HPV vaccination rate of 70 percent is possible and reasonable

According to calculations by the German Cancer Research Center (DKFZ), around 7,700 people developed types of cancer caused by infection with human papillomavirus (HPV) last year, including almost 4,000 cases of cervical cancer alone. The majority of these tumors could be prevented by the HPV vaccination. The vaccination is recommended by the German Standing Committee on Vaccination (STIKO); it is paid for by the health insurance companies and except for in very rare cases does not have any lasting side effects – yet the vaccination rate in Germany among 15-year-old girls and boys was only 31.3 percent in the last survey (2015).

"There are clear indications that the number of cases of certain kinds of HPV-induced cancer is currently still on the rise in Germany. Moreover, the number of precancerous conditions requiring treatment is many times higher than that of manifest cases of cancer. Even young adults can be affected, causing both great physical and above all mental strain," remarked Klaus Kraywinkel, head of the German Centre for Cancer Registry Data at the Robert Koch Institute (RKI).

What would be a reasonable target for the HPV vaccination rate, and what would be realistic? Why are the HPV vaccination rates in Germany so much lower than in places such as Australia and the Scandinavian countries, where they are around 80 percent? These questions were recently discussed by representatives of the health sector, research and politics at a Round Table to Eradicate HPV-Related Cancer in Germany. The event was hosted by DKFZ and the Preventa Foundation and supported by Nobel Laureate Harald zur Hausen.

In Germany, the HPV vaccination rates have gradually increased in recent years – something that is partly due to the ongoing activities of health alliances. There are considerable regional differences, however: "While good rates of around 60 percent are currently being reached among 15-year-old girls in the federal states of the former East Germany, the southern states in particular – Bavaria and Baden-Württemberg – are very much lagging behind, with rates of only around 35 percent," noted Ole Wichmann, head of the Immunization Unit at RKI.

The Round Table participants agreed on the goal of achieving an HPV vaccination rate of at least 70 percent among 15-year-olds within the next five years. "In view of the current vaccination rates in Germany, this target would appear to be realistic and feasible. That would also bring us up to a level that epidemiologists regard as sufficient to interrupt transmission of the virus and to ensure community protection," explained Nobila Ouédraogo, public health expert at DKFZ.

The Round Table participants identified three points as the main reasons for the current lack of visibility of the HPV vaccination:

• New target age group: While the vaccination rates among young children are generally good, the age group of 9- to 14-year-olds, for whom the HPV vaccination is recommended, calls for new channels of communication: In addition to pediatricians, general practitioners and gynecologists also need to be involved, for example. New studies by RKI show that active recommendation by doctors can boost HPV vaccination rates to up to 80 percent, highlighting the relevance of providing doctors with in-depth information about the opportunities offered by the HPV vaccination.
• In Germany, despite the recommendation by the STIKO and the decision by the Federal Joint Committee, the HPV vaccine is generally prescribed as a patient prescription or individual prescription. This means that it has to be collected from the pharmacy after an initial consultation and the vaccination itself is performed at a second appointment, involving considerable effort for everyone concerned. In addition, not all specialist doctors are able to bill for the vaccination in some federal states, not even the public health service.
• Up to now, there have not been any central, nationwide information campaigns about the HPV vaccination that are primarily geared to the new target groups, especially young people, via channels such as social media. The level of awareness that this could create can be seen from the slogan "Don't give AIDS a chance", which the Federal Centre for Health Education has been using for its HIV prevention campaign for decades.

The Round Table participants identified the following steps as suitable measures to increase the HPV vaccination rate to more than 70 percent in Germany:

• Voluntary school vaccinations are successfully established, as they already have been in some countries (Australia, Sweden, Norway, Ireland, Iceland, Austria). Schools are the right place to teach health skills. The relevant education resources need to be mobilized and made extensively available.
• Low-threshold services such as vaccination consultations that people can visit without an appointment. In rural regions in which there are not enough doctors, mobile vaccination units may be useful.
• Linking the HPV vaccination and the scheduled check-up examinations for young people with an invitation-based procedure, as has already been established for the recommended and in some states mandatory early detection screening program for children (scheduled check-ups 4–9).
• Centrally steered and coordinated information campaigns professionally geared towards the relevant target group (doctors, parents, young people, multipliers).
• Standardized prescription of the HPV vaccine (as practice overheads) throughout the country.
• Recall systems and implementation of an electronic vaccination pass as part of digitalization of the health sector.

"We still have a difficult road ahead of us before HPV-induced tumors are eliminated in Germany. The Round Table is a way of addressing the problem of the lack of overall responsibility and the myriad different duties," remarked Claus Köster, Managing Director of the Preventa Foundation. "The Round Table participants are now teaming up to form working groups that will process the content of the measures independently over the next few years," he added. "We hope that increased public relations work and mobilization of stakeholder groups will encourage policymakers to support implementation of these measures."