Human Papillomavirus Vaccination Challenges and Strategies

Human papillomavirus (HPV) vaccination has revolutionized cervical cancer prevention. The challenge is persuading anti-vaccine parents to their vaccinate their children ...

SUNY Upstate Medical University, Syracuse, NYMDPI, Creative Commons – Clinical trials confirm that the quadrivalent (HPV types 6, 11, 16, 18) and bivalent (HPV types 16, 18) vaccines effectively prevent Human Papillomavirus  infections and cervical neoplasia.

The latest HPV vaccine protects against nine virus types responsible for 90% of cervical cancer cases globally. Despite their undoubted effectiveness in reducing morbidity and mortality associated with HPV infections, challenges in vaccine coverage and uptake persist.

HPV is a highly contagious virus linked to cervical cancer, posing a significant public health challenge both domestically and worldwide. The introduction of HPV vaccines has significantly improved the prevention of cervical cancer and other HPV-related morbidity and mortality.

The current study aimed to identify the primary challenges associated with HPV vaccination, propose effective strategies to improve vaccination uptake, and compile relevant evidence into a comprehensive overview to inform policy and practice.

A systematic review protocol, following PRISMA-P and PRISMA guidelines, was established.

Articles were sourced from the Web of Science using keywords from a comprehensive review of HPV vaccination challenges and strategies. Studies published between 1 January 2020, and 1 May 2024, including RCTs and observational, qualitative, and cross-sectional studies, were included, while reviews, protocols, and commentaries were excluded.

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“The American Cancer Society estimates that in 2024, 4,360 women will die from cervical cancer.” – Google AI 

Titles, abstracts, and full texts were screened per PRISMA guidelines. The review identified five key strategies to improve HPV vaccination uptake: parental and school engagement, use of technology and multimedia tools, healthcare providers’ role, multicomponent interventions, and targeted interventions for immigrant groups.

This review emphasized the need for a multifaceted approach to improving vaccination rates, offering a robust foundation for policy and stakeholder initiatives.

Over the past twenty years, significant progress has been made in the development and efficacy of human papillomavirus (HPV) vaccines alongside a marked increase in global vaccination initiatives.

Several countries have accumulated valuable experience in delivering HPV vaccines to adolescent girls through pilot programs, demonstration projects, and nationwide implementations, most of which occurred in the four years preceding 2020.

A recent study in England evaluated the national HPV vaccination program, initiated in 2008 for girls aged 12–13, and included additional efforts for older teenagers. Results revealed that vaccinated women had an 83.9% reduction in cervical cancer and a 94.3% reduction in grade three cervical intraepithelial neoplasia (CIN3) rates compared to those unvaccinated.

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“Cancer experts trumpet a 65% reduction in cervical cancer among 20- to 24-year-old women from 2012 to 2019. They were among the first group of 11- and 12-year-olds to receive vaccination against the human papillomavirus, or HPV.” – SUNY Upstate Medical University, Syracuse, NY

Of note, a considerable number of clinical trials have shown that the quadrivalent vaccine (targeting HPV types 6, 11, 16, and 18) and the bivalent vaccine (targeting HPV types 16 and 18) are highly effective in preventing persistent HPV infections and CIN, which are critical precursors to cervical cancer.

These vaccines have been approved and are now available on the market, demonstrating sustained immunity and strong antibody responses, which suggest long-term protection. Additionally, research indicates that the bivalent vaccine offers significant cross-protection against other HPV types.

Gardasil 9, the latest and most comprehensive HPV vaccine, protects against nine HPV types: 6, 11, 16, 18, 31, 33, 45, 52, and 58. These types are responsible for approximately 90% of cervical cancer cases globally.

Implementing three-dose vaccine campaigns in young girls has posed challenges, including difficulties in ensuring adherence to multiple dosing regimens in some ethnic groups, increased costs, and unavailability of health insurance.

This has prompted consideration for transitioning to two or even one dose to enhance vaccination efforts.

Notably, administering a single dose of the HPV vaccine can potentially enhance vaccine uptake.

Evidence indicates that a single-dose routine vaccination could prevent nearly as many cervical cancers as the two-dose regimen if the vaccine’s protective duration exceeds 20 to 30 years. This approach would be more efficient, easier to implement, and less costly.

Furthermore, during the 18-month trial period, single-dose bivalent and nonavalent HPV vaccines demonstrated high effectiveness in preventing new persistent oncogenic HPV infections, comparable to the protection offered by multidose regimens.

In 2020, the World Health Organization (WHO) launched the Global Cervical Cancer Elimination Initiative to eradicate cervical cancer.

This initiative emphasizes prevention, screening, and treatment. By 2030, it aims to reduce the global incidence of cervical cancer to fewer than four cases per 100,000 women. Key targets include vaccinating 90% of girls by age 15, screening 70% of women with high-performance tests at least twice by age 45, and ensuring 90% of identified cases receive treatment.

However, the feasibility of such a comprehensive approach across diverse socio-economic and healthcare settings globally needs to be adequately addressed.

Moreover, the initiative’s reliance on achieving high vaccination rates, widespread screening, and ensuring timely treatment overlooks women’s numerous barriers to healthcare access in many regions, including financial constraints, cultural stigmas, and infrastructure deficiencies.

Additionally, the target of reducing cervical cancer incidence to fewer than four cases per hundred thousand women per year by 2030 seems overly optimistic, given the current disparities in healthcare systems and resource allocation worldwide …

Vaccine Hesitancy

There is limited understanding of how to address parental vaccine hesitancy. While barriers have been identified, prompting factors for vaccine-hesitant parents (VHPs) are underexplored but crucial for effective interventions.

Evidence on strategies to improve vaccine uptake among VHPs’ children is scarce, with existing studies using diverse approaches.

Gaining insight into obstacles and aids to HPV vaccination is crucial. Zheng et al. (2021), in their systematic investigation, uncovered barriers hindering HPV vaccine uptake, including insufficient understanding of HPV and the vaccine, safety apprehensions, financial limitations, and discrimination related to vaccination.

“By vaccinating boys and girls, you are protecting both genders from developing HPV-associated cancers later in life.” – SUNY Upstate Medical University

Conversely, factors facilitating vaccination encompassed confidence in vaccine effectiveness and safety, affordability, favorable recommendations, perceived risk of HPV infection, and recognition of vaccine benefits.

Despite being accessible for 14 years, knowledge deficits endure, underscoring the pressing necessity for educational campaigns aimed at adolescents and young adults to bolster vaccination rates and grasp early vaccination determinants.

Beavis et al. (2022) conducted a study aiming to identify potential strategies perceived by vaccine-hesitant parents as motivating for vaccinating their children against HPV.

They found that concerns about safety and necessity, frequently impacted by adverse anecdotal reports, were significant factors causing hesitancy.

While pediatricians served as the primary source of vaccine information, many parents expressed dissatisfaction with these interactions.

Parents indicated a need for comprehensive information regarding vaccine benefits and risks and resources to facilitate discussions with providers.

Proposed strategies included detailed discussions with pediatricians, provision of written materials by pediatricians, and facilitation tools to prepare for pediatrician visits.

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