I don't know what HPV is, and I don't want my child to know, is one of the comments that is Center for Investigative Journalism (CIN-CG) received during the conduct of an anonymous online questionnaire about vaccination against the human papilloma virus (HPV), which is currently carried out in Montenegro. This respondent stated that he will not vaccinate his child, and that he believes that he is not sufficiently informed about the vaccine, and for this dangerous, sexually transmitted virus, he thinks it is a fungus.
The HPV vaccine is intended for children and young people between the ages of nine and 26, so CIN-CG surveyed parents and young people about the level of information about HPV, and asked them whether they would vaccinate themselves or their child. The results of the survey showed that although the majority of respondents have a positive attitude towards the vaccine, as many as 25 percent have prejudices. When asked if they would get vaccinated, they answered that they would not or that they were not sure yet.
Prejudiced respondents express doubt and fear about the vaccine, and the survey shows that many are strongly influenced by misinformation and conspiracy theories. There is also a degree of stigma and ignorance regarding sexual health in general.
Thus, among the interviewees was a parent who has HPV, but will not vaccinate his child, but also several who believe that there is no need to vaccinate male children, which is another of the misconceptions and is not true.
The Institute for Public Health of Montenegro (IJZCG) has been providing vaccines for boys and young men since February 2024, which is in accordance with the recommendations of the World Health Organization (WHO).
The skepticism of many is also related to the pandemic caused by the corona virus and the distrust that comes from vaccines against covid. Thus, one respondent stated that he will not be vaccinated because, as he says, "as of 2020, no vaccine is safe".
It seems that these respondents have a greater fear of the vaccine than of cervical cancer, which in over 70 percent of cases is the result of untreated HPV virus. Montenegro has the highest incidence rate of cervical cancer, which is one of the most common types of cancer caused by HPV, as well as the highest mortality from this disease in Europe. In a much smaller percentage, as a result of HPV, both women and men can develop other types of cancer, and they are all sexually transmitted.
Human papilloma virus (HPV) is the name of a group of 200 known viruses, some of which are highly secretive. Each of these types of virus is easily transmitted, and preventive vaccination against HPV plays a key role in preventing these types of cancer.
Far from the desired number of vaccinated
Until the beginning of March of this year, 7.640 people were vaccinated against HPV in Montenegro, of which only 68 were male, according to the data of the Ministry of Health and Welfare.
"The response is satisfactory for now, but a lot of work still needs to be done to improve the vaccination program," the IJZCG told CIN-CG.
They emphasize that the small number of vaccinated men is a consequence of the fact that the male vaccination program only started in February.
In Montenegro, one dose of vaccine is used for complete vaccination of persons aged nine to 20 years and two doses for persons aged 21 to 26 years. The effectiveness of the vaccine decreases with age and the vaccine will not provide protection against the types of viruses with which the person has already come into contact, the IJZCG explains.
The goal of the World Health Organization (WHO) for the European region, to which Montenegro also belongs, is for the vaccination rate of girls to be at least 90 percent by 2030, as well as to significantly increase the number of vaccinated boys and young men.
"In order to have visible results, there should be at least half of the vaccinated in the population for which the vaccine is intended, continuously for 10 years or more," says IJZCG epidemiologist Milko Joksimović for CIN-CG.
"For now, we are far from that and the focus this year and the next few years will be on individual protection and a gradual increase in the vaccination rate, above all among children aged nine to 14, which is one of the main goals of the WHO, especially when it comes to girls."
IJZCG urges parents to vaccinate children aged nine to 14 as soon as possible, because at that age the vaccine is especially recommended and has the greatest effectiveness.
"The HPV vaccine will not be available indefinitely due to the high price, so they appeal to all those who have been offered vaccinations in this round of the program to take advantage of the opportunity," the IJZCG points out.
The HPV vaccine has already proven its effectiveness. Although it has been available in Montenegro since 2022, it has been available worldwide since 2006. In societies that have implemented vaccination programs, there are lower rates of HPV transmission and fewer cases of cervical cancer, as well as other types of cancer associated with the virus. Studies have proven a reduction of HPV infections and genital warts by up to 90 percent, among teenage girls and young women in Australia, Belgium, Germany, Sweden, Great Britain, the United States of America and New Zealand, explains the IZJCG.
