Variation in HPV Vaccination Coverage Across the European Union

Abstract

Human papillomavirus (HPV) is the most common sexually transmitted infection globally. While most infections resolve spontaneously, persistent infection with high-risk genotypes (HPV-16 and HPV-18) is causally linked not only to cervical cancer but to a broader spectrum of malignancies, including anal, oral, and oropharyngeal cancers, affecting both women and men. Since its introduction in 2006, the HPV vaccine has proven near-complete efficacy against cervical cancer and approximately 82.7% efficacy against oral and oropharyngeal cancers, establishing vaccination as a cornerstone of cancer prevention. In 2021, Europe’s Beating Cancer Plan set the target of 90% HPV vaccination coverage among girls by 2030, alongside the elimination of cervical cancer (fourth most common cancer in women). All EU/EEA member states now recommend the two-dose HPV vaccination for both adolescent girls and boys within national immunisation programmes, with three countries following the WHO 2022 one-dose regimen guideline (off-label use as the EMA still did not approve it). Five countries have already reached the 90% coverage threshold among girls by age 15. However, despite universal public funding of HPV vaccination across the European Union, the variation of vaccination rates between member states is striking. Uptake ranges from 4% in Bulgaria to 97% in Portugal (2024), with major economies such as France falling below 50%. This paper will try to investigate the current structural, cultural, and programmatic determinants of HPV vaccination differences across EU member states. It will mainly focus on the potential enablers and inhibitors of vaccination: vaccine hesitancy, cervical cancer prevalence, immigration, single-dose regimen adoption, parent support, physician recommendation practices, and school-based vaccination policy.

1. Introduction

Cervical cancer is a widespread and threatening public health burden. It affected approximately 660,000 women globally and caused 350,000 deaths in 2022 [1]. The disease is disproportionately prevalent in low- and middle-income countries, yet far from absent in high-income settings. In Europe, it is the third most common cancer among women under 44 years of age [2]. The disease is causally driven by persistent infection with high-risk genotypes of human papillomavirus, HPV-16 and HPV-18, which together account for approximately 70% of cervical cancer cases [3]. HPV also leads to a broader spectrum of malignancies affecting both sexes (including anal, oropharyngeal, and penile cancers), making it a broader oncological threat extending beyond women’s health [4].

Cervical cancer is almost entirely preventable. Since its 2006 introduction, the HPV vaccine has demonstrated near-complete efficacy against the high-risk genotypes responsible for many cervical cancers, as well as a 82.7% relative reduction in oral and oropharyngeal HPV infection [5]. A 20-year post-introduction English study reported zero cervical cancer deaths among women aged 20–24 fully vaccinated in adolescence, representing a mortality reduction of 100% [6]. In addition, recent randomised controlled evidence confirms that a single dose of either approved vaccine confers at least 97% protection against HPV-16/18 persistent infection over 5 years, non-inferior to two doses [7]. In this context, the WHO has set an elimination target, 90% first-dose coverage among girls by 2030 [1], supported within Europe by the 2021 Europe’s Beating Cancer Plan [2,8]. All EU/EEA member states now recommend HPV vaccination within national immunisation programmes and publicly covers it.

However, the gap between prevention potential, and its realisation is stark. Across EU member states, HPV vaccination uptake (adolescent girls who received a first dose) ranges from 4% in Bulgaria to 97% in Portugal, with major economies, including France, below 50% (See Table 1) [9]. This variation cannot be explained by cost: public funding is near-universal. Instead, the evidence points to structural, programmatic, and demand-side factors. Knowledge and information about the disease are still lacking. Cultural beliefs and vaccine hesitancy prevail in certain areas, and physicians lack proactiveness and do not embrace their educator’s role. Finally, school-based delivery infrastructure is promising but inconsistently explored across national context and population subgroups.

Table 1. European Centre for Disease Prevention and Control. (2026). Vaccination coverage dashboard. https://vaccination-coverage.ecdc.europa.eu/ (accessed on 19 September 2026) [9].

Vaccination Uptake in Europe (First Dose Completion Amongst Girls by Age 15)
Country	Uptake (2014)	Uptake (2024)
Portugal	99%	97%
Iceland	99%	96%
Norway	80%	92%
Sweden	82%	91%
Denmark	88%	91%
Spain	67%	90%
Malta	89% (2015)	90%
Luxembourg	52%	87%
Finland	66%	82%
Lithuania	51% (2020)	82%
Belgium	66%	80%
Hungary	75%	76%
Austria	7%	75%
Ireland	87%	74%
Cyprus	52%	73%
Czechia	73%	69%
Germany	45%	68%
Italy	71%	68%
Netherlands	64%	65%
Estonia	59%	63%
Slovenia	45%	61%
Latvia	63%	58%
Croatia	3%	53%
France	19%	48%
Slovakia	24% (2023)	33%
Romania	14% (2023)	23%
Bulgaria	24% (2016)	4%

This paper investigates the determinants of such striking intra-EU divergence. Drawing on recent evidence from low- and high-performing member states, it examines the relative contributions of hesitancy, structural, and programmatic design to national coverage outcomes. It further explores how two underutilised policy levers, school-based vaccination programmes, and adoption of a single-dose regimen could accelerate convergence toward the 90% EU target, with particular attention to the potential gains for persistently underperforming countries.

