gms | German Medical Science

Background: The human papillomavirus (HPV) is responsible for half of all virus-related malignant tumours and for almost all cervical cancer [1]. The Standing Committee on Vaccination (STIKO) has recommended the HPV vaccination for girls since 2007 and for boys since 2018. The vaccination age was lowered in 2014 from 12 to 17 years to 9 to 14 years with the possibility of completing vaccination up to 17 years. Two or three vaccine doses are required for complete immunization depending on age group. In order to eliminate cervical cancer, the WHO is aiming for a global vaccination rate of 90 percent for girls by 2030 [2]. The study uses health insurance data to examine the incidence of cervical cancer and the development of HPV vaccination rates.

Materials and Methods: Database: BARMER health insurance data up to the year 2022 excluding former insurees of Deutsche BKK (around 10% of all SHI-insured persons) [3]. The HPV vaccination was identified via the billing of the fee codes for the vaccination service, which are defined in Annex 2 of the Federal Joint Committee’s (G-BA) vaccination guidelines: 89110A and 89110B. In addition, special codes were taken into account that only applied to certain Association of Statutory Health Insurance Physicians (KV) and only for certain periods. The first vaccination of a calendar year was defined as the initial vaccination if no HPV vaccination had been billed for the child/adolescent in the five preceding years. The age reached in the respective calendar year was calculated from the year of birth. Definition of incident cervical cancer: documentation of an inpatient main diagnosis ICD-10 code C53 in the observation year and no outpatient diagnosis with the addition “confirmed” and no inpatient main or secondary diagnosis 4 calendar years before.

Results: The average incidence of cervical cancer in 20- to 29-year-old women fell by 53% from 2.51 to 1.18 per 100,000 women from 2011 to 2017 to 2018 to 2022 (periods before and after the introduction of the vaccination). In the group of 30- to 39-year-old women who did not have the chance to benefit from the vaccination, however, there was a slight increase in the incidence of cervical cancer from 12.2 to 12.7 per 100,000 women.

At the age of 14, 59.7% of girls in a cohort observed from the age of 9 were fully vaccinated in 2022, 58.4% in 2021 and 55.5% in 2020. Around 30% of girls in these cohorts had not been vaccinated and around 13% were incompletely vaccinated. Boys who could be observed up to the age of 13 were fully vaccinated in 24.8% of cases. Among the girls in a cohort that was observed from the age of 9 and turned 17 in 2022, 61.3% were fully vaccinated. In this cohort, girls who were first vaccinated at a younger age were more likely to be fully vaccinated than girls who were vaccinated later. The rate of complete vaccination by federal state varied in this cohort from 51.3% in Bavaria to 75.7% in Saxony-Anhalt. In the cohort of boys observed up to the age of 13, Bavaria also had the lowest vaccination rate at 15.7% and Saxony-Anhalt the highest at 41.8%.

A decline in HPV vaccination activity was observed after 2016, particularly from 2021 to 2022. The number of vaccine doses administered per 100 children fell from 9.8 to 7.5 for girls and from 8.5 to 5.8 for boys.

Over the years, the proportion of initial vaccinations administered to girls by pediatricians rose from 51% in 2015 to 68% in 2022, while the number of initial vaccinations by gynecologists fell. An increase from 63% in 2018 to 81% in 2022 was also observed for boys, while the first-time vaccination by GPs declined.

Conclusion: The data confirmed the effectiveness of the HPV vaccination with a decrease in the documented incidence of cervical cancer in the age group of women who have been offered HPV vaccination from the vaccination. The rates of complete vaccination of 60 percent for 14-year-old girls and 25 percent for 13-year-old boys are still a long way from the proclaimed target of 90%. If the observed trend of declining vaccination activity, particularly from 2021 to 2022, cannot be reversed, even lower rates of fully vaccinated children can be expected in the future. The situation could be improved by the introduction of an additional preventive check-up for children aged 9 to 10 years, which is currently being discussed [4], as well as the increased use of vaccination reminder systems, e.g. via the pediatricians’ “My Pediatric Practice” app. Health insurance companies can also help to increase vaccination rates by identifying unvaccinated or incompletely vaccinated children based on billing data and reminding them of the HPV vaccination, as well as by providing a digital vaccination record with a reminder function.