Human papillomavirus (HPV) is the name of a group of viruses that cause skin infection. HPV is the major “sexually transmitted” virus that are responsible of 99% of cervical cancer [1]. In the U.S., most adult women go to see doctors for comprehensive annual health exam and the cervical cancer screening test (Papanicolaou [Pap] smear) is a must part of women's annual check-up. The Pap smear test is strongly recommended either to all women who started sexual intercourse regardless of age or any woman who is older than 21 regardless of previous sexual history. In the meantime, the test is not socially perceived nor recommended as a routine test for women in Korean until advanced age, causing high morbidity and mortality rate due to the failure of early detection and treatment for the cancer.

Cervical cancer can be prevented up to 90% by proper HPV vaccination. Since the HPV vaccine was developed and used worldwide, the cervical cancer rate has been consistently decreasing in the U.S. and many countries in Europe for last decade [1]. On the other hand, according to a recent report of Ministry of Health and Welfare [2], the incident of cervical cancer in Korea has been continuously increased for last 20 years. It was 44,000 in 1999 but became 103,000 in 2017, which is 2.5 times higher. Multiple factors contributed to the increase in combination including social/cultural stigma on preventive screenings, related public health policies, and health care delivery system in Korea. However, the largest problem is that the perceived significance of HPV vaccine among Korean is still very low compared to the U.S. and other developed European countries, resulting in low HPV vaccination rate and delayed its inclusion to the Korean National Immunization Program (NIP).

Most people in Korea have an idea that cervical cancer occurs in only for women of middle or old age, but another recent health statistics reported that the cervical cancer rate in 20s and 30s in Korea has been consistently increased and it counts as more than 10% of total incidents as of 2016 [3]. Considering the current early age of women who start sexual activities compared to their parent's generation, there is an urgent need for health care providers and public health sectors in Korea to try to prevent HPV infection via proper HPV vaccination before women and men start any sexual relationship. In June 2016, Korea included free HVP vaccinations in its NIP. However, the HPV vaccine provided by NIP in Korea has not brought significant change as expected. There are several problematic issues to be discussed in timely manner. It is important to critically appraise those issues related to current NIP related to HPV vaccine and what we can do to make it better at this point.

The purpose of this issue paper is to thoroughly examine the critical issues in current HPV vaccination and its related NIP policies in Korea comparing to the U.S. and other developed countries and to explore the strategies and solution for increasing HPV vaccine rate and preventing the misuse of the vaccine.

Most of all, prompt change in health policies are required so that all 3 kinds of HPV vaccines (Cervarix, Gadasil 4, and Gadasil 9) can be covered by national health insurance in Korea for at least the HPV vaccine recommendation age group (age of 9 to 26). It is shameful that Korean NIP decided to provide free HPV vaccination almost 10 years later than the U.S. and other developed countries in Europe, but it is more shameful that Korean NIP takes an outdated action by offering only 2 HPV vaccines, which are NOT used any more in other developed countries, and to those girls who were born in only specific year (age 12). If she missed the HPV vaccine before December 31 of the offered year, she becomes not qualified for the free vaccine. This absurd NIP policy could sound so ridiculous for many others like me who have lived in different health care delivery system for several decades. Many might think, the decision to include HPV vaccine to the NIP looks like just another show-up business of Korean public health government sector, saying nothing more than “at least, we did something here”. Doing something is NOT important when we are talking about public health people in the nation. “We do the things in right ways” should be more like it. To do it in right ways, Gadasil 9 which can prevent HPV types 52 and 58 (most prevalent cervical cancer-causing HPV type among Korean women) should be properly included in the NIP in Korea with extended covered range of age and should be available to the public at more affordable price.

