Results
We found that mean coverage of HPV1 vaccination programmes has been trending upwards in high income countries overall since 2010 and the number of high income countries that have introduced HPV vaccination nationally has also been increasing (figure 1). In low and middle income countries, coverage of HPV1 vaccination programmes increased overall in 2010-19, peaking in 2016, when a number of countries reported very high coverage (≥95%), followed by a 6% reduction in 2016 that stabilised in 2017-19. Mean coverage of HPV1 vaccination programmes among target girls decreased from 65% during the period before the covid-19 pandemic (2010-19) to 50% during the pandemic (2020-21) in low and middle income countries, compared with an increase in high income countries from 61% to 69% for the same periods. Before the pandemic, mean programme coverage for girls was higher in low and middle income countries compared with high income countries.
Figure 1Mean programme coverage with first dose of human papillomavirus (HPV) vaccine (HPV1) among girls, by country income category, worldwide, 2012-21. Mean programme coverage calculation does not include countries without an existing HPV vaccination programme. Country income categories were based on criteria from 2022 World Bank income categories for high income countries (HICs) and low and middle income countries (L&MICs). Three countries did not have a World Bank income category and were excluded (Venezuela, Niue, and Cook Islands). Values are mean and 95% confidence interval
Population adjusted HPV1 coverage among girls was highest among those in high income countries in 2010-21 compared with girls from other country income categories (figure 2). Coverage among boys in high income countries has been gradually increasing since 2010. During the covid-19 pandemic, population adjusted HPV1 coverage among boys in high income countries was higher and remained higher than that in girls from low and middle income countries (ie, upper middle income, lower middle income, and low income countries).
Figure 2(Top) Population adjusted coverage for first dose of human papillomavirus (HPV) vaccine (HPV1), by country income category and sex, worldwide, 2010-21. HICs-girls=coverage in girls from high income countries; HICs-boys=coverage in boys from high income countries; UMICs-girls=coverage in girls from upper middle income countries; LMICs-girls=coverage in girls from lower middle income countries; LICs-girls=coverage in girls from low income countries. Country income categories were based on criteria of 2022 World Bank income categories for low income, lower middle income, upper middle income, and high income countries. Three countries did not have a World Bank income category and were excluded (Venezuela, Niue, and Cook Islands). (Bottom) Population adjusted coverage with HPV1 among girls by World Health Organization region, worldwide, 2010-21. AFR=African region; AMR=Americas region; EMR=Eastern Mediterranean region; EUR=European region; SEAR=South East Asia region; WPR=Western Pacific region
Overall, the number of gender neutral HPV vaccination programme introduced increased from 0 to 48 between 2010 and 2022. As of July 2023, no low income country has a gender neutral vaccination programme, compared with 37/58 (64%), 9/52 (17%), and 1/53 (2%) in high income, upper middle income, and lower middle income countries, respectively. Also, a gender neutral HPV vaccine programme was introduced in 2019 in a country with no income categorisation by the World Bank (Niue). During the covid-19 pandemic, population adjusted HPV1 coverage among girls in upper middle income countries was proportionally more affected, with a decrease from 24% before the pandemic (2019) to 14% at the end of the pandemic (2021) for this analysis compared with the decrease in coverage among girls in high income countries (6%) and low income countries (4%).
We found no net change in coverage among girls in lower middle income countries between 2019 and 2021; however, coverage in lower middle income countries was the lowest across all country income categories before and during the covid-19 pandemic (2010-21). In 2021, HPV1 (first dose) vaccination coverage of ≥90% was achieved in eight (4%) countries, but only four (2%) countries globally achieved ≥90% with their complete HPV vaccination series. Among regions, population adjusted coverage was highest globally in the Americas region since 2012, but regional coverage also decreased the most from 68% in 2019 to 51% in 2021, which was mainly explained by reduced coverage in Mexico from 94% to 1% (figure 2). Overall, population adjusted HPV1 coverage has increased in the African region since the first introduction in 2011 (Rwanda), and a marked improvement in coverage was found from 8% in 2017 to 31% in 2019, followed by a reduction to 26% in 2021.
