The status of human papillomavirus vaccination recommendation, funding, and coverage in WHO Europe countries (2018–2019)

Figures & data

Table 1. Key definitions of categories used during the data collection

Data field	Category	Definition
HPVv cohort	Primary cohort	Population targeted at first intent by the national immunization programs: i.e. adolescents for HPVv
	Catch-up cohort	A population that is older than the primary cohort and has therefore initially missed the chance of receiving the vaccine and is subsequently covered by an extended (i.e. catch-up) vaccination program.
HPVv funding	Fully funded	No out-of-pocket payment required for the individual to receive the HPV vaccine.
	Partially funded	Partial out-of-pocket payment required for the individual (individual’s personal funds or through individual’s private insurance) to receive the HPV vaccine.
	No funding	Individual required to pay the full cost of the HPV vaccine.
HPVv Recommendation	Recommendation and Funding (partial or full)	HPV vaccines are recommended by health authorities and are included in the national immunization program with partial or full funding.
	Recommendation Only (no funding)	HPV vaccines are recommended and can be included in the national immunization program without funding.
	No Recommendation or Funding	No recommendation or immunization program for HPV vaccines.
	No data	There was no information on HPV vaccine recommendation or funding available from official government/public health websites
Setting where HPVv took place	Health center	Any facility where healthcare professionals (HCPs) work, such as primary healthcare facilities (e.g. General Practitioners (GP), local clinics, HCP offices), hospitals, and vaccination centers.
	School	HPVv is administered at school
HPV VCR	Target VCR	A pre-defined proportion of girls and/or boys who will receive HPVv in a specific timeframe, as set by national health authorities.
	Monitored VCR	The proportion of girls and/or boys who have received HPVv at the time of assessment.
	Categorization of VCR	High VCR (≥71% coverage), moderate VCR (51–70% coverage), low VCR (31–50% coverage), very low VCR (≤30% coverage)

Abbreviations: VCR, vaccination coverage rate; HCP, healthcare professional; HPVv, human papillomavirus vaccination.

Table 2. Overview of HPVv recommendations for primary cohorts by country in WHO/ER (n = 53)

