Perspectives | Public Health

HPV Vaccine: Lessons we have learned

By - 13.04.2023

And how I learned them the hard way.

A scientific paper published in early January 2023 confirms that HPV vaccines are safe, efficient and beneficial to adults regardless of whether they have been previously infected with any of the human papillomavirus (HPV) strains. For those of us who advocate for equal access to HPV vaccines, it was something we were already familiar with, considering that — according to the Medicines and Medical Devices Agency of Serbia website — the vaccines have been green-lit for all residents of Serbia aged 9 and up.

In 2017, I was treated for cervical cancer, one of several types of cancer caused by HPV. I found out around that time that Australia was the first country to record a sharp drop in HPV infections among people who were vaccinated.

It has been proven not only that the HPV vaccine works, but also that mass immunization in school-aged children will potentially eradicate all HPV-induced types of cancer by 2035. After Australia introduced a national immunization program, the U.K. and a number of other countries followed suit in the late 2000s. Today these each of these countries proudly displays the results they’ve achieved.

How did I take an interest in HPV?

When you have cancer, you think it’s the worst thing that can possibly happen to you. After remission, life ensues — but so does the horror. Since I was diagnosed with a type of cancer caused by a virus, how can I be so sure I am no longer infectious?

I’ve been faced with a bizarre set of facts. It’s not just that there has been a lack of discussion about the connection between cervical cancer and HPV, it’s that doctors used to parrot the line that, “It’s too late for you to get vaccinated now.”

That’s where my own research started. I’m a long-time writer in the media and I decided to produce a documentary on cancer prevention titled “One and a Half Women Every Day.” Unlike many others, I had the opportunity to reach out to experts, so I got a number of gynecologists, oncologists, immunologists, microbiologists, pathologists and geneticists to explain what was happening to me. Was I contagious? Could I get infected again? Was there any way to protect myself?

How do you protect yourself?

I was 34 at the time and I wanted to know how I would live out the rest of my life. We tend to say that nothing is more important than life, but that somehow disregards health and quality of life. The first thing I did was I got a HPV viral load test — it came back negative. A virologist explained to me that the HPV had been surgically removed from my body. It’s not a type of virus that stays inside your body forever. After the radical surgery, there was no more virus in my body.

It seems that I was given a second chance at life, together with many other women who had precancerous changes (i.e. small lesions) or cancer removed from their cervix. Though we no longer have the virus, we don’t have immunity. This means that we can get infected just like anyone else. This realization is where my fight began — my goal is to help as many people who can contract HPV or HPV-related diseases to get well and to gain free access to HPV vaccines. Anyone who can get infected can and should be able to protect themselves.

What’s the global situation?

The first national immunization programs were launched in Australia, the U.K., the U.S. and the EU in 2007. Since 2008, HPV-related disease prevention campaigns have been implemented by almost every EU member state, while there is also a growing trend of gender-neutral immunization schemes. The programs have been made available cost-free in most countries.

According to Dr. Ian Frazer, who developed the HPV vaccine, the most decisive factor in terms of immunization is the cost — if you provide the vaccine for free, people will take it.

Through the Australian Embassy to Serbia, I managed to get in touch with the doctors Julia Brotherton and Suzanne Garland, who were the first to offer evidence that cervical cancer can be eradicated. In 2019, they recommended that Serbia adopt a national policy. Unfortunately, Serbia has not taken up this recommendation.

According to Dr. Ian Frazer, who developed the HPV vaccine, the most decisive factor in terms of immunization is the cost — if you provide the vaccine for free, people will take it. Vaccine availability is of greatest significance for developing countries, where people are exposed to numerous risks such as limited access to healthcare, lack of birth control, unhealthy lifestyles and poverty.

The only vaccine available to everyone is a free one. 

The cost of health and a race against time

The best time to get vaccinated is to do so before ever having intercourse. In such cases the vaccine is more than 95% effective. Even though statistics show that its effectiveness decreases with age, almost all countries have catch-up programs aimed at safeguarding everyone under 26. National HPV immunization schemes are often free for young people, considering them as a socially vulnerable group.

According to general consideration, the working population, as far as they wish to, could get access to vaccines to protect themselves. However, as we see, it would be beneficial if HPV immunization was part of every health insurance plan in developing countries. Vaccination dramatically reduces the costs of repeated Pap smears in cases of precancerous lesions, or of further medical interventions during cancer treatment, which is why it is the most cost-effective preventive measure.

Where does the Balkans stand?

Eastern and Southern Europe are weighed down by high cervical cancer incidence and related deaths. 

According to a European Centre for Disease Prevention and Control report, Moldova was the European country with the highest rate of cervical cancer risks. In 2020, with only a partially introduced HPV prevention program in Moldova in 2018 and rates that did not exceed 49% of coverage (first dose in 2019), this country lowered the incidence of cervical cancer from 28.2 per 100,000 women to 22.8 in 2021, accordint to the HPV Information Centre

This means that Moldova is now leaving several Balkan countries behind.

