Cervical Cancer Elimination in Scotland Expert Group Final Report

8. Vaccination Subgroup

Background

Human Papillomavirus (HPV) Vaccination coverage across Scotland remains high, reflecting the hard work and commitment of Public Health Scotland, NHS Scotland colleagues and education partners, as well as their recognition of the benefits of vaccination. However, declining HPV vaccine coverage rates have been recorded over recent years, a trend which has also been observed UK-wide and globally.

PHS publishes HPV immunisation coverage rates annually in November for boys and girls in their first, second, third and fourth year of secondary school (S1, S2, S3 and S4). However, a widening and troubling inequalities gap in coverage has been observed across various metrics, including:

• sex
• deprivation (as measured by SIMD)
• ethnicity
• rural/urban classification

The reasons for these declines are multifactorial and include, for example: changing global attitudes to vaccination following the COVID-19 pandemic; changes in school attendance patterns (absences as well as remote learning)^[14] and false health information about vaccines harms.

HPV Vaccination Programmes

Background

HPV vaccine is offered to every S1 pupil in Scotland. The HPV vaccine protects both boys and girls from HPV-related cancers, specifically: cervical cancer, head and neck cancers (particularly of the oropharynx), anogenital cancers, penile, vulval and vaginal cancer.

In 2023, the routine HPV immunisation schedule in Scotland moved to one dose (previously three doses, reducing to two) offered initially in S1. Any young person in Scotland who does not take up their HPV vaccine offer in S1 will have further opportunities to receive their vaccination while in school and will continue to be eligible to receive the vaccine free of charge until their 25^th birthday^[15].

HPV vaccination is also available to men who have sex with men (MSM) up to and including age 45 years of age through sexual health/HIV clinics (regardless of risk, sexual behaviour or disease status).

Recent 2023/24 statistics and trends

HPV vaccination coverage has gradually declined over the past 10 years. This decline in immunisation uptake rates has been observed across the UK and globally However, uptake of one dose of HPV vaccine for S1 pupils slightly increased in 2024/25, with overall coverage rates of 72.6%, compared with 71.5% in 2023/24.

Each year, since the vaccine was first offered to boys in 2019/20, coverage has been lower than that of girls, and pupils living in the most deprived quintiles had lower coverage, compared with pupils from the least deprived quintiles. These inequalities have worsened over time.

Vaccine coverage in the 2024/25 school year varied by ethnicity. Among all S1 pupils, coverage ranged from 61.1% in Caribbean or Black ethnic groups to 74.1% in White ethnic groups. However, both the lowest and highest overall coverage was found within the White ethnic group; Gypsy/Traveller^[16] ethnicity had vaccine coverage of 22.7%, whilst coverage was highest in Irish ethnicity at 85.2%.

Geographic variation was also observed. S1 coverage was highest in accessible small towns and rural areas, and lowest in remote and urban areas. For example, coverage in accessible small towns was 75.3%, compared to 61.7% in very remote small towns.

Key Priorities of the Scottish Government and Public Health Scotland

The Scottish Government is working - through the Scottish Vaccination and Immunisation Programme (SVIP) - with Public Health Scotland and Health Boards to reduce vaccine-preventable diseases, increase vaccination uptake, and reduce inequalities. The first Annual Vaccination and Immunisation Report published by PHS^[17] in October 2024 noted that: “There is a pressing need to halt the current declines in childhood immunisation uptake rates across Scotland and (ensure) demonstrable improvements are achieved. Uptake of teenage immunisations has recovered following the COVID-19 pandemic, but not yet to pre-pandemic rates. This must be monitored closely.”

SVIP has published a SVIP 5 Year Vaccination and Immunisation Framework and Delivery Plan^[18] and an underpinning Implementation Plan is currently in development. The Framework and Delivery Plan highlights that: “in Scotland, despite the achievement of high vaccine uptake rates, avoidable inequalities in vaccination still exist within some population groups. Therefore, it is essential to achieve high vaccine uptake rates, especially in those within underserved communities, and this framework contains an outline of the delivery plan which is focused on the outcomes of increasing vaccination uptake, tackling inequality, and improving population health.” The Implementation Plan is developing actions to improve HPV vaccination uptake to support cervical cancer elimination. This provides the opportunity for the HPV vaccination programme to be an exemplar for the framework in action.

Alongside this, SVIP has introduced interim National Standards for Vaccination Services. Underpinning indicators and targets will follow. In guidance to Health Boards, they have been asked to demonstrate how they meet or are working towards meeting the standards in their Annual Delivery Plans for 2025/26.

