Bert van Enter
General practitioner, Master in International Health (MIH), Physician in Global Health and Tropical Medicine (not practising) and PhD student
A. Klein Velderman
Advisor for youth healthcare at the Association of Regional Public Health Services and Regional Medical Emergency Preparedness and Planning (GGD-GHOR)
Dr. Danielle Jansen
Associate professor Organisation of care for children and adolescents, University Medical Center Groningen, University of Groningen and Accare, the Netherlands
In the Netherlands, human papillomavirus (HPV) vaccination was introduced in 2010 in the national immunization programme, targeted towards adolescent girls in the year they turned 13 years old. The selected vaccine is bivalent, targeting HPV types 16 and 18. In 2022, the HPV vaccination programme was extended to boys, with the first round of vaccinations held in March and April 2022. The age of first invitation also reduced to the year that boys and girls turn ten years old. In addition, a catch-up campaign will be organised in 2023 for young adults between 19-26 years of age who have not yet been vaccinated.We believe that the new strategies will increase HPV vaccine uptake and thereby contribute to herd immunity to protect the population against HPV. In Australia, where boys have already been vaccinated for several years and where vaccine uptake for both boys and girls is high (3-dose coverage for adolescents turning 15 years old in 2016: 78.6% for girls and 72.9% for boys) – research shows significant declines in HPV infection. As a result, a significant drop in HPV-related cancer rates is predicted in the future.1Hall MT, Simms KT, Lew J Bin, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Heal. 2019;4(1):e19-e27. doi:10.1016/S2468-2667(18)30183-X2Machalek DA, Garland SM, Brotherton JML, et al. Very Low Prevalence of Vaccine Human Papillomavirus Types among 18- to 35-Year Old Australian Women 9 Years Following Implementation of Vaccination. J Infect Dis. 2018;217(10):1590-1600. doi:10.1093/infdis/jiy075 The National Institute for Public Health and the Environment (RIVM) developed a public campaign to highlight the 2022 changes in the Dutch national immunisation program. The main difference from the previous campaign was the shift of focus from sexual transmission of HPV to the prevention of cervical cancer. The campaign was developed with support from the Communication Activation Strategy Instrument (CASI), a tool from the Dutch government which supports applying scientific insights about behaviour in communication.3Public Information and Communications Service, Dutch Ministry of General Affairs. CASI – Communication Activation Strategy Instrument. https://www.communicatierijk.nl/documenten/publicaties/2021/12/09/casi-in-english The CASI process was used to support an analysis of factors that influenced the intention to get vaccinated against HPV and preferred (communication) strategies.
Shifting the message from sexual transmission of HPV to the prevention of cancer can be beneficial to improve vaccine uptake in the whole population, but also specifically in the underserved target populations that RIVER-EU is aiming to reach in the Netherlands. Preliminary Dutch results show that people with a Turkish or Moroccan migration background in the Netherlands often believe that HPV vaccination is not necessary for them. Within the Islamic faith, sexual intercourse before marriage is discouraged. Therefore, practising Muslims estimated their risk of infection to be low and consequently did not see the importance of vaccination. Emphasizing the prevention of HPV-linked cancer instead of sexual transmission of HPV can help underline the importance of HPV vaccination.Results from the first round of vaccinations in March-April of 2022 show an overall decline in HPV vaccine uptake in the Netherlands. In previous years, vaccine uptake was around 60%; this year HPV vaccine uptake for boys and girls has, thus far, only reached 42.8% and 49.2% respectively.4RIVM. Bijna helft 9/10-jarigen haalt HPV-vaccinatie bij eerste mogelijkheid. Published 2022. https://www.rivm.nl/nieuws/bijna-helft-910-jarigen-haalt-hpv-vaccinatie-bij-eerste-mogelijkheid A possible reason for lower uptake could be the COVID-19 pandemic. In the Netherlands, children 5-11 years old were invited to receive the COVID-19 vaccine in January 2022, putting the first invitation for HPV vaccination very close to the COVID invitation. This unfortunate planning and vaccine hesitancy towards COVID vaccines may have caused people delaying vaccination against HPV.5Lier EA van, Oomen PJ, Giesbers H, et al. Vaccinatiegraad en jaarverslag Rijksvaccinatieprogramma Nederland 2021, RIVM-rapport 2022-0017. Published online 2022:1-64. Furthermore, in this first round of vaccination, it was the first time boys were invited for HPV vaccination which might also have influenced vaccine uptake. The second round of vaccinations was completed in the fourth quarter of 2022, but the uptake figures from this second round of vaccinations are not yet available.
Despite efforts to organise inclusive vaccination campaigns and support parents and children from underserved communities to make informed choices about HPV vaccination, current coverage rates demonstrate that not all health system barriers have been removed. We believe there are health system barriers that we don’t yet fully understand. It emphasizes the importance of RIVER-EU’s work, both in the Netherlands and beyond. With the results of RIVER-EU project, we hope to contribute to aligning the future HPV vaccination campaigns with the needs of the Dutch communities whose access to vaccination services has not been ensured.
Summary: HPV immunisation program in the Netherlands and RIVER-EUHPV vaccination in the Netherlands is given through mass vaccination programs and vaccination is free of charge for children up to 18 years old. For adolescents and young adults (19-26) invited within catch-up campaigns, vaccination is also free of charge. National registries are used to invite eligible (boys and girls in the year they become ten years old and adolescents up to 18 years old who are not vaccinated yet). National HPV vaccine uptake among girls used to be around 60% (2020). However, uptake among girls with a Turkish or Moroccan migration background living in the Netherlands was found to be much lower (less than 30%).6de Munter AC, Klooster TMS van t., van Lier A, Akkermans R, de Melker HE, Ruijs WLM. Determinants of HPV-vaccination uptake and subgroups with a lower uptake in the Netherlands. BMC Public Health. 2021;21(1):1-13. doi:10.1186/s12889-021-11897-0 RIVER-EU in the Netherlands aims to reduce health system barriers for HPV vaccine uptake in females with a Turkish and Moroccan migration background.
- 1Hall MT, Simms KT, Lew J Bin, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Heal. 2019;4(1):e19-e27. doi:10.1016/S2468-2667(18)30183-X
- 2Machalek DA, Garland SM, Brotherton JML, et al. Very Low Prevalence of Vaccine Human Papillomavirus Types among 18- to 35-Year Old Australian Women 9 Years Following Implementation of Vaccination. J Infect Dis. 2018;217(10):1590-1600. doi:10.1093/infdis/jiy075
- 3Public Information and Communications Service, Dutch Ministry of General Affairs. CASI – Communication Activation Strategy Instrument. https://www.communicatierijk.nl/documenten/publicaties/2021/12/09/casi-in-english
- 4RIVM. Bijna helft 9/10-jarigen haalt HPV-vaccinatie bij eerste mogelijkheid. Published 2022. https://www.rivm.nl/nieuws/bijna-helft-910-jarigen-haalt-hpv-vaccinatie-bij-eerste-mogelijkheid
- 5Lier EA van, Oomen PJ, Giesbers H, et al. Vaccinatiegraad en jaarverslag Rijksvaccinatieprogramma Nederland 2021, RIVM-rapport 2022-0017. Published online 2022:1-64.
- 6de Munter AC, Klooster TMS van t., van Lier A, Akkermans R, de Melker HE, Ruijs WLM. Determinants of HPV-vaccination uptake and subgroups with a lower uptake in the Netherlands. BMC Public Health. 2021;21(1):1-13. doi:10.1186/s12889-021-11897-0