HPV-vaccination in the Netherlands

Abstract

The Human Papillomavirus is a virus which can infect cells in the cervix and other parts of the human body. Most of these infections pass unnoticed. But the virus can remain present and can cause cell abnormalities and in some women these cell abnormalities develop into cervical cancer. In the Netherlands there are around 700 cases of cervical cancer and 200-250 deaths per year despite a screening program which already exists since 1976. In 2006 a first vaccine against HPV gained market approval in Europe, this vaccine (Gardasil) protects against HPV type 16 and 18 which cause 70% of all cervical cancers and protects against genital warts (HPV 6 &11). In 2007 another vaccine became available, Cervarix, which protects against HPV type 16 and 18. When the vaccines were available in Europe, the Dutch Minister of Health requested the Health Council to develop an advice about the HPV-vaccination in 2007. This advice was given in March 2008. It stated that HPV-vaccination should be added to the National Immunization Program for 12 year old girls and a catch-up campaign for girls 13 to 16 years should be performed if the price of the vaccine would be low enough. The problem is that the vaccine is not successfully adopted. Only 52% of the 13 to 16 year old girls in the 2009 cohort took the vaccine. The RIVM, which is responsible for vaccination in the Netherlands, made efforts in 2010 to increase HPV-vaccination acceptance, but vaccination coverage did not increase. Many different actors and factors influenced the HPV-vaccination in the Netherlands and the actors which made HPV-vaccination possible were not able to make the invention of the HPV-vaccine into the desired societal success. This problem is researched with innovation system theory, which focuses on the actors, institutions and networks behind an innovation. To determine the performance of this system over time, functions of innovation systems are used. These functions are linked to aspects determining the performance of an innovation system, aspects such as knowledge developed and diffusion, goals and expectations set by industry and government and the lobby for and against a technology are researched. Beside the functions of innovation systems lock-in is researched as well. Lock-in is the intertie of actors or the system to adapt to a new technological paradigm because of previous routines. The innovation system and its dynamics have been researched using a qualitative method. Information resources have been scientific articles, media articles, websites of related actors, interviews with key actors, meetings and an internship at GlaxoSmithKline. To get an overview of the dynamics over time, events related to the innovation system functions are put on a timeline. The results showed that the low performance of HPV-vaccination (expressed in vaccination coverage) is mainly linked to a low creation of legitimacy for the HPV-vaccine, especially during the start of the vaccination campaign in 2009. Knowledge development and knowledge diffusion started late in the Netherlands and the guidance of the government was not sufficient to overcome a negative attitude. A comparison with England, where HPV-vaccination was successful, endorses this view, guidance of the government led to a more positive public opinion in England, making vaccination widely accepted. The main conclusion about the innovation system behind HPV-vaccination is that all system elements to make HPV-vaccination possible in the Netherlands are present, with the RIVM as a central actor in the current system. Lock-in did not occur on a specific technology; HPV-vaccination is offered nationwide within 2,5 year after introduction and possibilities of re-innovation of vaccination and screening practices are researched. Lock-in can been seen in the way the vaccine has been offered through the RVP, the vaccination campaign has been considered as too old fashioned. To improve the performance of HPV-vaccination, increasing the acceptation is of most importance. A long term policy is necessary, since the 2010 campaign showed that a low vaccination coverage does not increase easily. Improved knowledge diffusion towards end-users and health organizations is of importance, the RIVM is most suitable for spreading knowledge. The activities of the pharmaceutical companies have been discussed very negatively, a cautious approach is desirable. But also politicians and media should be aware of their responsibilities, public statements have consequences. A possible system alteration is to provide the HPV-vaccine through the drug reimbursement system. If HPV-vaccination is offered in this way, vaccination coverage can increase.