About this white paper

This white paper is an evidence-based call to action for Belgian policymakers on how to eliminate HPV-related cancers and diseases in Belgium by 2030. The first version was published in November 2023 and an update was published in February 2025. It describes the current situation on vaccination, screening, and data collection, creates an overall ambition to eliminate HPV-related cancers and diseases in Belgium by 2030, and gives recommendations on how to achieve this ambition. The recommendations in this baseline plan ensure that all people are protected from highly-preventable HPV-related cancers and diseases.

This report is developed with support of the following experts (in alphabetical order):

Prof. Dr. Maarten Albersen. Laboratory for Experimental Urology, Gene and Stem Cells Applications, Department of Development and Regeneration, University of Leuven, Leuven, Belgium.
Dr. Bart Demyttenaere. Director Study Department and Policy, Solidaris, Brussels, Belgium.
Dr. Kobe Dewilde. Department of gynecology and obstetrics, University hospitals Leuven, Leuven, Belgium.
Veerle Doosche. Policy officer, Sensoa, Antwerp, Belgium.
Prof. Dr. Gilbert Donders. Femicare, Department of Obstetrics and Gynecology, University Hospital Antwerp, Edegem, Belgium.
Anne De Middelaer. President Gynca’s, patient representative organization for gynecological cancers in Belgium, Sint-Niklaas, Belgium.
Dr. Pascale Grandjean. Department of gynecology and obstetrics, CHR Mons-Hainaut, Mons, Belgium.
Dr. Stéphanie Henry. Medical oncologist, “Head and Neck cancer” medical coordinator, BGOG steering committee member, Université Catholique de Louvain & CHU UCL Namur site Ste Elisabeth, Namur, Belgium.
Dr. Deborah Konopnicki. Chief of Medicine Department of Infectious Diseases, University Hospital Saint-Pierre, Brussels, Belgium.
Dr. Patrick Martens. Director of Center for cancer detection Flanders, Bruges, Belgium.
Prof. Dr. Willy Poppe. Department of gynecology and obstetrics, University Hospitals Leuven, Leuven Belgium.
Prof. Dr. Philip Roelandt. Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.
Prof. Dr. Beatrice Swennen. School of Public Health, Research Center of Health Policy and Systems – International Health, Université libre de Bruxelles, Brussels, Belgium.
Prof. Dr. Vincent Vander Poorten. Section Head and Neck Oncology, Otorhinolaryngology-Head and Neck Surgery and Department of Oncology, University Hospitals Leuven, Leuven, Belgium.
Sandra Van den Eynde. Department Head Advocacy, Sensoa, Antwerp, Belgium.
Prof. Dr. Marc Van Ranst. Laboratory of Clinical and Epidemiological Virology (Rega Institute) and Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium.
Prof. Dr. Alex Vorsters. Centre for the Evaluation of Vaccination, University of Antwerp, Antwerp, Belgium.

Executive summary

Purpose and scope

This white paper presents a practical plan for eliminating Human Papillomavirus (HPV)-related cancers and diseases in Belgium by 2030. This plan aligns with Sweden’s approach and centers on three main tactics: vaccination, early screening, and data collection.

Background and context

Human Papillomavirus (HPV) infection is responsible for approximately 5% of cancers across the globe [1]. Although more than two hundred types of HPV have been identified, persistent infections of twelve types are linked with cancer. Another seven genotypes were sporadically recovered from cancer tissues, but their oncogenic potential is uncertain [2]. HPV16 and HPV18 are known to be responsible for most HPV-related cancers [3].

HPV is largely linked to cervical cancer, which is the most common form of cancer caused by the virus. However, the virus also plays a role in cancers of the vagina, vulva, anus, penis, as well as some parts of the head and neck [4]. Additionally, HPV is related to non-cancerous diseases such as genital warts [5] and recurrent respiratory papillomatosis (RRP) [6]. It is estimated that over 1.000 people were diagnosed with cancer attributable to HPV in Belgium in 2021. Around 40% of these HPV-related cancers were not located in the cervix, underlining the importance of taking all HPV-related cancers into account when aiming for the elimination of the burden of cancers attributable to this virus [7] [8] [9].

Next to morbidity and mortality, HPV-related cancers are associated with a significant impact on quality of life. People living with HPV-related cancers have critical structures negatively impacted that are involved in breathing, eating, speaking, bodily waste elimination, and sexuality [10]. Cancer diagnoses in general are associated with a slightly decreased divorce rate, yet cervical cancer is linked to a higher divorce rate that may be due to the impact on intimacy and decreased sexual activity [11]. People who have survived head and neck cancers are twice as likely to die from suicide compared to people who have survived other types of cancer [12]. HPV-related cancers not only cause significant health burdens but also bring along substantial economic costs.

