Journal of Public Health

, Volume 16, Issue 4, pp 291–298 | Cite as

The introduction of policies for human papillomavirus vaccination in Europe

  • Pierre Van Damme
  • Sergio Pecorelli
  • Elmar A. Joura
Review Article



Human papillomavirus (HPV) vaccines represent a major advance in the prevention of cervical cancer and other HPV-related diseases. The availability of HPV vaccination and cervical cancer screening creates the unique opportunity to combine primary and secondary prevention of a cancer. HPV vaccination is currently being adopted in Europe at a faster rate than has been seen with most previous vaccines.

Aims and methods

This article analyses the reasons for the rapid and broad access to this cancer prevention measure to illustrate the new sociopolitical environment that drives vaccination policies in the 21st century.


The promise of this intervention to prevent infection by the virus that can cause these diseases in young women created an environment receptive to vaccination. However, it was robust data generated by research specifically targeted to public health needs that have convinced various stakeholders to advocate, license, recommend, and fund vaccination. It was not just the usual host of actors who rallied to this process: early support for decision-making came from experts and scientific societies, patient and women’s groups, and policy makers at the EU and national levels. Implementation now looms as the greatest challenge to vaccine uptake, in particular in the adolescent target group. Determinants of successful implementation include well-informed healthcare professionals who in turn can educate parents and adolescents on the infectious disease, its consequences, and the efficacy and safety of vaccination, and successful provision of equitable access to vaccination. The integration of vaccination and screening must also be carefully managed and adapted to the situation in each country.


Inevitably, the impact of this promising public health intervention will depend upon the continuing engagement of all stakeholders to maintain interest and confidence in vaccination.