By region, HPV vaccination has yet to be introduced in 4/35 (11%), 9/53 (17%), 6/27 (22%), 21/47 (45%), 5/11 (45%), and 17/21 (81%) countries in the Americas, European, Western Pacific, African, South East Asian, and Eastern Mediterranean regions, respectively (as of July 2023). During the covid-19 pandemic, 23 countries globally reported a severe reduction in coverage of national HPV vaccination programmes (≥50% reduction in coverage). Two countries in the WHO European region recorded a severe reduction compared with 11 countries in the Americas region and seven countries in the African region. Globally, 23 countries did not report HPV vaccination coverage in 2021 compared with only nine countries in 2019.
During the covid-19 pandemic, the number of girls worldwide who received a HPV vaccine increased both by improved coverage in some countries (1.3 million more girls) and by the introduction of national vaccine programmes (0.7 million more girls received a vaccine) in 2021 compared with 2019 (figure 3). Reduced HPV1 coverage in existing HPV programmes during the covid-19 pandemic (2020-21), however, resulted in 3.8 million more girls being missed globally. This finding gave an overall reduction in the total number of girls who received a HPV vaccine globally from 12.3 million in 2019 to 10.6 million in 2021.
Figure 3Global incremental gains and losses in number of girls who were vaccinated with first dose of human papillomavirus (HPV) vaccine (HPV1) by year, 2019-21. Girls reached=number of girls who were reported to have received at least one dose of HPV vaccine; coverage improved=number of additional girls who were vaccinated with at least one dose of HPV vaccine in countries with existing HPV programmes as a result of improvement in coverage; new introduction=number of additional girls reached with at least one dose of HPV vaccine in countries that introduced a new HPV vaccine programme during that calendar year; girls missed=number of girls who did not receive a HPV vaccine compared with the previous year in countries with an existing HPV vaccination programme
Most high income countries introduced the HPV vaccine nationally in the decade following the first availability of the HPV vaccine in 2006 (figure 4). From 2006 to 2016, 45 high income countries introduced the vaccine compared with 24 non-Gavi eligible middle income countries and only two Gavi eligible low or middle income countries. During the covid-19 pandemic, we found a large reduction in the number of countries, regardless of income category, introducing HPV vaccination. Overall, 18 HPV vaccine programmes were introduced in 2019, four in 2020, six in 2021, and 13 in 2022. The rate of Gavi eligible countries introducing national HPV vaccination by year increased from four countries in 2018 to eight in 2019, before decreasing to three in 2020. Three and five HPV vaccine programmes were introduced in Gavi eligible countries in 2021 and 2022, respectively. Of the 10 new introductions of national HPV vaccine programmes during the pandemic period, eight countries reported the introduction year coverage (mean 59%). Before the pandemic (2010-19), 63 of 83 countries that introduced HPV vaccination reported introduction year coverage (mean 62%). Several low and middle income countries with high annual numbers of patients with cervical cancer have yet to introduce HPV vaccination or vaccinate in select subnational geographies, including China, India, Russia, and the Democratic Republic of the Congo (figure 5). Among high income countries, several countries with a high disease burden have HPV1 coverage <70%, including Japan, France, and Italy.
