Barriers to the HPV vaccine

In an inspiring session at COGI 2018, four experts discussed the human papillomavirus (HPV) vaccine; its safety, efficacy and some of the key barriers to a successful vaccination programme.

Since the introduction of the HPV vaccine around 10 years ago, the UK has developed a largely successful vaccination programme. Dr. Elmar Joura shared data demonstrating that coverage rates are almost 90% and prevalence of HPV16 and HPV18 have in turn reduced by 75% and 86% respectively. However, in other countries coverage rates are much lower. Dr. Joura explained that Japan has a rate of just 0.6%. A 2016 study showed Italy, Netherlands, Norway and Spain also have coverage rates under 60% while France has a rate of just 20%.[1]

The efficacy of the vaccine has been established, Prof. Jorma Paavonen explained, with Phase III trials demonstrating protection against persistent HPV infections, a range of precancers and genital warts (HPV6/11). Safety of the vaccine has also been carefully studied.  Research indicates that the HPV vaccine does not have adverse effects on pregnancy outcomes or cause the onset of autoimmune diseases.[2],[3] In addition the World Health Organisation (WHO) have investigated a number of rare conditions that have speculatively been associated with the vaccine. It concluded that there was no increased risk in outcomes after vaccination.

So, with the efficacy and safety of the vaccine supported by extensive research, why are attendance rates so variable?


The path to vaccine hesitation

Dr. Pauline Paterson explained that vaccine hesitancy should be considered as a continuum. While there are individuals that refuse all vaccines, some only delay vaccination and others comply but with hesitation or caution.

There are three main drivers of hesitancy, explained Dr. Paterson.

-          Complacency – This can lead people to perceive a lack of value or need for the vaccine. No visibility of disease threat or misinformation over the seriousness of a disease can all contribute.

-          Convenience – Poor access to the vaccine can prevent people from attending vaccinations

-          Confidence – People may lack trust in vaccines, healthcare providers or scientific truths.  

It is these hesitant groups that can more easily be affected by rumours, stories and case histories that may be expressed in the media. In today’s digital world, the internet allows for rapid global spread of misinformation that exacerbates mistrust and hesitancy over vaccination programmes.

A clear example of this is in Japan. Following several years of a successful HPV vaccination programme with attendance rates of around 70%, a Japanese social media scare caused widespread national public concern over the safety of the vaccine. As a result the Japanese government stopped proactively recommending the vaccination and even provided compensation to one individual leading to mass one sided media coverage. Dr. Paterson explained how the internet allowed fears raised in Japan to spread globally, as far as Kenya, Colombia and the UK.  


How can we combat vaccine hesitation?

Combating vaccine hesitation is essential for maintaining good public health. When addressing the issue it is important to remember that while healthcare providers remain the most trusted influencer of vaccination decisions, they need more support to address public questioning over vaccines.

Dr. Paterson suggested that strategies addressing hesitancy should be multi-factorial, combining mass media, social mobilization and communication training for healthcare professionals. When considering how to improve HPV vaccination attendance, she indicated four key steps to consider:

-          Ensure the programme is gender neutral

-          Provide a school-based programme

-          Ensure gynecologists keep patients informed, and HCPs keep healthcare professionals continue sharing key factual information

-          Implement organised HPV screening


There are many challenges to overcome in addressing vaccine hesitation and the barriers to attendance. However, evidence demonstrates that the HPV vaccine is both safe and effective. We hope that in the future we can combat these barriers to vaccination and work towards effective eradication of HPV.


[1] Uhart M, Adam M, Dahlab A, Bresse X. Loss of chance associated with sub-optimal HPV vaccination coverage rate in France. Papillomavirus Res. 2017;3:73-79.

[2] Scheller NM, Pasternak B, Mølgaard-Nielsen D, Svanström H, Hviid A. Quadrivalent HPV vaccination and the risk of adverse pregnancy outcomes. N Engl J Med. 2017;376(13):1223–33.

[3] Lehtinen M, Eriksson T, Apter D, et al. Safety of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in adolescents aged 12-15 years: Interim analysis of a large community-randomized controlled trial. Hum Vaccin Immunother. 2016;12(12):3177-3185.