HPV Vaccination Immunization policy 


  1. Adami H-O, Pontén J, Sparén P, Bergström R, Gustafsson L, Friberg LG (1994) Survival trend after invasive cervical cancer diagnosis in Sweden before and after cytologic screening. Cancer 73:140–147PubMedCrossRefGoogle Scholar
  2. Arbyn M, Autier P, Ferlay J (2007a) Burden of cervical cancer in the 27 member states of the European Union: estimates for 2004. Ann Oncol 18:1423–1425PubMedCrossRefGoogle Scholar
  3. Arbyn M, Raifu AO, Autier P, Ferlay J (2007b) Burden of cervical cancer in Europe: estimates for 2004. Ann Oncol 18:1708–11715PubMedCrossRefGoogle Scholar
  4. Anttila A, Ronco G, Clifford G, Bray F, Hakama M, Arbyn M, Weiderpass E (2004) Cervical cancer screening programmes and policies in 18 European countries. Br J Cancer 91:935–941PubMedGoogle Scholar
  5. Asaria P, MacMahon E (2006) Measles in the United Kingdom: can we eradicate it by 2010? BMJ 333:890–895PubMedCrossRefGoogle Scholar
  6. Austrian Superior Medical Council (2006) Recommendations for 2007 Austrian Vaccination Programme. November 21, 2006Google Scholar
  7. Baird G, Pickles A, Simonoff E, Charman T, Sullivan P, Chandler S, Loucas T, Meldrum D, Afzal M, Thomas B, Jin L, Brown D (2008) Measles vaccination and antibody response in autism spectrum disorders. Arch Dis Child (In Press). Published online 5 Feb 2008; DOI 10.1136/adc.2007.122937
  8. Belgian High Health Council (2007) Publication du Conseil Supérieur de la Santé n°8204. May 2, 2007Google Scholar
  9. Boehner CW, Howe SR, Bernstein DI, Rosenthal SL (2003) Viral sexually transmitted disease vaccine acceptability among college students. Sex Transm Dis 30:774–778PubMedCrossRefGoogle Scholar
  10. Bosch FX, Castellsaguè X, de Sanjosè (2008) HPV and cervical cancer: screening or vaccination? Br J Cancer 98:15–21PubMedCrossRefGoogle Scholar
  11. British Department of Health (2007) Press release, 20 June 2007. Available online at Accessed on February 26, 2008
  12. Chen RT, Hibbs B (1998) Vaccine safety: current and future challenges. Pediatr Ann 27:445–455PubMedGoogle Scholar
  13. Danish Centre for Health Promotion and Prevention (2007) Recommendation to introduce human papilloma virus vaccination into the DANISH Childhood Vaccination Programme. October 4, 2007Google Scholar
  14. Danish National Board of Health (2008) Announcement available online at Accessed on February 28, 2008
  15. Davis K, Dickman ED, Ferris D, Dias JK (2004) Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. Obstet Gynecol Surv 59:82–822CrossRefGoogle Scholar
  16. Dempsey AF, Zimet GD, Davis RL, Koutsky L (2006) Factors that are associated with parental acceptance of human papillomavirus vaccines: a randomized intervention study of written information about HPV. Pediatrics 117:1486–1493PubMedCrossRefGoogle Scholar
  17. Drummond M (2008) The need for greater understanding of the economic issues. J Public Health (Suppl) (to be completed)Google Scholar
  18. ECCA (European Cervical Cancer Association) (2008) Available online at Accessed on February 26, 2008
  19. ECDC (European Centre for Disease Control) (2008) Guidance for the introduction of HPV vaccines in EU countries. Available online at Accessed on February 26, 2008
  20. ECPC (European Cancer Patient Coalition) (2008) Available online at Accessed on February 26, 2008
  21. European Commission (2006) Summary of Community decisions on marketing authorizations in respect of medicinal products from 1 September 2006 to 30 September 2006. Official Journal of the European Union, 27 October 2006. Available online at Accessed February 29, 2008
  22. Ferlay J, Bray F, Pisani P, Parkin DM (2004) Globocan 2002. In: Ferlay J, Bray F, Pisani P, Parkin DM (eds) Cancer incidence, mortality and prevalence worldwide. IARC Press, Lyon (France)Google Scholar
  23. FitzSimons D, Vorsters A, Hoppenbrouwers K, Van Damme P (2007) Prevention and control of viral hepatitis through adolescent health programmes in Europe. Vaccine 25:8651–8659PubMedCrossRefGoogle Scholar
  24. French Vaccination Technical Committee and High Council for Public Hygiene (2007) Opinion about the vaccination against the human papillomaviruses 6, 11, 16 and 18. March 9, 2007Google Scholar
  25. Garland SM, Hernandez-Avila M, Wheeler CM, Perez G, Harper DM, Leodolter S, Tang GWK, Ferris DG, Steben M, Bryan J, Taddeo FJ, Railkar R, Esser MT, Sings HL, Nelson M, Boslego J, Sattler C, Barr E, Koutsky LA (2007) Quadrivalent vaccine against Human Papillomavirus to prevent anogenital diseases. New Engl J Med 356:1928–1943PubMedCrossRefGoogle Scholar
  26. German Standing Committee on Vaccination (STIKO) (2007) Recommendation and explanatory statement about vaccination against Human Papilloma virus for girls of 12 to 17 years of age. March 23, 2007. Available online at Accessed February 28, 2007