To tackle this widespread public health problem, the WHO and the European Commission have adopted strategies to eliminate cervical cancer, setting targets for vaccination, screening, and treatment. An overview of the most important targets is depicted in Table 1. These are further strengthened by the Council Recommendation on vaccine-preventable cancers to support Member States in increasing vaccination rates and improving monitoring of vaccination coverage, i.e. increasing efforts towards fully vaccinating at least 90% of girls against HPV at EU level by 2030, and aiming to significantly increase the vaccination of boys against HPV over the same period, so as to reduce the risk of transmission [13].

Despite these goals and sharp deadlines, country strategies at national and regional levels remain underdeveloped. Progress in achieving these targets varies between countries.

This report aims to assess the status, challenges, and opportunities in Belgium to contribute to the broader mission of reducing the burden of HPV-related cancers.

Current situation in Belgium

Vaccination

Vaccination data for Belgium show disparities in coverage between the first dose and full vaccination, and between the different federated entities. This holds opportunity for further improvements (see Table 2). It is important to emphasize that the latest figures for Flanders were recorded during the COVID-19 pandemic and are having an impact as a result.

The vaccination rate for the French Community in 2022-2023 had a relative increase of ~10% compared to 2020 [16] [17] .  

Suboptimal vaccination coverages in Belgium can be attributed to a complex interplay of factors. Firstly, a disconnect exists between the recommendations put forth by the Belgian Superior Health Council and the reimbursement policies of the National Institute for Health and Disability Insurance (NIHDI). There is currently no reimbursement for catch-up vaccinations after 19 years old, as well as for certain immunocompromised groups such as people living with HIV and pretransplant patients, and other populations with a greater likelihood to develop HPV-related cancers. This disparity hinders access and affordability, discouraging individuals from getting vaccinated.

Additionally, disparities in HPV vaccination coverage rates across Communities are primarily due to differences in the implementation of organized school vaccination programs between the Flemish and French Community. An analysis revealed that some services offer HPV vaccination while others do not [18]. It is observed that the eligible population of boys and girls for school-based HPV vaccination is unevenly distributed among these service types, with a substantial proportion overseen by services that do not offer vaccination (“non-vaccinating centers”) (30,6%) [18].

Gender disparities stem from the historical focus of vaccination programs on girls, perpetuating the misconception that HPV vaccination is exclusively for girls and solely related to cervical cancer prevention.

Parental consent requirements for underage students further complicate matters, as levels of education, awareness, and confidence regarding HPV vary among parents. Using a consistent and simple consent letter is a prerequisite in the engagement process for parents. While there were complexities in the French Community regarding the parental consent letter in the past, as compared to the Flemish Community, efforts have been made to create a clear, consistent, and simple template letter. However, this template letter is not systematically used by the extra-scholar health services. The lack of consistency can lead to less convincing parental advice, potentially resulting in suboptimal vaccine coverage rates for their children.

Screening

Specific for HPV-related cancers, organized screening of a target population for cervical and anal cancer is a second important pillar in the aim for eliminating HPV-related cancers in Belgium. In general, cancer screening can be conducted through two distinct approaches: opportunistic and organized screening. Opportunistic screening occurs when individuals decide to undergo screening at their own initiative or through a healthcare provider’s recommendation. Organized screening is a systematic and proactive approach where public authorities plan and implement screening programs targeting a predefined population with a high risk of developing a certain cancer.

Cervical screening

Similar to the HPV vaccination surveillance data, cervical cancer screening data also demonstrates disparities between the different regions, showing another opportunity to improve the screening coverage rates (Table 3). It is important to note that the figures for the Walloon and Brussels-Capital Region are underestimations due to the restriction to reimbursed Pap smear tests and the exclusion of non-reimbursed smears from the count.

Opportunistic screening prevails in Belgium due to low response rates in organized screening (14,6%) [20], resulting in a significant number of unscreened or irregularly screened women.

The Interministerial Conference for Public Health (IMC) announced in December 2022 that all women between 30 and 64 years old will be able to have an HPV test every five years, thereby replacing the current three-yearly cytology test [21]. KCE endorsed HPV-testing as primary screening test for cervical cancer in 2015 [22] and this evidence-based policy decision became effective on 1 January 2025 [23].

Suboptimal cervical cancer screening coverage in Belgium can be attributed to several drivers that contribute to disparities in screening rates. The discrepancy in cervical screening coverage rates between the Regions is most likely related to the presence of a structural, organized screening program in Flanders, which facilitates wider access to screening services and increased awareness among the population. The lack of a similar, well-established program in the French Community has likely contributed to lower screening rates in that area. As of January 2025, an invitation-based screening program was established for the Walloon Region [24].