2. Methods

This work is a narrative review, undertaken to synthesize heterogeneous evidence on the determinants of HPV vaccination coverage variation across EU/EEA member states. A narrative approach was selected because the relevant evidence spans epidemiological surveillance data, health system descriptions, qualitative studies of parental and physician attitudes, programme evaluations, and randomized trial data. These are bodies of literature that are not commensurable and cannot meaningfully be pooled. No meta-analysis was attempted.

Literature was identified through a search of PubMed, Google Scholar, the NIH, and the Lancet between 11 June 2026 until 26 June 2026 using a combination of terms “HPV vaccination,” “vaccination coverage in the EU,” “Vaccine hesitancy,” “school-based vaccination,” “single dose HPV vaccination,” and individual member states names. Coverage data were drawn from the ECDC 2026 report on HPV vaccination programmes in the EU/EEA [9]. Reference lists of included articles were hand-searched. Inclusion was limited to peer-reviewed studies and official reports published in English or French concerning EU/EEA population from 2015 onwards, except where earlier work documented programme introduction or historical determinants of vaccine confidence.

Country selection was purposive rather than exhaustive, following a positive and negative deviance logic. Countries were selected to represent the extremes of the EU coverage distribution (Portugal and Bulgaria) and influential member states performing below the EU average despite substantial health system capacity (France). They were also selected to isolate programmatic from cultural determinants, such as states sharing France’s Catholic tradition, migration profile, and universal coverage, but achieving markedly higher uptake (Spain and Portugal).

Not all references specifically defined vaccine uptake or completed vaccination. Sometimes, references reported at least a first dose of HPV vaccine was administered, which is specified in this review, but not all. Therefore, if not specifically specified, it is assumed that vaccine uptake can be interpreted that at least a first dose was given.

3. Part 1—The Disease and the Case for Vaccination

In 2022, cervical cancer ranked as the fourth-leading cause of cancer-related death among women globally and the second most common cancer by incidence and mortality in women of reproductive age [1,10]. More than 80% of sexually active adults will be exposed to human papillomavirus (HPV) in their lifetime; while most infections are cleared spontaneously by the immune system, persistent infection with high-risk strains (principally HPV-16 and HPV-18, two of over 170 known genotypes) drives malignant transformation across multiple anatomical sites [10,11]. It is estimated that HPV accounts for 90% of cervical and anal cancers; 70% of vulval, vaginal, and oropharyngeal cancers; and 60% of penile cancers, making it a disease burden affecting both sexes [11,12,13]. Globally, approximately 660,000 new cases arise annually, resulting in around 350,000 deaths [1]. While the highest incidence and mortality are concentrated in sub-Saharan Africa, Central America, and Southeast Asia, the disease remains a significant burden within the European Union, where around 33,000 cases of cervical cancer and 15,000 related deaths occur each year [14].

The HPV vaccine, targeting HPV L1 major capsid proteins, was first introduced in 2006 under a three-dose regimen, subsequently reduced to two doses in 2013. Three products are currently licensed in the EU: the bivalent Cervarix (GlaxoSmithKline Biologicals,, London UK) targeting the HPV high risk 16 and 18 subtypes; the quadrivalent Gardasil vaccine (Merck Sharpe and Dohme, Rahway, NJ USA) targeting the HPV genital 6, 11 subtypes and HPV high-risk 16 and 18 cancer subtypes; and the nonavalent Gardasil 9 vaccine (Merck Sharpe and Dohme) targeting the HPV 6, 11 genital subtypes and the HPV cancer 16, 18, 31, 33, 45, 52, and 58 cancer subtypes, the latter now the most widely used. The evidence for their efficacy is overwhelming. A Scottish study by Palmer et al. found that women vaccinated at age 12–13 with the bivalent vaccine recorded zero cases of invasive cervical cancer, indicating 100% vaccine efficacy; among women aged 14–22 who received three doses, cervical cancer incidence was 3.2 per 100,000 compared with 8.4 per 100,000 in unvaccinated women [5]. Most recently, a 2026 English study reported that among women aged 20–24 vaccinated at age 12–13 with coverage of 88–90%, no cervical cancer deaths occurred between 2020 and 2024, against 23 expected based on historical rates, a mortality reduction of 100% [6]. In earlier cohorts where vaccination was offered up to age 18, mortality reductions of 80% and 69% were observed in women aged 20–24 and 25–29, respectively [6].