"This is also expected in our country after 10-15 years of using the vaccine," says Joksimović.
Apart from the fact that Montenegro has the highest mortality rate from cervical cancer, our country also had one of the lowest screening rates for this disease in Europe during the 2019 WHO survey. Statistics are also a big problem, so currently in Montenegro it is not known how many women suffer from cervical cancer. The last official data are older than 10 years, from 2013.
The IJZCG announces that they will work on improving statistics, primarily in the department that deals with the registration of cancer cases, but also with the general record of causes of death in Montenegro, says Joksimović.
According to WHO data, the percentage of vaccinated girls in the European region in 2022 was around 32 percent, with some countries having a percentage of over 90 and some below five percent.
The HPV vaccine is not mandatory, but strongly recommended.
Both parents and young people are insufficiently informed
"Parents usually ask if the child may have any consequences, most often it refers to the fear of sterility... And the vaccine does the exact opposite. Namely, when there is an infection with HPV and consequently, for example, cervical cancer, depending on the degree of severity of the disease, there may be various surgical procedures, including the removal of genital organs, in order to save lives, which leads to difficult conception or sterility. ”, says Ivana Lakićević, specialist in pediatrics from the Podgorica Health Center, for CIN-CG.
Lakićević, as he says, uses every opportunity to talk to parents and children about the HPV vaccine during systematic examinations and clear up any doubts.
Almost 60 percent of the parents surveyed in the CIN-CG questionnaire said that the pediatrician did not inform them about the vaccine, while over a third of the respondents in the group of young people up to 26 years of age believe that the public lacks clear and reliable information about the HPV vaccine.
The majority of parents surveyed by CIN-CG, 80 percent of them, said they would vaccinate their children. Among the parents who do not want to vaccinate their children, they state that their children have already received enough vaccines, that they did not receive adequate information from the Ministry of Health, and that prevention in the form of gynecological examinations is sufficient. Some of them think that the vaccine is dangerous or they have among their friends people who are strictly against the vaccine.
There was a lack of appropriate involvement of local health centers when it comes to informing patients about vaccination, the IJZCG told CIN-CG.
"The big problem is that in some municipalities there is a shortage of pediatricians who are otherwise burdened with work and do not have time to actively devote themselves to promoting the HPV vaccine," says Joksimović.
According to the data of the IJZCG, vaccination rates outside the active campaign period were extremely low, said Joksimović.
Over 80 percent of parents and young people believe that educational institutions should be more seriously involved in education about the HPV vaccine. "Educations were carried out in schools for the parents of girls who were the first group to be vaccinated, online educations for educators in primary schools at the end of 2023, and educations for teaching staff and students in secondary schools are also planned, which will be done after agreement with the Ministry education", said Joksimović.
In general, the vaccination rate in Montenegro is decreasing
Only 56 percent of preschool children received the mandatory measles, mumps, and rubella (MMR) vaccine last year. At the end of 2023, UNICEF warned that Montenegro is the country with the lowest rate of routine vaccination of children in Europe, and that it must urgently increase the rate of immunization, because a large number of children are at risk of hospitalization, and even death, due to easily preventable infections.
"The decline in the vaccination rate was recorded for all vaccines that should be regular, and it was particularly pronounced for the MMR vaccine," says Joksimović.
"The rate of revaccination against diphtheria, tetanus and pertussis, which is carried out during the second year of life, has also decreased," says this epidemiologist.
Trust in childhood vaccines has generally declined in Europe and Central Asia since the Covid pandemic, UNICEF warned last year. Immunization is one of man's greatest achievements, and a large number of people are victims of misinformation caused by the pandemic, UNICEF said at the time. From 2020 to 2022, UNICEF recorded the largest decline in vaccination rates in the last 30 years, globally.
