Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India–2018–2019
Open accessAbstract
BACKGROUND: Cervical cancer is a leading cause of cancer-associated mortality among women in India, with 96,922 new cases and 60,078 deaths each year, almost one-fifth of the global burden. In 2018, Sikkim state in India introduced human papillomavirus (HPV) vaccine for 9-13-year-old girls, primarily through school-based vaccination, targeting approximately 25,000 girls. We documented the program's decision-making and implementation processes. METHODS: We conducted a post-introduction evaluation in 2019, concurrent with the second dose campaign, by interviewing key stakeholders (state, district, and local level), reviewing planning documents, and observing cold chain sites in two purposefully-sampled community areas in each of the four districts of Sikkim. Using standard questionnaires, we interviewed health and education officials, school personnel, health workers, community leaders, and age-eligible girls on program decision-making, planning, training, vaccine delivery, logistics, and communication. RESULTS: We conducted 279 interviews and 29 observations in eight community areas across four districts of Sikkim. Based on reported administrative data, Sikkim achieved >95% HPV vaccination coverage among targeted girls for both doses via two campaigns; no severe adverse events were reported. HPV vaccination was well accepted by all stakeholders; minimal refusal was reported. Factors identified for successful vaccine introduction included strong political commitment, statewide mandatory school enrollment, collaboration between health and education departments at all levels, and robust social mobilization strategies. CONCLUSIONS: Sikkim successfully introduced the HPV vaccine to multiple-age cohorts of girls via school-based vaccination, demonstrating a model that could be replicated in other regions in India or similar low- and middle-income country settings.
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Few studies have specifically examined vaccine acceptability in adult women ages 18-26, who are vaccine-eligible but too old to be reached through traditional, school-based HPV vaccine campaigns.
“Few studies have specifically examined vaccine acceptability in adult women ages 18–26, who are vaccine-eligible but too old to be reached through traditional, school-based HPV vaccine campaigns [20].”
From Acceptability of HPV vaccination for cervical cancer prevention amongst emerging adult women in rural Mysore, India: a mixed-methods study (2024) · cites this paper as [20]
The Background (page unavailable) says Sikkim’s school-based HPV campaign targeted girls aged 9–13, supporting the point that women aged 18–26 were outside that campaign’s target group. The paper does not establish that few studies examine vaccine acceptability in women aged 18–26, or address their vaccine eligibility. (LLM, conf=0.82)
Experimental — accuracy not yet measuredOut-of-school girls often come from marginalized or tribal populations and remain underrepresented in HPV vaccination, echoing equity challenges across LMICs.
“Out-of-school girls often come from marginalized or tribal populations, which remain underrepresented, echoing equity challenges seen across LMICs56.”
From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [56]
The Results (Vaccine delivery and coverage; page unavailable) report that tracking out-of-school girls at sub-district level was lacking, supporting a concern about reaching them. The paper does not say that these girls often come from marginalized or tribal populations, establish that they were underrepresented in vaccination, or document the claimed equity pattern across LMICs. (LLM, conf=0.86)
Experimental — accuracy not yet measuredState-level HPV vaccination programmes in Punjab and Sikkim provide practical models for effective implementation among school-going girls, supported by mandatory school enrolment, integration of health and education departments, comprehensive training, and strong community engagement.
“In India, the state-level HPV vaccination programmes, particularly from Punjab and Sikkim, provide practical models for effective implementation, among the school-going girls55, supported by mandatory school enrolment, integration of health and education departments, comprehensive training, and strong community engagement56.”
From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [56]
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Dhanasekaran, K., Tamang, T., Pradhan, S., Lhamu, R., & Hariprasad, R. (2022) · ecancermedicalscience · doi:10.3332/ecancer.2022.1492 · Cited by 11 · see citing works
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“Few studies have specifically examined vaccine acceptability in adult women ages 18–26, who are vaccine-eligible but too old to be reached through traditional, school-based HPV vaccine campaigns [20].”
BackgroundBarriers to HPV vaccination among adolescent girls in India: A scoping review
Josten, K., Rose Dhar, R., Reshmi, B., Natti Krishna, V., & Vennila, J. (2026) · The Indian Journal of Medical Research · doi:10.25259/ijmr_1834_2025 · Cited by 6 · see citing works
“However, physicians in rural and semi-urban India remain under-utilized, a challenge echoed in other LMICs 49,53 .”
- Authors
- Ahmed, D., VanderEnde, K., Harvey, P., Bhatnagar, P., Kaur, N., Roy, S., Singh, N., Denzongpa, P., Haldar, P., & Loharikar, A.
- Affiliations
- World Health Organization (CH)
- Government of Sikkim (IN)
- Government of India (IN)
- Centers for Disease Control and Prevention (US)
- Corresponding author
- Ahmed, Danish
- Loharikar, Anagha
- Venue
- Vaccine
- Publisher
- Elsevier BV
- Published
- 2022-03
- Volume
- 40
- Pages
- A17-A25
- ISSN
- 0264-410X (ISSN-L)
- PMC
- PMC10874777
- OpenAlex
- W3193313864
- Cited by
- 58
- References
- 1
- Citations by year
- 2026: 14 · 2025: 18 · 2024: 16 · 2023: 6 · 2022: 4
- FWCI
- 4.68
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Vaccine (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion, cc-by-nc-nd)
- Funders
- Bill and Melinda Gates Foundation
- World Health Organization
- UNICEF
- Indian Council of Medical Research
- Ministry of Health and Family Welfare
- National Institutes of Health (CC999999)
- Topics
- Health Sciences › Medicine › Epidemiology › Cervical Cancer and HPV Research
- Social Sciences › Health › Vaccine Coverage and Hesitancy
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
- Keywords
- HPV vaccine, school-based vaccination, cervical cancer prevention, adolescent girls, vaccine rollout, cold chain, vaccine logistics, social mobilization, political commitment, health and education collaboration, vaccine acceptance, Sikkim
- MeSH terms
- Adolescent, Uterine Cervical Neoplasms, Child, Female, Humans, India, Sikkim, Vaccination, Immunization Programs, Papillomaviridae, Papillomavirus Infections, Alphapapillomavirus, Papillomavirus Vaccines
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