International HPV Awareness Day (IHAD) 2022 is on 4 March. Inaugurated by the International Papillomavirus Society (IPVS) in 2018, it provides an opportunity for organisations to focus attention on HPV, to improve public understanding and awareness, and to help prevent all the cancers caused by the virus.
This year’s HPV Awareness Day is branded #onelessworry. The idea is that, through education, vaccination, and screening, one big health concern can be ticked off the list.
HPV currently causes about 5% of all cancers worldwide, resulting in almost half a million deaths a year. In Europe, the proportion is lower – HPV causes around 2.5% of cancers – but that’s still some 87,000 cases annually. Cervical cancer is the best-known cancer caused by HPV but it also causes vaginal, vulval, anal, penile, head and neck cancers. Up to 30% of HPV cancer cases are in men.
Almost all of these cancers can be prevented through vaccination, ideally given to all boys and girls in adolescence. The vaccines are typically given to 11-13 years olds as this age-group is unlikely to have been exposed to HPV, which is a sexually transmitted infection.
A large-scale study of women in England found that women who were vaccinated at the age of 12-13 are almost 90% less likely to develop cervical cancer than women who have not been vaccinated at any age. The researchers concluded that the HPV immunisation programme has “successfully almost eliminated” cervical cancer in women born since 1 September 1995.
Cervical cancer screening programmes will remain essential for the foreseeable future. This is because vaccination only began in Europe in 2008 and there are no countries that have achieved 100% vaccination uptake. Screening can reduce cervical cancer mortality by up to about 90%, according to an analysis of its impact in Europe.
HPV vaccination programmes can be effective only if uptake is high enough to create ‘herd protection’. The sufficient level of uptake is normally defined as 80% of the target population. Most countries do not reach that threshold: in 2019, before Covid-19 disrupted programmes, only a quarter (24%) of girls (and a very small proportion of boys) in the WHO European region received the full course of vaccinations.
Some countries still do not have any HPV vaccination programmes. Others do but the programmes can sometimes be difficult to access. In many, ‘vaccine hesitancy’ by the public is a key barrier. A study of the determinants of HPV vaccine hesitancy in Europe identified 10 key factors, the top three being concerns about information, vaccine safety, and the trustworthiness of health authorities and vaccine manufacturers.
Europe’s Beating Cancer Plan, published by the European Commission (EC) in 2021, contains a very welcome and significant ‘flagship’ commitment to eliminating all the cancers caused by HPV through gender-neutral vaccination programmes. WHO Europe is currently consulting on a roadmap to accelerate the elimination of cervical cancer as a public health problem in its region and it is hoped that it follows the EC’s example on gender-neutral vaccination.
The European Cancer Organisation (ECO) and its HPV Action Network believe that action is now needed on four main fronts. First, all countries must commit to introducing gender-neutral vaccination as soon as possible and making it easily accessible, for example at schools.
Significantly, the UK’s vaccination advisory committee (JCVI) is currently consulting on whether HPV vaccination programmes should be one-dose rather than two-dose. The JCVI believes that a one-dose programme could help to improve uptake by reducing the ‘needle burden’ in adolescents and by being “more acceptable to the population”.
Secondly, it is essential that healthcare professionals (HCPs) – whether GPs, nurses, pharmacists, paediatricians or dentists – are trained and feel confident to discuss HPV vaccination with young people, parents and care givers. There is good evidence that HCPs, as a trusted source of information, can have a significant impact on vaccine uptake through one-to-one conversations with their patients.
Thirdly, there is a need for wider public health information campaigns using a range of media that communicates clearly and concisely with specific target audiences. The importance and potential of such campaigns is clear from Ireland where HPV vaccination uptake fell sharply in 2015 after vaccine safety concerns were promoted by social and mainstream media. In response, the government and a wide range of other organisations, including charities, produced new information materials which included quotes from vaccinated girls and their mothers and there was also a national radio and social media campaign supported by senior politicians and international experts.
This was enhanced in 2018 by the intervention of a 25 year-old Irish woman, Laura Brennan, who had been diagnosed with terminal cervical cancer.
She became a very powerful vaccine advocate, appearing on national television and with an extensive social media following. The outcome was a significant reversal of the fall in vaccine uptake.
And, fourthly, action is needed to improve cervical cancer screening programmes so that they are provided systematically to all eligible citizens throughout Europe. Programmes must utilise the latest technologies – HPV testing rather than cytology – and widen access by allowing self-sampling. Self-sampling can be as accurate as clinician sampling and helps to overcome a range of barriers including geographical isolation and cultural inhibitions. This approach is already being used successfully in the Netherlands where uptake has been high.
We largely know what to do to increase HPV vaccination uptake and screening and, ultimately, to eliminate all the cancers caused by HPV. They key question is: if not now, when?
Peter Baker, HPV Action Network Consultant, European Cancer Organisation