Region^1	Country	HPVv policy	Primary cohort gender	Primary cohort age (years)	HPVv funding	Year of HPVv introduction	Setting for HPVv
Eastern Europe	Bulgaria	▀	F	12–13	Full	2012	Health center
	Czech Republic	▀	F, M	13–14	Full	F: 2012 M: 2018	Health center
	Hungary	▀ ▓	F M	12(Grade 7) >9	Full None	2014 NA	School NA
	Moldova	▀	F	10	Full	2017	NA
	Poland**	▓	F, M	11–12	None	NA	NA
	Romania	▀	F	11–14	Full	2020	Health center
	Russian Federation**	▓	F	12–13	None	NA	NA
	Slovakia	▀	F, M	13	Full	NA	School
	Belarus	◺	NA	NA	NA	NA	NA
	Ukraine	◺	NA	NA	NA	NA	NA
Northern Europe	Denmark	▀	F, M	F:12–17 M: 12	Full	F: 2009 M: 2019	Health center
	Estonia	▀	F	12–14	Full	2008	School
	Finland	▀ ▓	F M	10–12 (Grade 5–6) 10–12	Full None	2007 NA	School NA
	Iceland	▀	F	12	Full	2011	School
		▓	M	9–17	None	NA	NA
	Ireland	▀	F, M	12–13 (1^st year secondary school)	Full	2010	School
	Latvia	▀	F	12	Full	2010	School
	Lithuania	▀	F	11	Full	2015	Health center
	Norway	▀	F, M	12(Grade 7)	Full	F: 2009 M: 2018	School
	Sweden	▀	F	10–12 (Grade 5 or 6)	Full	2010	School
	UK	▀	F, M	11–14	Full	F: 2008 M: 2019	School
Southern Europe	Andorra	▓	F	12	None	NA	NA
	Albania	◺	NA	NA	NA	NA	NA
	Bosnia & Herzegovina	▓	F	NA	None	NA	NA
	Croatia	▀	F, M	13–14	Full	2016	School
	Cyprus	▀	F	12–13	Full	2016	School
	Greece	▀	F	11–12	Full	2008	Health center
	Italy	▀	F, M	12	Full	F: 2008 M: NA	Health center
	North Macedonia	▀	F	12	Full	2008	School
	Malta	▀	F	12	Full	2012	Health center
	Montenegro	▀	HPV9 vaccine listed in the reimbursement list; however, no official recommendation was identified. Online news suggested that 9–11 year old girls are recommended to take part in a fully funded HPVv.
	Portugal	▀	F	10	Full	2017	Health center
	San Marino	▀	F	11–14	Full	NA	NA
	Serbia	▓	F, M	12	None	2017	NA
	Slovenia	▀	F	11–12	Full	2009	Health Center and School
	Spain	▀	F	11–12	Full	2007	School or health center based on regions
	Turkey	◺	NA	NA	NA	NA	NA
Western Europe	Austria	▀	F, M	9–12	Full	2014	School
	Belgium, Flanders	▀	F, M	12–13	Full	2010	School
	Belgium, Wallonia-Brussels	▀	F, M	13–14	Full	2011	School
	France	▀	F	11–14	Partial	2007	Health center
		▓	M	11–14	None	2019	NA
	Germany	▀	F, M	9–14	Full	F: 2007 M: 2018	Health center
	Luxembourg	▀	F, M	9–13	Full	F: 2007 M: 2017	Health center
	Monaco	▀	F	14	Partial	2018	Health center
	Netherlands	▀	F	12–13	Full	2010	Health center
	Switzerland	▀	F, M	11–14	Full	F: 2008 M: 2016	Health center and School
Central/Western Asia	Armenia	▀	F	13	Full	NA	NA
	Azerbaijan	◺	NA	NA	NA	NA	NA
	Georgia	▀	F	9	Full	NA	Health center
	Israel	▀	F, M	13–14 (Grade 8)	Full	2013	School
	Kazakhstan	▓	F	11–12	None	2013	NA
	Kyrgyzstan	◺	NA	NA	NA	NA	NA
	Tajikistan	◺	NA	NA	NA	NA	NA
	Turkmenistan	▀	F, M	9	Full	NA	Health center
	Uzbekistan	▀	F	10–12	Full	NA	Health center and School

Abbreviations: NA – not available; F – female; M – male; y/o – years old; WHO/ER – WHO/Europe; HPVv – human papillomavirus vaccination.

Legend: ▀Recommendation and Funding (partial or full), ▓Recommendation Only, ◺No Recommendation and No funding.

** Absence of a national HPVv program; HPVv implemented and managed by regional/municipal authorities.

¹The regional divisions are based on the definition used by the Statistics Division of the United Nations Secretariat for statistical analysis of the global data: https://unstats.un.org/unsd/methodology/m49

See supplementary table 5 for data sources for the primary cohort.

See supplementary table 6 for details of gender-neutral vaccination programs.

Figure 1. Recommendations and funding status across the WHO/ER for the primary cohort in girls and boys

Table 3. List of WHO/ER countries with a reported HPVv recommendation and/or program for the catch-up cohort (n = 18)