Based on the above evidence, global and regional health authorities have set ambitious elimination targets. The WHO has identified cervical cancer as a priority, with a goal of 90% vaccination coverage among girls by 2030 [1]. Europe’s Beating Cancer Plan (2021) mirrors this ambition, designating cervical cancer as an eliminable malignancy on a global scale and committing to vaccinate at least 90% of the EU target population of girls, alongside a significant increase in boys’ coverage, by the same date [15]. Reinforcing this momentum, recent high-quality evidence (including a 2025 randomised controlled trial published in the New England Journal of Medicine) has confirmed the non-inferiority of a single-dose regimen [7,16], prompting the WHO to recommend its adoption. While single-dose scheduling has been taken up primarily in lower-income settings where financial and logistical barriers are most acute, it remains without EMA approval at EU level; three member states (Iceland, Spain, and Estonia) currently prescribe it on an off-label basis.

The scientific case is unambiguous: immunisation against HPV, and the elimination of cervical cancer, is within reach. Yet vaccination across the EU remains deeply fragmented, with member states consistently falling short of the targets set.

4. Part 2—Europe and a Fragmented Vaccine Coverage

Every EU/EEA member state now recommends HPV vaccination for girls, with the majority having extended their programmes to boys in pursuit of gender-neutral coverage [17]. Yet, the 2024 ECDC vaccination coverage reporting tool reveals a landscape of striking fragmentation (See Table 1) [9]. These vaccine coverage percentages are based on the administrative and/or survey data that countries report to WHO on an annual basis through the WHO/UNICEF electronic Joint Reporting Form [9]. Each country may have a different vaccination schedule and different target populations, which may include boys, but the EU average first-dose coverage among girls stands at approximately 70% (well short of the 90% target set by the EBCP), and the range across member states is extraordinary: from 4% in Bulgaria to 97% in Portugal. Five countries have already met or exceeded the 90% threshold: Portugal (97%), Iceland (96%), Sweden (91%), Spain (90%), and Malta (90%). At the other extreme, Bulgaria (4%), Romania (23%), and Slovakia (33%) remain dramatically below it, with Bulgaria’s coverage representing one of the most acute implementation failures in EU public health. Most surprisingly, the two largest economies on the continent (France and Germany) are far from immune to this underperformance. Germany records 68% coverage, while France remains the fourth-lowest performer in the EU at 48%. The distribution cannot be reduced to a geographic or economic divide. High performers include both Nordic and Southern member states, while low performers span Central, Eastern, and Western Europe; France and Germany record lower coverage than several member states with considerably smaller health budgets. Between 2014 and 2024, Austria rose from 7% to 75%, Croatia from 3% to 53%, and Spain from 67% to 90%, demonstrating that rapid convergence is achievable within a decade. Others moved in the opposite direction: Ireland fell from 87% to 74%, Latvia from 63% to 58%, and Bulgaria from 24% to 4%. Bulgaria’s position, therefore, likely reflects programme collapse rather than a programme that never began, and high coverage, once achieved, cannot be assumed to persist.

Coverage and current disease burden are correlated across member states. Bulgaria recorded cervical cancer mortality of 8.4 per 100,000 in 2021, among the highest rates in the EU alongside Romania and Latvia, and more than double the WHO elimination threshold, alongside 4% first-dose coverage [18]. The relationship is not, however, causal: cervical cancer develops over decades, and the cohorts eligible for vaccination are still too young to have reached the ages at which the disease occurs; today’s mortality reflects historical screening performance rather than recent vaccination. The two figures are best read as shared symptoms of weak preventive infrastructures rather than as cause and effect and as an indication of the burden that will likely persist in unvaccinated cohorts for a decade [18].

Portugal illustrates the opposite end of the distribution, though its benefits are likewise projected rather than yet observed. With the highest coverage in the EU at 97%, it demonstrates a substantial long-term return: a cost-benefit analysis estimated that Portugal’s national immunisation programme generates a benefit-cost ratio of 4.4 from a societal perspective and 3.8 from a governmental perspective, preventing an estimated 2.75 million HPV-related cases and generating €2.12 billion in healthcare cost savings over a 100-year horizon [19]. This return remains above 1.0 even when the programme is extended to adult males at near-complete coverage. It should be noted that this study was funded by Merck Sharp and Dohme, Rahway, NJ USA, and its conclusions should be interpreted accordingly. Together, these two cases illustrate that high vaccination coverage is not merely a public health achievement but a rational investment and that the cost of inaction falls most heavily on the populations already furthest from the elimination target.