Multiple studies have shown a strong link between belief in conspiracy theories and vaccine aversion. People who distrust vaccines and believe in conspiracy theories tend to distrust science, according to the 2022 study, "On the Relationship Between Conspiracy Theories, Misinformation, and Vaccine Abstention."
The statements of some of the respondents of CIN-CG show that conspiracy theories also affect the inhabitants of Montenegro.
“I lost all confidence in vaccines after the 'corona pandemic'. It is clear that there was no virus, a lot of people died and are still dying from vaccines to this day... I would not take the vaccine again even at the cost of my life", said one of the CIN-CG respondents.
Some stated that they did not want to "introduce a cancer-causing virus" or "poison healthy children" with a vaccine, and several of them mentioned that there are bigger problems "that are not talked about", such as "GMOs" and "5G radiation".
Conspiracy theorists can influence even well-informed and educated people with their crazy stories, which are often found in the media, Darvin Murić, editor-in-chief of the "Raskrinkavanje.me" portal, which monitors fake news and misinformation.
"The fact that diseases that were eradicated in the last century are returning to Montenegro shows that disinformation and the anti-vaxxer movement go together and are leading society into regression," says Murić.
Debunking faces daily conspiracy theories related to this or that vaccine, explains Murić.
"There is almost no anti-vaxxer who has health problems that the anti-vaxxer movement, which is well networked in the online world, does not attribute to the vaccine against COVID," says Murić for CIN-CG.
The situation is similar with the MMR vaccine.
"Almost not a day goes by that we don't find claims that it causes autism on social networks and marginal portals, although there are countless studies, articles, and scientific analyzes that prove that this is not true. I think the impact of misinformation about the MMR vaccine and autism is best demonstrated by the examples we all have around us. Let's say, I have friends who are educated, are not part of the anti-vaxxer movement, have been vaccinated against COVID, but they delay vaccinating their child because they are waiting for the child to speak first. I know many such examples".
Stigmatization of sexuality is an important factor
Health workers must have an approach that is attentive, open and empathetic when discussing the HPV vaccine with parents and adolescents, which can lead to positive effects, says psychologist Stela Burzanović for CIN-CG.
Good preparation, the doctor's ability to communicate and approach the patient in the right way is key to obtaining information, giving adequate advice and instructions, explains Burzanović.
The sexual aspect is particularly important, explains Burzanović.
"Sexuality is a complex and sensitive topic that concerns every individual. However, society often sets norms, expectations and prejudices that can result in stigma that can have serious consequences on the emotional and psychological state of individuals, create feelings of shame, guilt, inferiority and isolation. This can prevent individuals from openly communicating about their concerns, needs, and have a negative impact on the care of sexual health", says Burzanović.
"Considering that this is the vaccination of a younger population, adolescents, it is of course important for a parent to be conscientious and educated, and the relationship between parent and child is also very important, for the parent to have an open and supportive attitude. And all this in order to break any pressures, stigmas, conspiracy theories", said Burzanović.
Women in low- and middle-income countries are at greatest risk
In 2019, HPV caused about 620.000 cases of cancer in women and 70.000 cases of cancer in men worldwide.
The highest cervical HPV mortality rate among women is in sub-Saharan Africa, followed by South America and the Caribbean, Eastern Europe, and Southeast Asia. In men, the incidence rates are lower.
Cervical cancer was the fourth leading cause of cancer and cancer death in women in 2022 with approximately 660.000 new cases and approximately 350.000 deaths worldwide. Cervical cancer accounts for over 90 percent of HPV-related cancers in women.
HPV is a very common infection, during life more than 80 percent of people will be infected with one or more types of this virus. The most dangerous types of this virus are "16" and "18", which are responsible for more than 70 percent of cervical cancer cases.
In most cases, the infection has no symptoms, which is why prevention is key. HPV screening and treatment of precancerous lesions is an effective way to prevent cervical cancer.
The infection is long-lasting, lasting one to two years on average and usually goes away on its own. In 90 percent of people, the body controls the infection on its own. However, at least one in 10 such infections become chronic and precancerous changes may develop. If these lesions are not removed in time, they can develop into an invasive form of cancer that can be life-threatening.
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