Region^1	Country	Catch-up cohort gender	Catch-up cohort age (years)	HPVv policy	HPVv funding	Additional notes
Eastern Europe	Poland	F	13–18	▓	None	No national funding, but many municipalities and local governments fund the vaccine for teenage girls as part of free local government programs.
Northern Europe	Denmark	F, M	F: 15–17	▀	F: Full	There are two catch-up programs offered for boys: 1) Boys who were 12 years old after July 2019 are covered by the free vaccine program that has just commenced in September 2019, and the program will be valid until they reach 18 2) An additional catch-up program for boys born in 2006–2007 was established for the year of 2020–2021 (age 14–15)
			M: 13–18	▀	M: Full
	Iceland	F	13–17	▓	None	Based on the 2019 vaccination scheme, vaccination is only targeted at 12-year old girls; older girls and boys may receive the vaccine if they obtain a prescription and must pay for it out-of-pocket.
	Sweden	F	13–26	▀	Full	The County Councils have offered free HPVv to girls born between 1993 and 1998 in an expanded (catch-up) program. Some county councils have offered free HPVv to women up to 26 years of age.
	UK	F, M	15–25	▀	Full	None
Southern Europe	Greece	F	13–18	▓	None	None
	Italy^2	F	12–18, 25, 26 or lifetime	▀	Partial-full	The primary cohort includes both genders starting at 12 years of age. Regional variations in age-based eligibility criteria for catch-up HPVv (from 12 up to 18, 25, or 26 years of age, or no age limit, i.e. lifetime coverage).
	North Macedonia	F	13–26	▀	Partial	None
	Slovenia	F	13–26	▀	Full	None
	Spain^2	F	14–26	▀	Full	Regional variations in age-based eligibility criteria for catch-up HPVv (from 12 up to 26 years of age).
Western Europe	Austria	F, M	13–15	▀	Partial	None
	Belgium	F, M	12–18	▀	Partial	None
	France	F	15–19	▀	Partial	None
	Germany	F, M	15–17	▀	Full	None
	Netherlands	F	Up to 18	▀	Full	None
	Switzerland	F, M	15–19	▀	Full	There is some variation in the age-based eligibility criteria for HPVv across cantons.
Western Asia	Israel	F, M	15–18	▀	Full	None

Abbreviations: NA – not available; F – female; M – male; WHO/ER – WHO/Europe; HPVv – human papillomavirus vaccination.

Legend ▀Recommendation & Funding (partial or full) ▓Recommendation only.

¹The regional divisions are based on the definition used by the Statistics Division of the United Nations Secretariat for statistical analysis of the global data.

²Regional variations.

See supplementary table 7 for a list of data sources for the catch-up cohort.

Table 4. List of WHO/ER countries reporting a monitored VCR (n = 30) ^†.

Country	Monitored VCR	Primary cohort gender	Monitored VCR range	Year of statistics*	HPVv dose received at time of VCR estimation	Primary cohort age/birth cohort group	Data source**
Turkmenistan	99%	F	○○○○	2018	RFS (i.e. ≥2)	9	WHO 2018 report
Portugal	90% −94%	F	○○○○	2018	≥2	2004–2006 birth cohort	National source
Belgium-Flanders^†	91%	F	○○○○	2016	≥2	9 ~ 14	National source
Iceland	91%	F	○○○○	2018	2	12	National source
Malta	89%	F	○○○○	2018	RFS (i.e. ≥2)	12	WHO 2018 report
Norway	88%	F	○○○○	2018	2	2002 birth cohort	National source
Sweden	84%	F	○○○○	2019	2	2006 birth cohort (grade 5 or 6)	National source
UK	84%	F	○○○○	2019	2	13 ~ 14	National source
Spain	73%	F	○○○○	2018	2	2005 birth cohort	National source
Spain	85%	F	○○○○	2018	1	2005 birth cohort	National Source
Ireland	72%	F	○○○○	2016	2	12 ~ 13	National source
Finland	70%	F	○○○	2019	≥2	2006 birth cohort	National source
Lithuania	65%	F	○○○	2018	RFS (i.e. ≥2)	12	WHO 2018 report
Austria	60%	F	○○○	2014	Unclear (i.e. ≥1)	10 ~ 15	National source
	40%	M	○○	2014	Unclear (i.e. ≥1)	10 ~ 15	National source
Czech Republic	60%	F	○○○	2017	≥1	13–14	National source
	30%	M	○	2017	≥1	13–14	National source
Switzerland	60%	F	○○○	2018	2	16	National source
	17%	M	○	2018	2	16	National source
Denmark	58%	F	○○○	2019	Complete scheme (i.e. ≥2)	2006 birth cohort	National source
Luxembourg	56%	F	○○○	2016	2	1991–2003 birth cohort	National source
Luxembourg	62%	F	○○○	2016	1	Born between 1991 and 2003	National Source
San Marino	52%	F	○○○	2018	RFS (i.e. ≥2)	11–14	WHO 2018 report
Italy	50%	F	○○○	2017	2	2005 birth cohort	National source
	5%	M	○	2017	2	2005 birth cohort	National source
Slovenia	50%	F	○○	2018	Unclear (i.e. ≥1)	Grade 6	National source
Israel***	48.8%***	F/M	○○	2007	RFS (i.e. ≥2)	Grade 8 (13–14)***	National source
Israel	59%	F/M	○○○	2007	1	Grade 8 (13–14 years old)	National Source
Latvia	48%	F	○○	2018	RFS (i.e. ≥2)	11	WHO 2018 report
Estonia	47%	F	○○	2018	2	12–14	WHO 2018 report
Netherlands	46%	F	○○	2019	RFS (i.e. ≥2)	2004 birth cohort	National source
Germany	45%	F	○○	2015	Unclear (i.e. ≥1)	17	National source
North Macedonia	45%	F	○○	2018	RFS (i.e. ≥2)	12	WHO 2018 report
Belgium, Wallonia-Brussels^†	36–50%	F	○○	2017	2 ~ 3	9–14	National source
France	23.7%	F	○	2019	3	16	National source
Kazakhstan	15%	F	○	2015	Unclear (i.e. ≥1)	11 ~ 12	National source
Armenia	8%	F	○	2018	RFS (i.e. ≥2)	13	WHO 2018 report
Bulgaria	4%	F	○	2018	2	12–13	National source

