In 2020, cervical cancer accounted for 2.5% of all new cancer cases diagnosed in women (excluding non-melanomxa skin cancers). It was also responsible for the deaths of 2.4% of women in EU Member States. However, cervical cancer is a disease that can be prevented as well as cured.
The Ministry of Health of the Slovak Republic introduced a free HPV vaccination to children between the ages of 12 and 13 in May 2022. One year on, what impact has this intervention had, and how has it assisted in dismantling health system barriers? We talk with Daniela Kállayová from the Ministry of Health of the Slovak Republic to discuss its impact.
Could you tell us more about the vaccination programme in Slovakia? Why was it implemented?
The HPV immunisation programme is part of a broader set of actions taken by the Ministry of Health to help eradicate cervical cancer, along with increasing HPV awareness, and putting in place a coordinated prevention and treatment strategy. Slovakia has set a goal to raise the vaccination rate for all children in the Slovak Republic by 2025 in line with Europe’s Beating Cancer Plan, which sets the target of VCR against HPV at 90% for girls until 2030, simultaneously calling for an increase in VCRs for boys. Presently, paediatricians immunise 12 year old children as part of the preventative check-up, but vaccination is not yet a structured programme because it is not mandatory but rather a suggested incentive.
From May 2022, all children aged 12 are fully covered by health insurance for the 9-valent HPV vaccine and from the 1st December 2023, the HPV vaccine is fully covered by health insurance for children aged 12-14 years (up until their 15th birthday). This coincides with the prevention components of the nation's National Oncology Programmes Action Plan. Since the rollout started, 5,800 doses of the HPV vaccine are thought to have been administrated a 23% increase from the total doses given from January to April of 2022.
However, coordinating and funding prevention is a constant challenge for us. With the decentralisation of the health system and the application of free market principles in healthcare, the coordination and financing of prevention from the position of the state are becoming more complex.
This programme is part of a broader set of actions to eliminate cervical cancer elimination taken by the Ministry of Health. How will this set of actions be implemented and what initiatives are you involved in to help support this action plan?
Since 2022, the Ministry of Health has been involved in the EU Joint Action PERCH that contributes towards the implementation of Europe's Beating Cancer Plan. It supports Member States' efforts to scale up routine HPV vaccination of all children to reduce the incidence of cervical cancer and other HPV-associated cancers over the next 10 years. This 3-year Joint Action (running from 1 November 2022-30 April 2025) funded by the European Commission involves 18 European countries and 34 partner organisations. Through collaborative efforts, the aim is to increase HPV vaccination coverage, particularly in low-coverage regions, and optimise data collection for monitoring HPV vaccination coverage and impact.
We work together to improve the capacity of Member States to plan and implement HPV vaccination campaigns by sharing knowledge and experience. The project also focuses on strengthening data collection and monitoring systems for HPV vaccination, expanding HPV vaccination data collection to ensure public availability and quarterly updates. We also conduct screening, raise awareness of HPV-related illnesses and cancer prevention among specific target groups (adolescent children), and enhance communication about the HPV vaccine among healthcare professionals. These sub-objectives will guide our future activity plan.
Due to the joint efforts of a range of actors in raising awareness about HPV and HPV vaccination, vaccination uptake has increased. Why is it important to have cross-sectoral approaches towards such a programme?
The well-known principle of Health in All Policies is poorly implemented as a standard in the Slovak Republic. However, in May 2022, several stakeholders, including representatives from the Ministry of Health, paediatricians, patient organisations, and representatives of health insurance companies, gathered to communicate on the topic of HPV vaccination. During this event, it became clear how important it is to have a common approach towards the topic and how significant knowledge exchange and collaborative approaches are in developing operational efficiency and building trust, in addition to sharing ideas for implementation. Having said this, the challenge still remains as to how we, in the health care sector, can make such joint-collaborative activities continuous and long-term.
The EU Joint Action PERCH also offers a perfect platform for collaboration. As a partner, we have identified key actors at the national level, the higher territorial unit level (self-government), the local level, as well as non-governmental organisations and academia.
If we intend to implement our interventions in school settings, these actors are particularly crucial. We conducted various rounds of interviews with a range of representatives, including those from patient organisations, towns and municipalities, local authorities, and paediatricians. In collaboration with our partners, we also gathered 2,280 online survey responses from parents and children between the ages of 9 and 15. The questionnaire gave us insight into the needs of the targeted group and furthered our understanding of the challenges that this group faces when it comes to vaccination and HPV awareness.
Often the biggest barrier to prevention is insufficient public awareness of the risks of HPV infection as well as negative perceptions around vaccination campaigns. But how can we break down barriers in terms of vaccine uptake?
The EU Joint Action PERCH focuses on raising awareness and providing more information to encourage vaccination uptake in targeted groups (girls and boys). This will lead to an increase in knowledge and awareness of HPV-related diseases and prevention among adolescent girls and boys. A lack of knowledge and the fear of the unknown are significant barriers to prevention. However, raising awareness through targeted communication campaigns and increasing access will help alleviate these obstacles.
For instance, rolling out vaccination programmes in schools might be a potential remedy for removing barriers. Vaccination in school settings appears to be very effective in Spain. The Spanish region of Murcia has an HPV vaccination coverage rate of over 80%, despite vaccination not being mandatory. Making vaccinations accessible in school can benefit children by integrating vaccine delivery of other health interventions. Similarly, having such a programme in a school setting can help optimise a healthy and caring school environment, which in turn will benefit the child, parents, and the wider community.