Greece illustrates a third trajectory: measurable progress that nonetheless falls well short of the target. Using the national electronic prescription database, Doulou et al. found that first-dose coverage among girls aged 9–15 rose from 34.7% in 2022 to 41.4% in 2024, while coverage among boys rose from 10.8% to 31.4% following their inclusion in the national immunisation programme [20]. Completed vaccination among girls by age 15 increased more modestly, from 47.7% to 52.5%, leaving approximately half of Greek girls incompletely vaccinated at the age specified by the WHO target, while completion among boys rose from 1.0% to 27.7% [20]. Initiation also remains concentrated after the recommended window: only 18.6% of girls and 16.6% of boys aged 9–11 had received a first dose in 2024, indicating systemic delay rather than outright refusal [20]. Coverage varied geographically, with the highest rates in Crete and the lowest in the North and South Aegean, and adolescents born outside Greece were substantially less likely to initiate or complete vaccination [20]. The Greek case demonstrates both that rapid gains are achievable, particularly through gender-neutral extension, and that aggregate improvement can coexist with persistent delay and inequality within a national programme.

These differences are not likely to be attributed to cost or formal availability: the vaccine is publicly funded and programmatically recommended across all member states. The gap between policy commitment and programme outcome, therefore, demands a closer examination of the structural, programmatic, and demand-side determinants that shape uptake.

5. Part 3—Structural and Programmatic Determinants

5.1. Physician’s Attitude

Physicians represent the most trusted source of health information in vaccine-hesitant societies, making their attitudes and knowledge a critical determinant of HPV vaccination uptake. Research consistently confirms that when a doctor proactively recommends the HPV vaccine, both parental knowledge and acceptance increase significantly; the knowledge gap is modifiable through provider intervention [21]. Yet in several low-coverage member states, the evidence suggests a troubling gap between this potential and its realisation. A study examining French physicians identified five attitudinal typologies (dissidents, hesitants, laissez-faire, educators, and uncompromising vaccinators) and found that approximately half adopted a laissez-faire approach, neither actively recommending the vaccine nor engaging with parental hesitancy [22]. A consistent pattern emerges in patient-reported experience: qualitative research captures French mothers expressing strong trust in their doctors and an explicit willingness to defer vaccination decisions to them (“we don’t ask ourselves too many questions; we trust the medical body”) yet simultaneously reporting that neither their GP nor their paediatrician ever raised the subject. As one mother observed, “my doctor, what’s strange, is that he doesn’t talk about it; and the paediatrician either. So I tell myself, it’s strange, I feel like in France, it’s not something really developed” [23]. This dynamic is particularly consequential given that more than 50% of French parents of adolescent girls held negative or uncertain views about the HPV vaccine in a 2016 national survey [24]. The combination of sceptical patients and non-proactive physicians creates a structural impasse: parents who would defer to a recommendation that never comes. Physician mistrust of the vaccine itself compounds the problem; many hesitant physicians reported feeling inadequately informed, heavily influenced by public controversies, including a 2011 open letter by French doctors questioning the vaccine’s safety, and critical of perceived ties between public health authorities and the pharmaceutical industry. Crucially, even physicians convinced of the vaccine’s importance largely declined to adopt an educational role, expressing the view that the decision rested solely with parents. In Bulgaria, the picture is arguably more alarming at the level of future providers: a 2025 study of Bulgarian medical students found that 20% had never heard of HPV vaccines, 78% did not believe the vaccine could benefit already-infected individuals, and 30% considered sexually active patients ineligible [25]. This knowledge gap, if left unaddressed, risks perpetuating low coverage into the next generation of clinical practice.

5.2. Opportunistic System vs. School-Based Program

Structural delivery models further constrain uptake independently of physician attitudes. Both France and Germany rely predominantly on opportunistic, practice-based immunisation systems, in which vaccination depends on a provider choosing to raise it during an existing appointment, a model poorly suited to hesitant populations and non-proactive physicians. Consequently, school-based programmes have emerged as a promising corrective measure. A study evaluating the Bremen school vaccination pilot found a coverage boost of 12.1 percentage points, with 39% of previously unvaccinated boys and 31% of girls accepting the school offer [26]. Notably, uptake was higher among students from lower socioeconomic backgrounds (37% vs. 30%), suggesting school programmes may narrow equity gaps, though this finding derives from a single pilot and requires replication. Critically, health insurance data from Bremen showed an association with rise in first-time HPV vaccinations in private practices following the school programme launch, consistent with a demand-generation effect, although the observational design cannot exclude secular trends or concurrent national campaigns, prompting parents to proactively consult their GP rather than substituting for that relationship. This spillover effect was similarly documented in France’s Nouvelle–Aquitaine regional evaluation, where 56% of parents who ultimately vaccinated their child via a GP reported that the school campaign had encouraged them to do so [27]. The additive effect of educational programming within school campaigns is further demonstrated by the French e-Bug pilot in Alpes–Maritimes, where parental acceptance reached 34.5% in the intervention school compared with 10.1% in comparator schools, a threefold gap sustained across two consecutive academic years [28].