The Population Health Framework^[19] was published in June 2025, and one of the primary focuses is prevention. HPV vaccine coverage has recently been introduced as an indicator in the Care and Wellbeing Dashboard^[20], which is designed to inform and provide a strategic focus for local planning work among local authorities and Community Planning Partnerships (with a key objective to reduce health inequalities).

Recommendations

SVIP and the CCE Vaccination Subgroup are considering many of the same potential actions to address declines in vaccination and inequalities in coverage in relation to HPV vaccination.

A range of cross-cutting actions have been identified which could lead to improved vaccine coverage and some of these are dependent on funding being available to support digital developments which are already under consideration.

These recommendations have been developed by the subgroup, within the context of the SVIP Implementation Plan, including:

Communications

• raising awareness of HPV as a cancer-causing virus for both boys and girls
• emphasising how common HPV is and the effectiveness of early vaccination against HPV
• implementing and evaluating tailored activities for stakeholders to address specific inequalities
• engaging with young people themselves and with parents/carers to gather insights on the programme

Resources

• providing national workforce education resources to help support the vaccination workforce to deliver the vaccination programme safely and effectively
• including better guidance on self-consent discussions
• helping support wider healthcare workforce and education colleagues to engage confidently in conversations about vaccination

Promoting Best Practice

• evaluating and sharing practices among Health Boards/vaccination teams to cultivate a collaborative and supportive culture

Ensuring Robust Processes

• identifying and vaccinating young people who have been missed or not engaged with the school-based programme
• developing initiatives to reach underserved groups, such as: children who do not attend school, sexual health service users, homeless people, young offenders and prison service users
• ensuring a consistent and optimal approach to self-consent by providing training materials and guidance, sharing best practice, and creating a supportive culture to empower the workforce.

Inequalities

• tackling inequalities that lead to variation in uptake and access, in line with recommendations set out in the Vaccination and Immunisation Framework and Delivery Plan

Engagement

• encouraging the involvement of vaccination advocates and trusted representatives within schools and communities to enhance efficiency to make every contact count – while ensuring they have the necessary resources to support their efforts
• promoting stronger engagement with education partners and other staff groups indirectly involved with or proximal to vaccination activities

Optimise delivery of the HPV vaccination programme

• ensuring multiple opportunities are available to access the vaccination throughout the school programme
• considering expansion of the current delivery model beyond school-based clinics by incorporating evening and weekend services in community settings and sexual health clinics – to reach individuals who are absent from school or no longer in the educational environment

Digital Innovation

• strengthening electronic recording and monitoring across school and community settings to improve data quality and enable targeted action to address inequalities
• improving user access to personal vaccination histories, with opportunities to integrate with wider NHS digital transformation (including mycare.scot) to enhance user experience, transparency, and awareness
• developing modern scheduling platforms and exploring digital consent solutions to streamline delivery
• optimising digital infrastructure to enable safe and effective integration of HPV vaccination data with cervical screening pathways

HPV/Screening offer

• exploring the offer of combined HPV vaccination and cervical screening using HPV self-sampling to women 25-29 years attending other health services such as sexual health clinics
• continuing to evaluate the vaccination programme and vaccine effectiveness as the programme progresses and matures

Conclusion

Coverage for the HPV vaccination programme in Scotland remains high and is amongst the highest in the UK – but has been declining in recent years, an adverse trend witnessed throughout the UK and beyond. We are pleased to note that research^[21] shows that there have been no cases of cervical cancer caused by HPV types targeted by the vaccine in fully vaccinated women who were given their first dose at aged 12 or 13 years old since the HPV programme was first introduced in 2008^{[22] [23]}.

This underpins the huge impact of the HPV vaccination programme on preventing cervical cancer and other HPV related cancers and diseases, for those who have been vaccinated. It is therefore imperative to halt the recent decline in HPV vaccination coverage but also that we strive to rapidly increase uptake for all eligible groups.

Scotland is well placed to make progress towards cervical cancer elimination by increasing HPV vaccination uptake. These preliminary recommendations have been formulated and will be refined with the welcome assistance of colleagues planning, delivering and supporting HPV vaccination across Scotland.

Of compelling importance, are inequalities in HPV vaccine uptake by deprivation category. This ‘vaccination gap’ has been recently widening – those school pupils living in areas of greatest deprivation are now less likely to be vaccinated than those living in more affluent areas than they were before. This is a clarion call for action and will require particular focus and resolve, going forward