A good path forward is to begin putting selected best practices into pilot projects in EU Member States to encourage international knowledge sharing and reciprocal learning between health authorities. For example, the European Commission funded 'Overcoming Obstacles to Vaccination' project arranges visits to EU Member States, to identify good practices in Europe.
How can a vaccination programme like this help to combat inequalities, especially in underserved communities?
Applying targeted vaccination programmes can have a profound effect in reducing health inequalities. Such programmes can grant health professionals unique access to guarded communities, provide significant insights into the various cultural needs of a particular community, and acknowledge the obstacles they may face when accessing health services.
In Slovakia, the RIVER-EU (Reducing Inequalities in Vaccine uptake in the European Region – Engaging Underserved communities) consortium is working to break down vaccination barriers. Partners collaborate to improve access to vaccination services for children and adolescents in five selected underserved communities, specifically reducing inequity in measles, mumps, rubella (MMR) and human papillomavirus (HPV) vaccines.
The marginalised Rome community in Slovakia is one of those targeted groups. In addition to incorporating lessons learned to change the behaviour of healthcare professionals, this initative will support the design and implementation of interventions to enable improved vaccine uptake in the five selected underserved communities.
What have been the most important lessons learned from this rollout one year on?
Although the country is already seeing a noticeable increase in the uptake since the implementation of this programme, this is just the beginning and there is still a lot of work to do and many obstacles to overcome, particularly at the decision-making level. To improve the current situation for all, we must continue this intersectoral collaboration of this intervention to raise awareness about HPV and HPV vaccination.
The Ministry of Health of the Slovak Republic is taking the lead in establishing the HPV National Coalition of Partners as part of its ongoing PERCH initiatives. On October 24, 2023, the coalition was officially launched with a kick-off event attended by our Minister. This ambitious endeavor aims to: craft a comprehensive framework for HPV communication strategy, develop a centralised design for future communication campaigns, implement a comprehensive plan for educational activities at schools, organise workshops for journalists to enhance public awareness about cancer prevention, HPV vaccination, and screening.
The Ministry of Health is committed to collaborating closely with all stakeholders to ensure the success of the HPV National Coalition of Partners. Through collective efforts, we can make a substantial impact in the fight against HPV-related cancers and improve the well-being of all Slovak citizens.
Looking forward, key steps to boost uptake include:
- Expansion of HPV vaccination data collection to ensure data will be publicly available and updated on a quarterly basis.
- Support doctors (e.g. technically or with behavioural interventions) to increase uptake and compliance with the second dose.
- Given the success of HPV vaccination rates in other countries, further expand vaccination programmes in schools and in cooperation with schools.
- Increase communication on prevention through awareness-raising campaigns at the national level.
- Support municipalities in the implementation of HPV prevention programmes, including mass HPV vaccination events to increase HPV vaccination coverage and target areas with lower vaccination rates.
Ensuring vaccine equity for all
The Roma community is one of the largest and most disadvantaged ethnic minority groups in Europe. Currently, there are approximately 440,000 Roma living in the country, and more than half are living in marginalised communities, determined by their social and spatial distance from the rest of the population. According to the RIVER-EU project, this underserved community faces some of the greatest barriers when it comes to accessing healthcare. However, though this is changing, there is still much to do. Daniela Fiľakovská Bobáková, from the Faculty of Medicine at the PJ Šafárik University and Country Coordinator for RIVER-EU in Slovakia, explains:
"Free HPV vaccination for twelve-year-old girls and boys is a very important step in cancer prevention. In recent months, we have noticed that this topic has started to resonate in the media. We also register several campaigns and initiatives that aim to convey information about the importance of this vaccination and the possibility of free vaccination in this age group to the public. There is an incredible amount of work behind it. However, there is still a lot to solve because, even though the vaccination rate in Slovakia is increasing, we are still quite far from the desired target of 90%.
We must not forget groups with limited access to information and health services and leave no one behind. In Slovakia, marginalised Roma communities could greatly benefit from the free vaccination offered, but they are not being reached by information campaigns. If we can make vaccination available to the most vulnerable populations, it will mean easier access for all.
One of the tools that could make this possible is to extend the interval in which the costs of the HPV vaccine are fully covered by health insurance. The most ideal would be to vaccinate children between the ages of 9 and 14, free of charge, with the two-dose schedule. Within the RIVER-EU project, we will certainly advocate for this, along with the implementation of tailored interventions aimed at increasing vaccination rates in underserved communities across Europe."
Further information
EuroHealthNet is part of the RIVER-EU and JA PERCH consortia. For information about all of our projects, click here.
NB: For the purpose of this article the terms, 'girls' and 'boys' are used to refer to the sex assigned at birth. You can find more information on EuroHealthNet's approach to Gender, Equality and Diversity by clicking here.
Daniela Kállayová
Daniela Kállayová is professionally qualified in public health and public health research with a focus on epidemiology, health inequalities and health promotion. Currently she works at the Ministry of Health of the Slovak Republic as Senior Officer responsible for health promotion and disease prevention, with a focus on cancer control and the health of vulnerable groups. Daniela is also a member of the Public Health Expert Group (PHEG), Disease Prevention and the Management of Non-Communicable Diseases and a member of the EU4Health Steering Group within the European Commission.