Taken together, the evidence points to a probable complementarity: school-based programmes generate demand and extend reach, but their full potential is realised only when physicians are adequately trained, proactively engaged, and positioned to convert that demand into vaccination. Neither lever appears sufficient in isolation.

5.3. Learning from Convergence: Why Iberia Succeeded Where France Did Not

The most instructive comparison within the EU is not between North and South, but between states sharing cultural and demographic characteristics that nonetheless diverge sharply in coverage. France, Spain, and Portugal are all majority-Catholic countries with substantial North African migrant populations and universal, publicly funded health systems. Their 2024 first-dose coverage among girls was 48%, 90%, and 97%, respectively [9]. Cultural inheritance, therefore, cannot carry the explanatory weight often attributed to it. The 67-country vaccine confidence survey conducted by Larson et al. among 65,819 respondents supports this directly and indeed points in the opposite direction: Roman Catholics, among all faiths surveyed, were associated with positive views on vaccine sentiment [29]. What the same survey did identify was a French outlier. The European region contained 7 of the 10 least confident countries on vaccine safety, with France the least confident globally: 41% of French respondents disagreed that vaccines are safe, against a global average of 13% [29]. French scepticism is thus not a Southern European or Catholic phenomenon but a nationally specific institutional artefact, shaped by the successive controversies discussed in Section 6.

Once cultural determinism is set aside, three programmatic differences appear to account for most of the gap.

Integration vs. stand-alone introduction: Portugal incorporated HPV vaccination into its National Vaccination Programme (PNV) as early as 2008, delivered free at all primary care units, and introduced the centralised digital registry VACINAS, used by primary healthcare nurses to track vaccination records and follow-up in cases of delay [30]. Programme integration within primary healthcare ensured vaccines were seamlessly incorporated into routine services, while clearly defined roles at national, regional, and local levels supported coordinated implementation and an established immunisation culture underpinned public trust. Coverage did not have to be generated: it was inherited from a system already providing near-universal adherence. The programme was subsequently extended in 2020 to boys born in or after 2009, with coverage among 12-year-old boys rapidly reaching 88% in 2023 [30].

Who is responsible for offering the vaccine: Spain’s decentralised introduction is revealing: of the 19 regions that introduced HPV vaccination between November 2007 and 2008, 11 administered the vaccine in schools and 8 in healthcare centres [31]. School delivery was the majority model from the outset, not a late corrective as in France. In both Iberian systems, the vaccine is offered by default, and the parental role is to decline rather than to request; in France, the offer is contingent on a physician raising the option during an unrelated consultation, a design that transmits provider ambivalence directly into coverage.

Financial architecture: Formal funding status is universal across the EU, but universality of funding does not necessarily mean equal access. In Portugal and Spain, the vaccine is free at the point of administration. In France, outside the school campaign introduced in autumn 2023, reimbursement is set at 65% on medical prescription, with the residual 35% falling to the family or its complementary insurer, and Gardasil 9 is priced at approximately 117 euros per injection [32]. Families must secure a prescription, purchase the vaccine at a pharmacy, and return for administration. The residual cost is modest; the three-step pathway is not, and its burden falls hardest on households least likely to persist.

Keys to success: Five transferable features characterise the highest-coverage member states: integration into a pre-existing national childhood immunisation schedule rather than a stand-alone HPV initiative; administration free at the point of care with no advance payment; delivery by school or primary-care nursing teams rather than gatekept by individual physician initiative; a population-based electronic registry enabling active recall of overdue adolescents; and early extension to boys, which reframes the vaccine as routine cancer prevention rather than a sex-specific intervention. Spain’s trajectory, from 67% in 2014 to 90% in 2024, is the more encouraging model for low performers since it demonstrates that convergence is achievable within a decade in a decentralized system aided by catch-up programmes for unvaccinated girls, the Public Health Commission’s January 2023 decision to include HPV vaccination for all minors regardless of sex and applied uniformly across Spain and off-label single-dose adoption [33].