Abbreviations: VCR, vaccination coverage rate; RFS, Recommended Full Scheme; F, Female; M, Male; WHO, World Health Organization; HPVv, human papillomavirus vaccination; WHO/ER, WHO Europe.

Legend: ○○○○ – High VCR (>70%); ○○○ – Moderate VCR (51–70%); ○○ – Low VCR (31–50%); ○ – Very low VCR (≤30%).

^†Although separate data were reported for Belgium’s Flanders and Wallonia-Brussels regions, Belgium has been counted as a single country for the purpose of this analysis.

* The data presents the year of statistics for the coverage as reported in the source rather than the year of the publication.

**The data sources are described in supplementary table 8.

*** Note that the VCR reported for Israel included the primary cohort which comprised both girls and boys. Separate data for girls and boys were not available.

Table 5. List of WHO/ER countries with target VCR (n = 10)

Country	Target VCR (%, definition where available)	Monitored VCR	VCR range	Primary cohort gender	Target year	HPVv dose received	Primary cohort age
Portugal	85%, for 10–14 y/o girls	90%-94%*	○○○○	F	2018	≥2	2004–2006 birth cohort
Sweden	>90%	84%*	○○○○	F	2019	≥2	2006 birth cohort
UK	90%, for 13–14 y/o girls to receive 2 doses	84%*	○○○○	F	2018–2019	2	13–14 y/o (Grade 9)
Ireland	≥80, for girls to receive to receive 2 doses	72%*	○○○○	F	2016	2	12–13 y/o
Switzerland	80%, for girls and boys to receive 2 doses	60%*	○○○	F	2018	2	16 y/o
		17%	○	M	2018	NA	16 y/o
Luxembourg	80%, for the recommended population to receive 2 doses	56%*	○○○	F	2016	2	1991–2003 birth cohort
Italy	≥95%, for 11–12 y/o girls	50%*	○○	F	2017	2	2005 birth cohort
France	60%, for girls to receive complete regimen	24%*	○	F	2019	2	16 y/o
Bulgaria	75%	4%*	○	NA	2018	2	12–13 y/o
Greece	90%	NA	NA	NA	NA	NA	NA

Abbreviations: WHO/ER, WHO Europe; VCR, vaccination coverage rate; F, Female; M, Male; HPVv, Human papillomavirus vaccination; y/o, years old.

NA, not available.

Legend: ○○○○ – High VCR (>70%); ○○○ – Moderate VCR (51–70%); ○○ – Low VCR (31–50%); ○– Very low VCR (≤30%).

* VCR from national-level data source; in the case, dose-related VCR is specified, the VCR for the target population who received 2 doses is presented.