  27. Greek Ministry of Health and Social Solidarity (2007) Press release, 19 October 2007. Available online at
  28. Gudmundsdottir T, Tryggvadottir L, Allende M, Mast TC, Briem H, Sigurdsson K (2003) Eligibility and willingness of young Icelandic women to participate in a HPV vaccination trial. Acta Obstet Gynecol Scand 82:345–350PubMedCrossRefGoogle Scholar
  29. Harper DM, Franco EL, Wheeler C, Ferris DG, Jenkins D, Schuind A, Zahaf T, Innis B, Naud P, De Carvalho NS, Roteli-Martins CM, Teixeira J, Blatter MM, Korn AP, Quint W, Dubin G, for the GlaxoSmithKline HPV Vaccine Study Group (2004) Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 364:1757–1765PubMedCrossRefGoogle Scholar
  30. Harper DM, Franco EL, Wheeler CM, Moscicki AB, Romanowski B, Roteli-Martins CM, Jenkins D, Schuind A, Costa Clemens SA, Dubin G, on behalf of the HPV Vaccine Study group (2006) Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 367:1247–1255PubMedCrossRefGoogle Scholar
  31. Health Council of the Netherlands (2008) Vaccination against cervical cancer. The Hague: Health Council of the Netherlands; publication no. 2008/08. ISBN: 978-90-5549-702-7Google Scholar
  32. Health Protection Agency (UK). Annual COVER report 2004/2005. Available online at Accessed on February 26, 2008
  33. Hessel L (2008) The contribution of vaccine manufacturers to the establishment of vaccination policies J Public Health (Suppl) (to be completed)Google Scholar
  34. Hinds A, Cameron JC (2004) Acceptability of universal hepatitis B vaccination among school pupils and parents. Commun Dis Public Health 7:278–282PubMedGoogle Scholar
  35. Italian Pharmaceutical Agency (2007) Publication in the Official Gazetta of the Italian Republic. February 28, 2007Google Scholar
  36. Jacobson RM, Targonski PV, Poland GA (2007) Why is evidence-based medicine so harsh on vaccines? An exploration of the method and its natural biases. Vaccine 25:3165–3169PubMedCrossRefGoogle Scholar
  37. Jansen VAA, Stollenwerk N, Jensen HJ, Ramsay ME, Edmunds WJ, Rhodes CJ (2003) Measles outbreaks in a population with declining vaccine uptake. Science 301:804PubMedCrossRefGoogle Scholar
  38. Jo’s Trust (2008) Available online at Accessed on February 26, 2008
  39. Joura EA, Leodolter S, Hernandez-Avila M, Wheeler CM, Perez G, Koutsky LA, Garland SM, Harper DM, Tang GWK, Ferris DG, Steben M, Jones RW, Bryan J, Taddeo FJ, Bautista OM, Esser MT, Sings HL, Nelson M, Boslego JW, Sattler C, Barr E, Paavonen J (2007) Efficacy of a quadrivalent prophylactic human papillomavirus (types 6, 11, 16, and 18) L1 virus-like-particle vaccine against high-grade vulval and vaginal lesions: a combined analysis of three randomised clinical trials. Lancet 369:1693–1702PubMedCrossRefGoogle Scholar
  40. Libbey JE, Coon HH, Kirskman NJ, Sweeton TL, Miller JN, Lainhart JE, McMahon WM, Fujinami RS (2007) Are there altered antibody responses to measles, mumps, or rubella viruses in autism? J Neurovirol 13:252–259PubMedCrossRefGoogle Scholar
  41. Lo B (2006) HPV vaccine and adolescents’ sexual activity - It would be a shame if unresolved ethical dilemmas hampered this breakthrough. BMJ 332:1106–1107PubMedCrossRefGoogle Scholar
  42. Lo B (2007) Human papillomavirus vaccination programmes. BMJ 335:357–358PubMedCrossRefGoogle Scholar
  43. Luxemburg High Council for Hygiene (2007) Recommendation of HPV vaccination for girls aged 11–12 years and catch-up vaccination in girls between 13 and 18 years of age. March 2007. Available online at Accessed February 28, 2008
  44. Macgregor JE, Campbell MK, Mann EMF, Swanson KY (1994) Screening for cervical intraepithelial neoplasia in north east Scotland shows fall in incidence and mortality from invasive cancer with concomitant rise in preinvasive disease. BMJ 308:1407–1411PubMedGoogle Scholar
  45. Madsen KM, Vestergaard M (2004) MMR vaccination and autism: what is the evidence for a causal association? Drug Saf 27:831–840PubMedCrossRefGoogle Scholar
  46. McClelland A, Liamputtong P (2006) Knowledge and acceptance of human papillomavirus vaccination: perspectives of young Australians living in Melbourne, Australia. Sex Health 3:95–101PubMedCrossRefGoogle Scholar
  47. Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Valentine A, Davies SE, Walker-Smith JA (2004) Retraction of an interpretation. Lancet 363:750PubMedCrossRefGoogle Scholar
  48. Nohynek H (2008) The decision-making process to recommend a new vaccine. From vaccine research to policy and programme implementation - the Finnish experience. J Public Health (Suppl) (to be completed)Google Scholar
  49. O.N.Da (Osservatorio Nazionale sulla salute della Donna) (2008) Available online at Accessed on February 26, 2008