6. Part 4—Demand-Side Determinants

6.1. Vaccine Confidence and the Information Environment

While structural and programmatic factors represent the primary levers for improving HPV vaccination coverage, demand-side determinants (patient attitudes, cultural beliefs, and information environments) compound intra-EU fragmentation and help explain why delivery reform alone is insufficient. France offers the most documented illustration of this dynamic. The country has historically recorded one of the lowest levels of public confidence in vaccination globally, a pattern shaped by decades of erosion in institutional trust: the 1980s contaminated blood scandal, controversy surrounding the hepatitis B vaccine and its alleged link to multiple sclerosis, and the widely criticised handling of the H1N1 vaccination campaign have collectively embedded a deep cultural scepticism toward government health decisions. HPV vaccination became a particular casualty of this climate. Following the 2016 national survey already mentioned, in 2023, another survey found that one third of respondents had never heard of HPV [24]. Qualitative research captures the texture of this hesitancy vividly: French mothers described the vaccine using the expression “pas anodin” (it is not insignificant and does not come without risks), framing vaccination as a “serious decision” requiring extended deliberation rather than a routine health act. Negative media coverage played a reinforcing role, with mothers recounting alarmist press articles linking the vaccine to multiple sclerosis and other serious conditions [23]. Online information was similarly skewed, with negative content predominating. Critically, this demand-side hesitancy and the supply-side physician ambivalence documented in Section 5 are mutually reinforcing: in a context where doctors themselves publicly questioned the vaccine’s safety, patient mistrust deepened, while physician uncertainty was in turn amplified by the controversy they observed among their patients, a vicious cycle that France has only recently begun to interrupt through its 2023 school-based campaigns.

Beyond national hesitancy patterns, population composition introduces an additional layer of intra-EU variation. With approximately 90 million international migrants across EU member states, ethno-cultural factors constitute a meaningful but underexplored determinant of coverage disparities. The evidence, however, is neither uniform in direction nor readily generalisable across settings. A Danish cohort study found lower HPV vaccination rates among immigrant populations, with particularly marked differences among women from North Africa, the Middle East, and the Caribbean [34,35], linked to socio-psychological and cultural barriers that standard campaigns are not designed to address. Notably, under-vaccinated girls in this study also showed lower uptake of standard childhood vaccines and had mothers less likely to attend cervical cancer screening, suggesting that HPV hesitancy in these groups reflects broader patterns of disengagement from preventive healthcare rather than vaccine-specific concerns.

Norwegian register data present a markedly different picture. In a nationwide register-based study of 177,387 girls in the first six birth cohorts eligible for vaccination (born 1997–2002) offered the vaccine free of charge at age 12 through the school-based Norwegian Childhood Immunisation Programme, uptake rose from 72.5% in 2009 to 87.3% in 2014 and increased in every country-background category [36]. The highest uptake overall was recorded among girls with East and Southeast Asian backgrounds (88.9% against 82.5% in the total population), and girls with South Asian and East/Southeast Asian backgrounds were significantly more likely to initiate vaccination than girls with Norwegian background [36]. Girls with Middle Eastern and North African backgrounds did not differ significantly from Norwegian-background girls, while lower uptake was observed among girls with Western European, Central and Eastern European, Sub-Saharan African, and American or Oceanian backgrounds [36]. Notably, in the programme’s early years, girls with Norwegian background had lower uptake than girls with Central and Eastern European, Middle Eastern and North African, and Asian backgrounds; the majority population subsequently increased fastest, which the authors attribute in part to majority parents having been more exposed to early negative media coverage [36]. Socioeconomic patterning was also counterintuitive: uptake decreased slightly with increasing parental education while increasing with household income, and the negative education gradient was strongest among girls with Asian and European backgrounds.

6.2. Socioeconomic Inequality and Health System Organisation

Socioeconomic position shapes HPV vaccination uptake, though not through a simple gradient. A global umbrella review of routine vaccination uptake found socioeconomic differences in uptake, but noted that the association did not always follow a gradient and that reviews focusing on high-income countries showed a greater prevalence of mixed findings than those on low- and middle-income settings [37]. The two mechanisms most frequently identified were vaccination knowledge and confidence in vaccination or vaccination providers, both understood by review authors as varying by level of education, a role the review found to be country-dependent rather than universal [37].

The pattern is clearer for migration and ethnicity. A systematic review of 24 studies across eight high-income countries with school-based programmes—Australia, Belgium, Canada, New Zealand, Norway, Sweden, Switzerland, and the UK—found that minority ethnic groups and migrants had lower uptake than White groups and non-migrants in all 11 studies reporting the comparison, while lower socioeconomic status was associated with lower uptake in 11 of 17 studies; associations with parental education and religion were less clear [38]. The authors conclude that inequalities persist even in high-income countries with high-coverage school-based programmes [38]. This qualifies the equity claim advanced in Section 5.2: school-based delivery narrows but does not eliminate differential uptake, and the Bremen finding of higher acceptance among lower-socioeconomic students should be read as encouraging rather than settled.

