The Human Papillomavirus (HPV) vaccine or HPV vaccination significantly reduces a woman’s risk of developing cervical cancer, one of the most common cancers for women in Singapore.

About HPV and its link to Cervical Cancer

What is HPV?

HPV stands for Human Papillomavirus, a common virus that can infect many parts of the body in both males and females.

There are more than 100 different types of HPV, grouped into (i) high-risk types (may cause cancer) and (ii) low-risk types (non-cancer causing).

About 40 HPV types can infect the genital area.

• High-risk types of HPV are associated with cervical, vaginal and vulvar cancer in women, and less commonly, anal or penile cancer in men. The most common high-risk types are HPB subtypes 16 and 18.
• Low-risk types of HPV may cause no symptoms or lead to genital warts. HPV types 6 and 11 are responsible for about 90% of genital warts.

Other HPV types may infect the skin of the fingers, hands, mouth, throat and face.

How is HPV related to Cervical Cancer?

Certain types of HPV can infect the cervix (the lower part of the womb), vagina and vulva. In most cases, the body's immune system can fight off the infection and clear the virus.

However, the HPV infection can persist sometimes and cause abnormal changes to the cells. Some of these abnormal cells may develop into cervical cancer. This usually takes years to develop but is one of the most significant impacts of being infected with HPV.

Specifically, HPV subtypes 16 and 18 account for about 70 per cent of cervical cancer cases.

What are the Risk Factors for Cervical Cancer?

Risk factors for the development of cervical cancer include the following:

• HPV subtypes - Persistent infection with high-risk types.
• Immune status - People who are immunocompromised, such as those living with Human Immunodeficiency Virus (HIV), are more likely to have persistent HPV infections and a more rapid progression to pre-cancer and cancer.
• Co-infection with other sexually transmitted agents, such as those that cause herpes, simplex, chlamydia and gonorrhoea.
• Multiple sexual partners.
• The onset of sexual intercourse at an early age.
• Tobacco smoking.

How is HPV transmitted?

HPV infection is very common in men and women.

It can be transmitted through skin-to-skin contact such as sexual activity (including oral sex), by sharing contaminated sex toys and very rarely, during delivery from an infected mother to her baby. HPV cannot be spread by sitting on toilet seats or touching common surfaces.

What are the signs and symptoms of an HPV Infection?

Most HPV infections do not have any signs or symptoms. Some HPV infections may cause genital warts, but they can also cause oral HPV infections such as warts in the mouth or throat or oropharyngeal cancers.

High-risk HPV infection of the cervix does not cause any signs or symptoms. The abnormality on the cervix is detectable by cervical screening (Pap test) and by HPV DNA (genetic material) tests.

Symptoms of cervical cancer include abnormal vaginal bleeding such as bleeding after menstrual periods or after sex. There may also be changes in the amount, colour or smell of the vaginal discharge.

Can HPV be treated?

No treatment is required for asymptomatic HPV infections. Most HPV infections (90 percent of the cases) are cleared by the body without the need for treatment.

Treatment is directed at HPV-associated conditions such as pre-cancerous lesions, cancer or genital warts.

Although the HPV virus cannot be treated, regular cervical cancer screening tests can either help to detect changes in the cervical cells caused by HPV infection (Pap test) or to identify high-risk HPV cancer-causing types.

How can I best protect myself against an HPV infection and decrease my risk of getting Cervical Cancer?

All females aged 9 - 26 are strongly recommended to get the HPV vaccination to prevent cervical cancer.

Even if you have received the HPV vaccination, it is important that you still go for regular cervical cancer screening as the HPV vaccination only protects against 70 to 90 per cent of high-risk HPV types.

Go for regular cervical cancer screening as it is the most effective way to detect high-risk HPV types that can cause cervical cancer. All women aged 25 and above who have ever had sex should have either a Pap test once every three years (for women 25 to 29 years old) or an HPV (or HPV DNA) test once every five years (for women 30 years and above).

Where can I go for a Cervical Cancer screening?

Females can get screened at their family doctor's clinic, selected Screen for Life (SFL) CHAS GPs or at a polyclinic. Do call your clinic and check if they offer cervical cancer screening services.

You can also call 1800 223 1313 for more information on cervical cancer screening and cervical cancer.

About the HPV vaccine

What is the HPV vaccination? Who is nationally recommended to take the HPV vaccination?

The HPV vaccination can help to protect against specific types of HPV infection that may lead to cervical cancer.

HPV vaccination is recommended under the National Childhood Immunisation Schedule (NCIS) and National Adult Immunisation Schedule (NAIS) for all females aged 9 to 26 because of the cost-effectiveness and significant impact of the vaccine in the prevention of cervical cancer.

What are the available HPV vaccines in Singapore?

The vaccines approved for use in Singapore are Cervarix and Gardasil 9. Details of the vaccinations are shown in the table below.

Cervarix provides protection against HPV types 16 and 18, which account for 70% of all cervical cancers, and have been shown to be both clinically- and cost-effective in the local setting for females. Gardasil 9 provides protection against an additional 20% of cancer-causing HPV types. It is clinically effective for both females and males. Individual males who feel that they are at high-risk of getting HPV may decide to get vaccinated.

The vaccines are most effective if given before first sexual exposure, in those who have not yet been exposed to the HPV types covered by the vaccine. Those who are sexually active may still benefit from the vaccine, as they may not be exposed to the HPV types covered by the vaccine.