  50. Norwegian Institute of Public Health (2007) Evaluation and recommendation of the HPV Vaccine.12 April 2007Google Scholar
  51. Paavonen J, Jenkins D, Bosch FX, Naud P, Salmerón J, Wheeler CM, Chow SN, Apter DL, Kitchener HC, Castellsague X, de Carvalho NS, Skinner SR, Harper DM, Hedrick JA, Jaisamrarn U, Limson GA, Dionne M, Quint W, Spiessens B, Peeters P, Struyf F, Wieting SL, Lehtinen MO, Dubin G, HPV PATRICIA study group (2007) Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial. Lancet 369:2161–2170PubMedCrossRefGoogle Scholar
  52. Portugese Government (2007) Declaration of the Prime-Minister before the Parliament. Transcript available at: Accessed on February 26, 2008
  53. Postma MJ (2008) Public Health Economics of Vaccines in the Netherlands methodological issues and applications. J Public Health (Suppl) (to be completed)Google Scholar
  54. Raffle AE (2007) Challenges of implementing human papillomavirus (HPV) vaccination policy. BMJ 335:375–377PubMedCrossRefGoogle Scholar
  55. Siegrist CA, Balinska MA (2008) The public perception of the value of vaccines. J Public Health (Suppl) (to be completed)Google Scholar
  56. Skinner SR, Kang M, Rosenthal SL (2007) Vaccinating young adults against human papillomavirus: the importance of understanding health decision-making and behaviour. Sexual Health 4:129–132PubMedCrossRefGoogle Scholar
  57. The FUTURE II Study Group (2007) Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ:a combined analysis of four randomised clinical trials. Lancet 369:1861–1868CrossRefGoogle Scholar
  58. Van Ballegooijen M, van den Akker-van M, Patnick J, Lynge E, Arbyn M, Anttila A, Ronco G, Dik J, Habbema F (2000) Overview of important cervical cancer screening process values in European Union (EU) countries, and tentative predictions of the corresponding effectiveness and cost-effectiveness. Eur J Cancer 36:2177–2188PubMedCrossRefGoogle Scholar
  59. van der Zeijst BA, Dijkman MI, Luytjes W, van Alphen AJ, van den Dobbelsteen GP (2007) On the design of national vaccination programmes. Vaccine 25:3143–3145PubMedCrossRefGoogle Scholar
  60. Villa LL, Perez G, Kjaer SK, Paavonen J, Lehtinen M, Munoz N, Sigurdsson K, Hernandez-Avila M, Skjeldestad FE, Thoresen S, Garcia P, Majewski S, Dillner J, Olsson SE, Tay EH, Bosch FX, Ault KA, Brown DR, Ferris DG, Koutsky LA, Kurman RJ, Myers ER, Barr E, Boslego J, Bryan J, Esser MT, Gause CK, Hesley TM, Lupinacci LC, Sings HL, Taddeo FJ, Thornton AR, Boulos M, Cox JT, Langmark F, Modlin J, Munoz A, Odlind V, Wilkinson E, Ferenczy A, Kurman R, Ronett B, Stoler M, Andreoni G, Bahamondes L, Camargos A, Costa R, De Andrade R, Fedrizzi E (2007) Quadrivalent vaccine against Human Papillomavirus to prevent high-grade cervical lesions. New Engl J Med 356:1915–1927CrossRefGoogle Scholar
  61. Spanish Ministry of Health and Consumption (2007) Press release, 10 October 2007Google Scholar
  62. Swedish Pharmaceutical Benefits Board (LFN) (2007) Available online at Accessed February 28, 2008
  63. Swedish National Board of Health and Welfare (Socialstyrelsen) (2008) Press release. Available at Accessed February 28, 2008
  64. Szucs T (2007) Seasonal influenza vaccination in Europe: 2007/7 coverage rates in 11 countries. Presentation to European Parliament. Available online at Accessed March 4, 2008
  65. Swiss Federal Commission for vaccination (2007) Recommendation for routine vaccination against cervical cancer and other HPV caused diseases. 18 June 2007Google Scholar
  66. Velasco-Garrido M, Busse R (2005) Health Technology Assessment - An Introduction to objectives, role of evidence and structure in Europe. European Observatory on Health Systems and Policies, available on Accessed on February 2008
  67. Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Harvey P, Valentine A, Davies SE, Walker-Smith JA (1998) Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 351:637–641PubMedCrossRefGoogle Scholar
  68. Wallace LA, Young D, Brown A, Cameron JC, Ahmed S, Duff R, Carman WF, Kitchin NR, Nguyen-Van-Tam JS, Goldberg DJ (2005) Costs of running a universal adolescent hepatitis B vaccination programme. Vaccine 23:5624–5631PubMedCrossRefGoogle Scholar
  69. Wynia MK (2007) Public health, public trust and lobbying. Am J Bioethics 7:4–7CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Pierre Van Damme
    • 1
  • Sergio Pecorelli
    • 2
  • Elmar A. Joura
    • 3
  1. 1.Centre for the Evaluation of Vaccination, (WHO Collaborating Centre), Vaccine and Infectious Diseases InstituteUniversity of AntwerpAntwerpenBelgium
  2. 2.Department of Obstetrics and Gynaecology, Division of Gynaecologic OncologyUniversity of BresciaBresciaItaly
  3. 3.Department of Obstetrics and GynaecologyMedical University of ViennaViennaAustria

Personalised recommendations