France again illustrates the interaction between structural and social determinants. A survey of 1889 parents of adolescents across 61 French middle schools, conducted between November 2021 and February 2022, found that parents working as factory workers or farmers had substantially lower odds of HPV vaccine awareness than executives and professionals and that parents in lower occupational categories with multilingual households were markedly less likely to intend to vaccinate their child [21]. A recent physician visit or vaccine offer emerged as a strong positive determinant of awareness, uptake, and intention [21]. In an opportunistic system, the households least likely to receive a proactive physician recommendation are also those least able to absorb the transaction costs of the three-step vaccination pathway described in Section 5.3; deprivation and delivery design compound one another rather than acting independently.

Health system organisation matters in a further respect: the presence or absence of a population-based immunisation registry. Portugal’s VACINAS system permits identification and active recall of individual adolescents whose doses are overdue; systems without equivalent infrastructure can neither target under-vaccinated subgroups nor verify coverage reliably, which also compromises the comparability of the national figures on which cross-country analysis depends.

7. Part 5—The Single-Dose Regimen, Potential to Close the Gap?

The WHO endorsed single-dose HPV vaccination schedules in 2022, recognising accumulating evidence that a single dose offers durable, non-inferior protection for immunocompetent adolescents. The EMA has not followed, constituting a policy lag with tangible consequences for member countries needing simplified delivery.

The evidentiary basis for this position is now robust. The ESCUDDO randomised controlled trial (Kreimer et al., NEJM, December 2025), the highest-quality evidence to date, enrolled 20,330 girls aged 12–16 and confirmed single-dose non-inferiority to two doses for both bivalent and nonavalent vaccines, with HPV-16/18 effectiveness of at least 97% at 5 years and no evidence of waning between months 24 and 60 [7]. This builds on over 35 post-licensure effectiveness studies synthesised by Stanley et al. (2024) [16], alongside 11- and 12-year immunogenicity data from Costa Rica and India, respectively, showing antibody titres stable at 10-fold above natural infection through 16 years. One formulation nuance warrants acknowledgment: the single-dose bivalent vaccine showed significantly lower protection against HPV-31 (38.3% vs. 82.6% for two doses), while single-dose nonavalent reached 98.0%, suggesting that the schedule’s full protective potential is formulation-dependent. Several high- and middle-income countries (including the UK, Ireland, Australia, Mexico, and Bolivia) have already switched, demonstrating operational feasibility across diverse health system contexts.

For low-uptake EU member states, the programmatic gains are substantial. Second-dose attrition alone accounts for approximately 10% of consenting students failing to complete vaccination in documented European settings [26,27]. Single-dose schedules eliminate this completion barrier entirely and simplify supply chains, factors that led to fragmentation in low-capacity systems such as Bulgaria [7,18]. Mathematical modelling suggests single-dose vaccination would reduce HPV-16/18 prevalence by 63% within 20 years [16]. The economic case is equally strong: single-dose remains cost-effective even under conservative efficacy assumptions, and the benefit-cost ratio strengthens further in low-coverage contexts where two-dose completion constitutes a logistic burden.

8. Discussion

8.1. Key Points

Cervical cancer is almost entirely preventable yet continues to claim approximately 15,000 lives annually within the EU. The disease burden documented in this paper resembles a policy failure: the vaccine is safe, effective, and publicly funded across all member states and has been available for two decades. The scientific case for universal adolescent vaccination is unambiguous and continues to strengthen. What remains contested is not the vaccine efficacy, but why the gap between its potential and its realisation persists so stubbornly.

EU’s fragmentation cannot be attributed to cost or regulatory availability. Instead, it reflects a constellation of structural, programmatic, and demand-side failures operating differently across national contexts. Among these, physician passivity emerges as perhaps the most consequential. The French case illustrates a structural impasse that is unlikely to be unique to France: hesitant patients waiting for a recommendation that a non-proactive physician never provides. When this dynamic coincides with knowledge deficit among providers themselves (as documented among Bulgarian medical students), the consequences for future coverage are worrisome.

School-based delivery offers an evidence-based corrective measure. Pilots in France and Germany consistently show uptake gains, equity benefits, and downstream spillover into primary care. Embedding vaccination in the school environment normalises it as routine care rather than a deliberate parental decision. But delivery reform alone is insufficient: two-thirds of unvaccinated students still declined the school offer, confirming that structural and demand-side interventions must operate in parallel. Demand-side factors compound structural deficits rather than driving them independently. France’s historical low institutional trust in health authorities created fertile ground for HPV vaccine hesitancy, amplified by skewed media coverage and a medical profession that publicly questioned the vaccine’s safety. In migrant communities across member states, distinct but overlapping barriers (cultural associations between the vaccine and sexual permissiveness, language obstacles, and broader disengagement from preventive care) further fragment coverage in ways that standard campaigns are not designed to address.

