cervical cancer to the history books

20. 20 |
Why are these events important?
 Building political support for elimination
– WCC 2018; IPVS 2018; FIGO 2018 – signals support of the expert communities
– Civil society support critical to engage Member States
– Civil society support critical to motivating WHO leadership to be aspirational
– Head of State champions critical to raise the profile on the global stage
– Head of State commitments foster cross party and pan-government support
 How can you help?
– Share the developments with your governments and convey the sense of a
growing coalition of civil society in support of the elimination agenda – across
health fields; geographies from community to global organisations
– Build your own regional or national coalitions to advocate collectively in 2019
– Press for similar Head of State support
– Press for a national commitment to elimination of cervical cancer

21. 21 |
Continuing country work
 Missions of the Joint Global Programme
– Uzbekistan: 23-25 October 2018; Mongolia: 13-15 November 2018
– Tanzania: 3-7 December 2018; Morocco: 17-19 December 2018
– Bolivia; Ghana; Guinea; Kenya; Madagascar; Malawi; Myanmar; Nigeria; Senegal;
Sierra Leone; Zambia; Zimbabwe : early 2019
 Developing cervical cancer strategies in JGP countries
– Costing of those plans advanced in 10 AFRO countries
– Investment case in development, critical for the engagement on UHC in 2019
 Growing support for scale up of screening and treatment of pre-cancers
– PEPFAR supporting 8 AFRO countries; new call for country proposals eg
Mozambique
– Coming soon in Q1 2019 – announcement of Unitaid awards