Figure 4Number of countries that introduced national human papillomavirus (HPV) vaccine programmes, grouped by income category (based on 2022 World Bank income categories) and eligibility for financial support from Gavi, the Vaccine Alliance (Gavi), worldwide, 2006-22. Non-Gavi middle income countries=middle income countries that were not eligible for Gavi (following criteria for the relevant year); Gavi countries=countries that met Gavi eligibility criteria in the year of introduction. Eligibility threshold was adjusted for inflation on an annual basis
Figure 5Burden of cervical cancer relative to coverage estimates of first dose of human papillomavirus (HPV) vaccine (HPV1), by country and income category, worldwide, 2021: high income (HIC), upper middle (UMIC), lower middle (LMIC), and low (LIC) income country. Size of squares is proportional to annual number of new patients with cervical cancer.7 Country income categories were based on criteria of 2022 World Bank income categories for low income, lower middle income, upper middle income, and high income countries. Three countries did not have a World Bank income category and were excluded (Venezuela, Niue, and Cook Islands). HIC: AUS=Australia; AUT=Austria; BEL=Belgium; CAN=Canada; CHL=Chile; CZE=Czech Republic; EST=Estonia; FIN=Finland; FRA=France; DEU=Germany; GRC=Greece; HRV=Croatia; HUN=Hungary; IRL=Ireland; ISR=Israel; ITA=Italy; JPN=Japan; LTU=Lithuania; LVA=Latvia; NLD=Netherlands; NOR=Norway; POL=Poland; PRT=Portugal; KOR=Republic of Korea; SAU=Saudi Arabia; SGP=Singapore; SVK=Slovakia; ESP=Spain; SWE=Sweden; TTO= Trinidad and Tobago; GBR=UK. URY=Uruguay. UMIC: ALB= Albania; ARG=Argentina; ARM=Armenia; AZE=Azerbaijan; BLR=Belarus; BIH=Bosnia and Herzegovina; BWA=Botswana; BRA=Brazil; BGR=Bulgaria; CHN=China; COL=Colombia; CRI=Costa Rica; CUB=Cuba; DOM=Dominican Republic; ECU=Ecuador; FJI= Fiji; GEO= Georgia; GTM=Guatemala; IRQ=Iraq; JAM=Jamaica; KAZ=Kazakhstan; LBY= Libya; MDA=Republic of Moldova; MYS=Malaysia; MEX=Mexico; NAM=Namibia; PAN= Panama; PRY=Paraguay; PER=Peru; ROU=Romania; RUS=Russia; SRB=Serbia; ZAF=South Africa; THA=Thailand; TKM= Turkmenistan; TUR=Turkey. LMIC: DZA=Algeria; AGO=Angola; BGD=Bangladesh; BEN=Benin; BOL=Bolivia (Plurinational State of); KHM=Cambodia; CMR=Cameroon; COG=Republic of Congo-Brazzaville; COM= Comoros; CIV=Côte d'Ivoire; EGY=Egypt; SLV=El Salvador; GHA=Ghana; HTI=Haiti; HND=Honduras; IND=India; IDN=Indonesia; IRN=Iran (Islamic Republic of); KEN=Kenya; KGZ=Kyrgyzstan; LAO= Lao People's Democratic Republic; LSO=Lesotho; MAR=Morocco; MMR=Myanmar; MNG=Mongolia; MRT=Mauritania; NPL=Nepal; NIC=Nicaragua; NGA=Nigeria; PAK=Pakistan; PNG=Papua New Guinea; PHL=Philippines; SEN=Senegal; LKA=Sri Lanka; SWZ= Eswatini; TJK=Tajikistan; TUN=Tunisia; TZA=United Republic of Tanzania; UKR=Ukraine; UZB=Uzbekistan; VNM=Vietnam; ZMB=Zambia; ZWE=Zimbabwe. LIC: AFG=Afghanistan; BFA=Burkina Faso; BDI=Burundi; TCD=Chad; PRK=Democratic People’s Republic of Korea; CAF=Central African Republic; COD=Democratic Republic of the Congo; ERI= Eritrea; ETH=Ethiopia; GIN=Guinea; LBR=Liberia; MDG=Madagascar; MWI=Malawi; MLI=Mali; MOZ=Mozambique; NER=Niger; RWA=Rwanda; SDN=Sudan; SLE= Sierra Leone; SOM=Somalia; SSD=South Sudan; TGO=Togo; UGA=Uganda