Finally, the single-dose regimen represents a potentially transformative opportunity for the member states furthest from the 90% target. For systems characterised by fragmented governance, low provider density, and persistent second-dose attrition, removing the completion barrier could produce coverage gains that communication investment alone cannot achieve within the 2030 timeframe. The EMA’s timely approval of single-dose HPV vaccine would likely help close the gap in vaccine uptake.

8.2. Recommendations

Four complementary interventions emerge from this analysis, which should be strongly considered. School-based vaccination programmes should be extended and reinforced as a priority, embedding vaccination into routine adolescent care and reaching the equity gaps that opportunistic systems miss. Physician training must be strengthened to ensure providers in low-coverage settings are both adequately informed and actively engaged in recommendations. The framing of HPV vaccination should shift decisively from STI prevention to cancer prevention (the evidence consistently identifies sexuality-linked framing as the primary driver of hesitancy across cultural contexts), and the alternative framing is accurate and more persuasive. Finally, the single-dose regimen should be formally adopted in low-coverage member states as a programmatic lever, with the EMA urged to align with WHO guidance without further delay.

8.3. Limitations

Several limitations warrant acknowledgment.

(1)

This is a narrative rather than a systematic review. No formal protocol was registered, study selection was not conducted in duplicate, and no structured appraisal of study quality was applied. Selection bias in the evidence discussed, therefore, cannot be excluded, and the synthesis reflects the authors’ judgment about which studies were most illustrative. Searches were limited to sources in English and French, which may have excluded relevant national-language literature from the member states discussed—a particular concern for a review of intra-European variation since programme evaluations are frequently published in national languages and in grey literature.

(2)

Country selection was purposive rather than exhaustive. Countries were chosen to illustrate mechanisms at the extremes of the coverage distribution and, in the case of France, Spain, and Portugal, to hold cultural and demographic factors approximately constant. This design supports the identification of plausible mechanisms but not estimation of their relative weight across the EU as a whole, and member states not examined here may exhibit configurations of determinants that the cases selected do not represent.

(3)

Cross-national coverage comparisons are constrained by heterogeneity in national reporting. Member states differ in target cohort, age at assessment, dose schedule, and catch-up eligibility and derive coverage from sources of differing completeness, ranging from population-based electronic immunisation registries to administrative, reimbursement, and survey data. Countries lacking registry infrastructure are liable to under-ascertainment, and reference years vary. Reported figures are therefore best read as indicative of relative position rather than as precisely comparable estimates, and small differences between member states should not be interpreted as meaningful.

(4)

Much of the evidence synthesised here is observational, and several arguments rest on ecological interpretation of country-level data. Associations observed between aggregate coverage and aggregate outcomes cannot be assumed to hold at the individual level, and the country-level comparisons presented in Section 2 and Section 5.3 are consistent with the mechanisms proposed but do not establish them. Programme evaluations of school-based delivery are predominantly pre-post or regional in design and cannot exclude secular trends or concurrent national campaigns. Comparisons across countries are further complicated by differences in the periods studied, as with the Danish and Norwegian data on migration background discussed in Section 6. Causal language has been avoided throughout, and the determinants identified should be understood as plausible contributors rather than as estimated effects.

(5)

The latency between vaccination and cancer outcomes means that no member state’s coverage is yet reflected in its cervical cancer incidence or mortality. Current disease burden reflects historical screening performance, and the benefits of present coverage, like the economic returns modelled for Portugal, remain projected rather than observed.

(6)

Health policy remains a member state competence, and the structural diversity across national systems limits the generalisability of country-specific findings. This paper has not reviewed all member states exhaustively, focusing instead on illustrative contrasts between high- and low-performing systems. The proposed reframing from STI to cancer prevention, while supported by existing hesitancy research, has not been formally tested in EU-specific intervention studies. Finally, while single-dose RCT evidence is now robust, long-term surveillance data remain accumulating, and the schedule applies specifically to immunocompetent adolescents; people living with HIV continue to require multi-dose regimens, meaning single-dose adoption addresses the majority but not all the target population.

9. Conclusions

Cervical cancer elimination through vaccination resembles more of a governance challenge than a scientific one. HPV vaccination has proven to be safe and highly effective. It is part of all member states’ immunization program and is publicly funded. HPV vaccine uptake varying from 4% to 97% reflects structural inertia, physician passivity, and patient-side hesitancy operating in different configurations across various national contexts. No single intervention will help to fully close the gap. Improvement across the continent should be tackled through simultaneous action, better provider engagement, reviewed communication framing, and scheduling simplicity. School-based programmes, provider training, and single-dose regimen implementation have the potential to be transformative levers, especially within member states furthest from the 90% target. With the 2030 target approaching, the EU must prioritize addressing fragmented vaccine coverage and not accept the frustrations of preventable deaths as a feature of its public health landscape.