And another significant problem regarding HPV vaccination in Korea is that, health care providers (e.g nurses and doctors) and health educators (e.g. public health nurse and school nurse) are minimally educated and have limited knowledge about HPV, HPV infection, and the effectiveness/clinical implication/safety of HPV vaccines. Maybe, the bigger problem is that there is serious lack of perception on how important it is to be professionally prepared to educate patients and public in general about the topics. As results, people, especially parents of teenagers, are not properly informed and have limited health resources to obtain appropriate knowledge about HPV risk and the various health benefits of getting HPV vaccine. Considering this, health researchers need to immediately investigate current knowledge level and lack of perceived importance of HPV vaccine among health care providers and educators in Korea as the first step. Then, systemic strategic plans aiming at increasing their knowledge and professional preparedness need to be developed in timely manners. Nurses are at the front line of public education about vaccination. It is also very important for professors of nursing program to integrate the knowledge about HPV and HPV vaccine into their course contents at early stage of program so that nursing students can properly educate patients, family, and community during their clinical practice as well as after graduation.

Health care providers and educators in clinical and academic settings need to take more active roles in educating young teenagers, their parents, and local public communities about the importance of getting HPV vaccine. Since HPV vaccines can be co-administered with the meningococcal conjugate vaccine or Tdap vaccine [6], nurses and doctors in primary care clinics can offer HPV vaccination when they visit the clinics for those other mandatory vaccines by emphasizing the importance of preventing HPV infection via getting vaccine early. To facilitate this, all of clinic providers and staffs should have proper training on how to successfully communicate with teenagers and their parents about HPV vaccination in more effective ways. In addition, starting with the front office, it is critical that everyone is on the same page when it comes to proper vaccination practices, recommendations, and how to answer parents' questions about HPV vaccine.

Korean health government sectors like Korean CDC should be able to provide health care providers and educators with most reliable evidence-based practice guidelines and to update it on regular basis. And differentiated HPV vaccine statements using age-appropriate languages need to be developed for more effective educational impact on different age group of people. In addition, broad spectrum of educational opportunities should be given to teachers and school nurses of all elementary, middle, and high schools, especially in rural areas, so that they can have clear understanding of how to prevent HPV infection and why getting vaccination is so critical for students.

Teenagers and their parents themselves should be properly motivated to learn about HPV and the vaccine. We need to utilize different formats of mass media as educational tools to deliver knowledge about HPV and HPV vaccine more effectively to teenager groups. For example, the education can be delivered via popular web-toons, music video filmed by K-POP idol groups, and public speech by Korean celebrities rather than by politicians or public health educators with no sense of humor. In addition, more aggressive strategic plans should be discussed to deliver the importance of HPV vaccination to the public in general using creative ways for actual impacts on their health seeking behaviors.

Lastly, the misuse/abuse of HPV vaccine as a way of making money among health care providers should be deterred by assuring (legal) enactment. Offering HPV vaccine to the women older than 45, who do not have any benefits from getting HPV, is wrongful deception, intended to have financial or personal gain. It is “fraudulent behavior” by its definition. The wrongful offer of HPV vaccine to those age group should not be considered as just unethical behaviors but be considered as serious fraudulent misconduct requiring corresponding penalty imposed by government sector. I have heard from many relatives and friends in late 40s that they got 3 doses of ‘a kind of HPV vaccine’ recommended by their doctor, ended up with paying at least 400,000–900,000 won because it has never been covered by Korean national insurance. None of those was properly informed about the details about HPV vaccine and its clinical implications. They said, they got the HPV vaccine because the doctors told them to get it to prevent the cervical cancer. As result, those women have the misleading idea that they would not have a cervical cancer in their later life and do not need to do any pap smear test. This can bring out serious long-term impacts on decreasing screening rate for cervical cancer. This issue should be brought to immediate attention of the public and government sectors.

This issue paper was aiming at examining several critical issues in current available HPV vaccination in Korea and its related NIP policies comparing to the U.S. and other developed countries. In addition, the author tried to provide an insight for developing proper strategies and solutions for the future to make health care providers and educator professionally prepared and to prevent the misuse of the vaccine.