Ongoing research efforts aiming to explore the most effective screening method for reaching specific population targets and underserved groups of women, including the use of self-sampling approach, add another layer of complexity to the suboptimal screening coverage. These research initiatives have yet to yield conclusive results, making it challenging to implement standardized and widely accepted screening protocols.

Anal screening

In Belgium, there is no organized screening program for anal cancer for high-incidence populations in place. As a result, coverage data about anal screening are lacking both at regional and at national level. As the burden of HPV-related cancers expands widely beyond the screening of cervical cancer alone, such screening program for people with a greater likelihood to develop HPV-related cancers and diseases should be implemented.

Data collection and quality assessment indicators

In the context of eliminating HPV-related cancers in Belgium, the goal is to support evidence-based decision making of academics, clinicians, and public health authorities. Enriched datasets have the potential to further direct research and public health measurements. This can be done by collecting the right datapoints, ensuring qualitative data and creating linkages between the different data repositories. Establishing effective data management for the epidemiology of HPV-related cancers, HPV vaccination coverage, and participation in cervical and anal screenings will enhance transparency regarding the progress made in Belgium towards achieving the various higher mentioned goals outlined by the WHO and the European Commission.

The management of HPV poses a multifaceted challenge in Belgium, primarily due to structural deficiencies and variations in data collection and linkage. One fundamental issue is the absence of the introduction of a systematic HPV test to detect high risk of any HPV-related oncogenic disease. This inability of the Belgian Cancer Registry to differentiate between HPV-related and non-HPV-related cancer, makes it difficult to gauge the actual impact of HPV on the cancer incidence in the country.

Also, completeness and accuracy of the collected data vary across different datasets. For instance, regional vaccination registers like Vaccinnet and e-vax are hindered by a lack of data collection for catch-up vaccinations and inconsistent participation by vaccinators, further complicating the assessment of vaccination coverage.

Furthermore, the lack of sustained linkage between vaccination registries and other data sources, such as screening and cancer registries, hampers the ability to conduct real-world evidence studies to evaluate the long-term effects of HPV vaccination.

Finally, the absence of a comprehensive report to monitor progress towards the elimination of HPV-related cancers, coupled with the quality of services and processes, leaves a critical gap in evaluating the effectiveness of public health measures in achieving international goals.

Conclusion and proposed actions

The well-defined targets set by the WHO, the European Commission, complemented with the European Council recommendations create a clear momentum to eliminate HPV-related cancers and diseases in Belgium by 2030. Despite that several measures for HPV prevention have already been implemented in Belgium, there is still room for improvement of the existing tools and the implementation of other targeted actions. Especially the disparities between Communities create opportunities to optimize the overall goal of eliminating all HPV-related cancers in Belgium by 2030.

To accelerate the elimination of HPV-related cancers and diseases, several practical and achievable steps can be taken to improve immunization rates and screening participation. In Table 4, a list of 14 actionable recommendations lumped to the following four major pillars are proposed: 1) HPV vaccination; 2) cervical and anal screening; 3) data and quality assessment indicators; and 4) multistakeholder commitment. Important progress has been made since the publication of the first edition of this whitepaper. However, there is still a large opportunity to take further steps towards making an important impact on public health.

Realizing the objectives necessitates a strategic and deliberate approach. Prioritizing actions based on their impact and effort required is obligatory to ensure effective channeling of resources and energies, in order to achieve a positive change.

In our view, the generalized administration of the HPV vaccination is a top priority (see actions 1-4, dark green). The rationale behind this is two-fold: firstly, the initial vaccination establishes long-term protection against HPV, thereby reducing the risk of any HPV-associated cancer. Secondly, it is important to administer catch-up vaccination up to the age of 30 years and to vaccinate immunocompromised groups. The former is crucial for reducing the transmission of HPV infection and the latter for altering the burden of developing HPV-related cancers eventually. This approach aligns with the EVEN FASTER concept for cervical cancer elimination in Sweden.

Subsequently, optimal screening for anal and cervical cancer is the next priority (see actions 5-8, grass green), as early detection leads to efficient interventions that prevent progression to invasive disease and ultimately increase survival rates.

Additionally, collecting and analyzing data on vaccination coverage, screening participation and disease prevalence helps in assessing the program’s impact and making informed decisions (See actions 9-11; light green). As these actions require deep-technical knowhow, it will take more effort and must be seen as part of a larger project, but for which the first steps should be set as of today.

Finally, stakeholder commitment by multiple partners is pivotal in sustaining and expanding HPV management efforts (see actions 12-14; gray). Therefore, collaborative engagement from healthcare professionals, experts, as well as from policymakers and the wider public is essential for ensuring the success and longevity of these initiatives.

Read the full white paper here.