If you are above 26 years old and wish to receive the HPV vaccination, you are advised to speak to your doctor to find out if it may benefit you.

Should my child be vaccinated?

The HPV2 vaccination is nationally recommended in Singapore for females aged 9 to 26 who wish to prevent HPV infection and the risk of developing cervical cancer. If your daughter is above 26 years old or your son who is aged 9 and above and wishes to receive the HPV vaccination, do speak to the doctor to find out how it may benefit your child.

The HPV vaccine is most effective in protecting against the selected HPV types if given prior to exposure to HPV through sexual activity.

Is HPV vaccination for males included in the National Childhood Immunisation Schedule (NCIS) and National Adult Immunisation Schedule (NAIS)?

Based on the recommendations by the Expert Committee on Immunisation (ECI), HPV vaccination is recommended only for females aged 9 to 26 years old under the NCIS/NAIS. It is advisable to speak to a doctor to find out more about the benefits and limitations of vaccinating males against HPV.

In what circumstances should HPV vaccine NOT be taken?

The HPV vaccine may not be suitable for you if you have had severe allergic reaction, after a previous dose of the vaccine, or to any of the vaccine components, including yeast.

If you have a moderate or severe acute infectious illness, please wait until you have recovered from the illness.

Consult your doctor to find out if a vaccination is suitable for you.

Is HPV vaccination compulsory?

No, the HPV vaccination is not compulsory in Singapore, but it is highly recommended as a way to protect women against cervical cancer.

HPV vaccination has also been included in the National Childhood Immunisation Schedule (NCIS) and National Adult Immunisation Schedule (NAIS) for females aged 9 to 26. Individual males who feel that they are at high risk of getting HPV may decide to get vaccinated.

How long does the protection from vaccination last?

Current evidence shows sustained protection against vaccine-targeted HPV-related diseases in long-term follow-up studies for the HPV vaccines. There is currently no recommendation for additional doses or booster shots.

Are the vaccines safe and effective?

Clinical trials and post-marketing surveillance have shown that HPV vaccines are safe and effective in preventing infections with selected HPV types.

The vaccines do not contain any live viruses or infectious material. This means you cannot become infected with HPV from the vaccines.

Are there any HPV vaccine side effects?

Pain, redness and swelling at the site of injection and headache and fever are some common side effects. They are expected to go away on their own or anti-fever medicines or painkillers may help with the pain, headache and fever. The symptoms of a drug allergy include one or more of the following:

• Swollen face/eyes/lips/tongue
• Difficulty in breathing
• Itchy skin rashes over your whole body

If you experience any of these symptoms, you should inform your healthcare professional immediately.

I am pregnant/breastfeeding. Should I be vaccinated?

HPV vaccines are not recommended for pregnant women.

If a woman is found to be pregnant during the HPV vaccination schedule, it is recommended that the remaining dose(s) of the series should be postponed until after delivery. If the HPV vaccine has been administered during pregnancy, please consult your doctor for further advice.

Available data is not sufficient to assess the effects of HPV vaccination on the breastfed infant or on milk production/excretion. You may wish to discuss this with your doctor.

I was diagnosed with a cervical abnormality that my doctor said may lead to cervical cancer (e.g. "Cervical Intraepithelial Neoplasia" or CIN). Should I get the HPV vaccine?

It is best to consult your doctor who will advise on the suitability of the HPV vaccine for you, and also check how often you should be going for Pap or HPV tests.

About subsidies, MediSave use and appointment booking

Which vaccine type is subsidised and how was it selected? What is the cost of the subsidised HPV vaccine? Can MediSave be used?

Female Singapore Citizens (SCs) and Permanent Residents (PRs) who fall within the recommended age group for HPV vaccination (i.e. from 18th birthday to before 27th birthday) will be able to enjoy subsidies and use MediSave for Cervarix. The HPV vaccine eligible for a subsidy and MediSave use was selected while taking into consideration factors such as the local disease burden, vaccine safety, clinical efficacy and cost-effectiveness of the vaccines.

Please refer to the table below on the subsidies available, MediSave use and additional discounts provided by Temasek Foundation.

Eligible SCs will be able to enjoy subsidies at CHAS GP clinics and polyclinics, while eligible PRs will be able to enjoy subsidies at polyclinics only.

At CHAS GP clinics, eligible SCs can expect to pay no more than $45 per dose after subsidies for HPV vaccination. CHAS Orange and Blue cardholders should strongly consider receiving the HPV vaccination at CHAS GP clinics participating in Temasek Foundation's HPV Immunisation Programme, where the remaining patient's co-payment will be fully funded ($0), subject to meeting the nationally recommended criteria for HPV vaccination.

For all nationally recommended vaccinations, including HPV vaccination, MediSave can be used to offset the remaining co-payment, if any. Individuals are advised to contact their preferred healthcare provider directly for their eligibility for subsidies, the costs of vaccinations, and the use of MediSave.

Where can I get the HPV vaccine? Where can I book an appointment?

You can receive HPV vaccination at a CHAS GP clinic, polyclinic or any medical clinic which keep stock of the HPV vaccine.

Under the national school-based health programme, HPB offers fully-subsidised HPV vaccinations to eligible Secondary 1 and 2 female students attending MOE-registered secondary schools, Special Education (SPED) schools, privately-funded schools and full-time madrasahs. Female students in other Secondary School levels can write to Contact_YPS@hpb.gov.sg to request for HPV vaccinations at the Student Health Centre at HPB. It is advisable to speak to your doctor to find out more about HPV vaccination.