The WHO has identified vaccine hesitancy as one of the top ten health threats in the world. Efforts to eliminate the diseases caused by HPV risk being undermined by a lack of public awareness about HPV, the diseases it can cause and the importance of vaccination. ‘Fake news’ about vaccination safety generally and HPV vaccination specifically is often relayed by mainstream media reports and amplified by social media. This has recently been associated with rapid falls in uptake in Denmark, Ireland and Japan. In Denmark specifically, the uptake of the first HPV vaccine dose was around 90% for girls born in the period 1998 to 2000 but dropped to 54% for girls born in 2003.87
Recent research suggests that only 73% of people in Northern Europe believe that vaccines, in a general sense, are safe. In Western Europe, this figure is even lower, at 59%; and in Eastern Europe this stands at 40%.88 Across Europe, the main causes of HPV ‘vaccine hesitancy’ specifically are related to: insufficient and inadequate information about HPV vaccination; misinformation about the potential side effects of the vaccine; issues around trust in health authorities, doctors and in new vaccines; and a perception of low vaccine effectiveness.89 There are differences between countries: in Italy, for example, there are greater concerns about the vaccine impacting negatively on sexual activity in younger women.
Many people currently lack basic knowledge about HPV and the associated risks. One study of men and women in the United Kingdom, where HPV vaccination for girls began in 2008 and systematic cervical cancer screening in 1988, found that just over one third (37%) had even heard of HPV.90 Of these, 70% were aware that HPV could be transmitted during sex, and about 40% recognised that HPV could cause oropharyngeal cancer but only two thirds (64%) knew that a preventive vaccine existed. A study of some 17,000 Europeans across 10 countries found that a quarter (24%) of people believed HPV to be ‘quite rare’ or ‘extremely rare’ and that over two thirds (70%) were not aware that HPV could cause cancer in males.91 There is also evidence that some women are deterred from screening because of a fear that it is a test for cancer rather than primarily a means of preventing cancer.
Online information provided about HPV, vaccination, cervical cancer and screening varies widely in terms of type and quality, according to a recent study conducted across 46 European countries.92 In 37 countries, information is provided through a government website and in only 19 countries was the quality of the information judged to be ‘excellent’ or ‘good’ across four domains (information on HPV; information on cervical cancer and screening; information on ways to access vaccines; and online discoverability). In 10 countries, the quality of information was deemed ‘insufficient’ across the four domains, suggesting that there is considerable room for improvement.
It is not yet possible to be certain of the impact of COVID-19 on vaccine confidence and uptake. It is possible that the pandemic will serve to increase public understanding of viruses in general and the potential role of vaccines in disease prevention and generate greater faith in and respect for science and scientists. The pandemic has certainly been a stark reminder of the impact of a serious disease in the absence of a vaccine and any effective treatment.
If a safe COVID-19 vaccine is successfully developed and delivered to millions of people worldwide, this could have a positive impact on vaccine confidence generally. But it is also apparent that COVID-19 has re-invigorated the anti-vaccination movement and sparked the proliferation of many patently absurd conspiracy theories.93 Vaccine scepticism may also be fuelled if participants in the COVID-19 vaccine trials suffer serious side-effects, if the vaccine (or vaccines) that are eventually deployed prove to be less effective than hoped, or if the governments that recommend them are not credible to their citizens because of their overall management of the pandemic.
There is a clear need to improve public knowledge about HPV-related health risks, to raise awareness of HPV in general, including the value of HPV screening and the safety of vaccination. The utilisation of a Precaution Adoption Process Model (PAPM), which describes the psychological stages individuals go through when making decisions about behaviour change, might be helpful.94 In Ireland, a sharp decline in HPV vaccination uptake was successfully reversed in part by the dissemination of emotive stories of patient advocates; such stories can be more impactful than science-based communications. Celebrities may also have a role to play.
Messages should be tailored to particular population sub-groups, differentiated by gender, sexuality, age, race and other identities. Action must be taken on a sustained basis but the annual HPV Awareness Day in March (run by the International Papilloma Virus Society), the European Immunisation Awareness Week in April and the European Cervical Cancer Prevention Week in January present particular opportunities, as do cervical cancer awareness weeks held at different times in individual countries.
The education of health professionals, especially in primary care, is also of critical importance. Consistent and well-informed information and advice to patients from GPs, nurses, pharmacists and dentists can make a significant difference to the decisions individuals make about vaccination and screening. There is evidence of doubts about vaccine safety generally among healthcare workers in several countries95 and of a need for additional training in HPV vaccination and screening in particular.96
After an emotive political debate, Ireland introduced a free school-based HPV vaccination programme for 1st year secondary school girls in 2010. The programme enjoyed high levels of uptake until a targeted media campaign by a small group of anti-vaccination activists led to a national TV ‘shockumentary’ catalysing a freefall in vaccine confidence. This campaign was professionally executed at local and national levels to the extent that the viability of the programme came under threat.
Over the next few years, The HPV Vaccination Alliance, a coalition of NGOs, health agencies, professionals and those impacted by HPV cancer, developed and implemented a recovery strategy which has restored levels of vaccine uptake close to those needed to ensure maximum health benefit in the community.
First and foremost, this initiative focused on collaborative communication, collegiately uniting various stakeholders under the one banner of communicating the facts about the opportunity that HPV vaccination gives to eliminate a number of dreadful diseases. Clear concise, easy to understand public communication tools, including social media, were employed to target parents as well as those being vaccinated.
Educational initiatives were developed and provided to ensure that key and trusted public gatekeepers, such as nurses, doctors and pharmacists, had access to robust information and could reinforce positive public health messages about the vaccine. Time was also spent to ensure that politicians and media had easy and ready access to factual information.
Public cancer advocates lent their voice and considerable insight to illustrate why the vaccine is important to young people. Leading international agencies, including the WHO, engaged with and endorsed the campaign and this was further reinforced by strong and unambiguous political support at the very top level from the health and prime ministers.
Distance learning has developed significantly in recent years. It has become an increasingly important part of the global mandate of the Education for All movement led by UNESCO and the COVID-19 pandemic has hugely reinforced its importance, not least for the training of health professionals.
The Cancer Epidemiology Research Programme at the Catalan Institute of Oncology (ICO) along with the ICO e-learning programme e-oncología, (www.e-oncologia.org), have been developing an extensive virtual training programme on HPV and associated diseases for over eight years.
The following courses are now available:
1. Cervical cancer prevention (launched 2011 and now available in seven languages); 18,500 students, to date.
2. Strategies in the primary and secondary prevention of cervical cancer (2017); 4,000 students.
3. HPV Epidemiology and Prevention to Paediatrics and Primary Care (2018); 1,000 students.
4. HPV Vaccine Safety (2018); 6,000 students.
5. HPV-associated Head and Neck cancers: epidemiology, prevention and clinical management (2020); 500 students.
The digital content of all the courses has been developed using interactive elements and multimedia to facilitate learning. The modular structure of the courses allows for the addition of specific modules including the prevention and screening protocols for the country or region of interest.
The course is intended for a wide range of professionals, including health professionals involved in the prevention of cervical cancer, gynaecologists, paediatricians, oncologists, microbiologists, primary care physicians, nurses, midwives, public health professionals, health managers and planners, researchers and educators.