In Albania, with no national HPV immunization program, cervical cancer prevention is reduced to screening programs with up to 5% coverage in the Tirana region, accompanied by self-paid voluntary vaccination against HPV with a licensed bivalent vaccine being available. 

Moldova was the European country with the highest rate of cervical cancer risks, but now it’s behind several Balkan countries.

With a history of high incidence of cervical cancer (18 per 100,000 women in 2020), Bulgaria started a national HPV prevention program in 2017 for girls age 12. Though coverage started to rise, progress was soon interrupted in 2020 by the pandemic and the numbers soon fell. According to the European Parliament, in 2021 Bulgaria had the lowest vaccine coverage of all EU member states (5.6%).

In 2014, Hungary introduced its national program for girls, of which an estimated 86% of whom have received the first dose, while 78% also got the second one.

Post-Yugoslav countries

In 2021, there were high rates of cervical cancer in Montenegro (26.2 per 100,000 women), Serbia (18.7) and Bosnia (14.3). None of these countries had a national HPV immunization scheme at the time. Montenegro introduced one in September 2022, targeting girls between 9 and 13 years of age.

North Macedonia and Slovenia introduced the HPV vaccine back in 2009 as a part of a continuous, organized and planned immunization program. Although vaccination is mandatory in the former, its coverage is low, ranging from 17.6% in the Ohrid area and 19.7% in the Skopje area to 99.2% in the Pehčevo area.

Slovenia set a 90-70-90 objective: to vaccinate 90% of girls by the age of 15, to have screened 70% of women by the age 35, and to properly treat 90% of women diagnosed with cervical cancer.

Since the 1990s, Slovenia has implemented an HPV prevention program as a part of a wider platform of eradicating cervical cancer. The program is called ZORA – the National Cervical Cancer Screening. It is managed by the Institute of Oncology Ljubljana.

They set a 90-70-90 objective: to vaccinate 90% of girls by the age of 15, to have screened 70% of women by the age 35 and again by the age of 45, and to properly treat 90% of women diagnosed with cervical cancer.

Beyond this comprehensive prevention policy, 60% of Slovenian girls were covered by a free vaccination scheme in 2020. However, it is not enough to obtain herd immunity and to achieve the desired effect on the wide population, so the complete elimination of cervical cancer is yet to be seen.

The first recommendations for the HPV vaccine in Croatia were published back in 2007 and the first HPV vaccinations were introduced in Zagreb. These were later followed by a program financed, partially or totally, by local governments in other parts of Croatia. A national immunization program began in 2015, when free voluntary vaccination was offered for girls in eighth grade. In 2016, the program was extended to boys and high school students as part of a gender-neutral catch-up program. Today, the HPV prevention program is accessible to all young people under 26.

In Kosovo,  the voluntary vaccination of girls aged 12 to 16 only started in October 2022. According to the Kosovo Ministry of Health (MoHK), about 100 women are diagnosed with cervical cancer each year. The MoHK has announced that from 2024 this vaccine will be included in the regular vaccination schedule. However, it will only be recommended and not mandatory.

What’s going on in Serbia?

The way Serbia kicked off its immunization soon became infamous — of 2,000 doses of the vaccine that were donated in 2016, only about 500 were used.

Some steps were made in 2020, but only by two local governments. The Šabac city assembly voted unanimously for the financing of a prevention program against HPV-related diseases but immunization has not been conducted. In Novi Sad, on the other hand, immunization was initiated within a project funded by the Ministry of Demography and Population Policy in 2021; immunization continued in this area owing to the financial support from the city government.

The HPV vaccine is a cancer vaccine — it is safe and efficient. The only thing we need now are politicians who will acknowledge the science.

Serbia saw its first national HPV prevention program begin in June 2022, targeting everyone between the ages of 9 and 19. According to the Dr. Milan Jovanović Batut Public Health Institute of Serbia, over 23,000 children have gotten the HPV vaccine since.

Science and politics — what can we expect?

Within the next decade, the countries that pioneered HPV vaccination campaigns are expected to announce one by one that cervical cancer has been eradicated. Meanwhile, Balkan countries are trying to outrun death.

Lagging behind Europe costs us our health; both women and men remain at risk of getting infected by HPV-related oral and anogenital carcinoma. Internationally, there are mounting concerns that medical professionals will not be able to treat these lethal diseases in their advanced stages simply because they have never encountered them in practice.

The HPV vaccine is a cancer vaccine — it is safe and efficient. The only thing we need right are politicians who will acknowledge the science.

Public healthcare systems need to recognize the facts that have been known to scientists since 2008, when the person who discovered the correlation between HPV and cancer was honored with the Nobel Prize. In order for us humans to outlive viruses, which have been around longer than us, it will take superhuman efforts to improve devastating stats.

In the Balkans, people die from preventable and curable diseases. HPV vaccines are a form of cancer protection — so let’s make it available to everyone. Health is a fundamental human right. We should never forget that fact.

Feature image: Atdhe Mulla / K2.0.