Introducing HPV vaccines for a cervical cancer-free generation in Montenegro

Cervical cancer is the fourth most common cancer in women. It is caused by persistent infection with a virus commonly transmitted through sexual contact called human papillomavirus (HPV). According to WHO’s estimates, Montenegro has the highest rate of cervical cancer in Europe. In 2020, 26.2* women developed cervical cancer and 10.5 women died from the disease for every 100 000 women in the country 1. Cervical cancer is preventable through vaccination and screening: although the first HPV vaccine was introduced in many countries in 2006, HPV vaccines were still unavailable in Montenegro in early 2022. One of the four vaccines currently prequalified by WHO against HPV is the 9-valent HPV vaccine. It protects against nine types of HPV and approximately 90% of cervical cancers. To enable its launch in Montenegro, WHO’s Country Office mobilized resources for planning and preparation. Introduced for nine-year-old girls in September 2022, the 9-valent HPV vaccine coverage had been extended to 13.07% of the target population by mid-November 2022 2. The HPV vaccine is expected to drastically reduce cervical cancer morbidity and mortality in Montenegro within a generation.

How did Montenegro, with the support of the WHO Secretariat, achieve this?

To pave the way for the HPV vaccine, a comprehensive systems strengthening approach was conducted. WHO Montenegro provided technical and financial support to organize and implement government meetings and engagements designed to strengthen policy, planning and technical capacity. At the highest level, the Prime Minister of Montenegro committed to global roadmaps that aligned the country’s cancer control strategy with WHO’s Roadmap for Health and Well-being in the Western Balkans, 2021–2025 and WHO’s European Programme of Work, 2020–2025, creating an overarching policy environment that enabled HPV vaccination.

The government of Montenegro had originally planned to launch an HPV vaccination programme in 2020, but the COVID-19 pandemic severely limited resources available for strategic thinking and action on non-COVID-19 health issues. As a result, plans for HPV vaccination were put on hold and HPV screening programmes either suspended or considerably affected, putting thousands of women at heightened risk of cervical cancer.

After the most critical phase of the COVID-19 pandemic was over, WHO catalysed HPV vaccination by mobilizing resources for planning and preparation. Given the shortage of resources, the government had only secured a limited number of vaccines necessitating a revision of the vaccination plan. In order for it to be a success, the plan had to be backed by all stakeholders. A WHO Montenegro expert, with technical inputs from two WHO Regional Office and five WHO headquarters technical experts, collaborated with counterparts in the Ministry of Health (MoH) to organize national stakeholder consultations around HPV immunisation. Parents, schools and institutions across Montenegro were consulted and a draft national action plan was developed. In June 2022, WHO facilitated a multisectoral national dialogue on HPV vaccination. The draft national action plan was presented to attendees including the Minister of Health and Minister of Education, and consensus generated on HPV vaccine introduction. With the problem of cervical cancer at the forefront, the MoH also decided to resume cervical cancer screening programmes in late 2022. Input from the country’s National Immunization Technical Advisory Group (NITAG) was crucial in driving the process forward. WHO had invested in strengthening NITAGs in Montenegro and other middle-income countries of the WHO European Region for many years through training, technical support and peer-to-peer learning. This included a 2019 training session held in Montenegro for NITAG representatives from nine middle-income countries. To build up sufficient technical capacity for vaccine administration at the subnational level, WHO in October 2022 trained 35 trainers from the MoH and other institutions.

The circulation of false or misleading information – otherwise known as an infodemic – in Montenegro was exacerbated by the COVID-19 pandemic, contributing to heightened vaccine hesitancy and a lack of trust in health authorities. There was a risk that HPV vaccine hesitancy would be further intensified given that the HPV virus is sexually transmitted and the HPV vaccine ideally administered before the recipient becomes sexually active. To improve uptake of the vaccines, it was necessary to ensure that parents understood the need for the vaccine as a proven intervention for cancer control. A communications expert from the WHO Regional Office created messages tailored for Montenegro’s cultural context, based on the data collected during the stakeholder consultation.

The COVID-19 pandemic demonstrated “ that effective communication is a pillar of a strong response. Clear communication helps to counter any myths or misunderstandings, as well as build understanding and trust. The same is true for the HPV vaccine - to have a successful vaccination campaign, effective communication between health care providers and patients is essential.” - Dr Mina Brajović, Head of WHO Montenegro

On September 26, 2022, the HPV vaccine was rolled out in the country, targeted at nine-year old girls. The vaccine is expected to dramatically reduce cervical cancer-related morbidity and mortality within a generation. By mid-November 2022, 654 doses had been administered, covering 13.07% of the target population. On October 28, 2022, WHO met with the National Health Parliamentary Committee to discuss issues related to health and well-being, and a political declaration on Universal Health Coverage was adopted. WHO continues to work with the government of Montenegro to strengthen HPV vaccination programmes. One of the major strengths of the approach taken so far has been the use of local instead of international experts, which has led to increased ownership, commitment and institutional capacity that is likely to be sustained into the future.

Knowledge

WHO country stories: delivering for all

“This impact story was published as part of the WHO country stories: delivering for all report, which presents a snapshot of how WHO has delivered on its mission in countries and contributed to health outcomes across a wide range of issues during 2022-2023.”