The HPV Vaccination in Japan: Issues and Options

"This paper explores how Japan’s response to HPV [human papillomavirus] vaccine concerns has been perceived across the globe and illustrates examples in other countries that have faced similar challenges, such as Australia, France, India, and the United Kingdom."

This advocacy report from the Center for Strategic and International Studies (CSIS) Global Health Policy Center focuses on maintaining the public’s trust in the HPV vaccine, using the case of Japan to discuss loss of public confidence and trust in the vaccine. It includes recommendations to the Japanese government on building public trust.

The document reviews the history of the HPV vaccine and discusses controversy surrounding its application in a number of countries. Vaccine challenges include:

• It is relatively complex to introduce - it cannot be included in childhood vaccinations when most individuals have regular physician checkups.
• Timing matters - the recommendation is for 3 vaccinations in a 6 month period.
• Moral judgments and religious and cultural taboos can interfere with medical matters related to prevention for diseases related to sexual activity, especially when prevention actions should be taken prior to sexual initiation.

In the case of Japan in 2013, the Japanese Ministry of Health, Labor, and Welfare (MHLW) stated that the vaccine should be neither promoted nor recommended, and the Vaccine Adverse Reactions Review Committee (VARRC) gave a conference featuring girls who alleged adverse effects from the vaccine. The authors found evidence that a global audience has been influenced by media reporting of the position of Japan’s MHLW. Country case studies describe adverse publicity and ways in which communication surrounding this publicity was managed by public health officials of various countries.

Recommendations from the United States Centers for Disease Control and Prevention (CDC) address the following mistakes in public health communication: mixed messages from multiple experts; information released late; paternalistic attitudes; not countering rumours and myths in real time; and public power struggles and confusion. These recommendations include:

1. "Be the first to provide information. Don't withhold factual information. If this is done, it leaves a vacuum that may be filled by people who don’t have the public’s best interest at heart.
2. Be accurate with information. Accuracy is important, and so is responding quickly. These aspects can sometimes be in tension. The government should release factual information quickly and state what is being done to get additional information. The public is better served by receiving reliable information sequentially than a fully complete report months after an event.
3. Be credible. Governments should not withhold information to avoid embarrassment or a possible public 'panic' that rarely if ever happens. Uncertainty is worse than not knowing; rumors are more damaging than hard truths.
4. Express empathy. When government officials acknowledge in words what people are feeling, it builds trust. Officials can say, 'We understand why this might be concerning.' This should be followed by information that addresses public concerns.
5. Promote action. Giving people positive steps they can take, such as, 'Talk to your doctor', or 'You can find out more on this website,' encourages them to feel more in control and empowered.
6. Show respect. In particular, governments should never be paternalistic, either withholding information from the public to ‘protect’ them or dismissing concerns."

 In their conclusions, the authors give these steps to restore public confidence and trust:

• "Providing the public with a clear and concise decision, restoring an active recommendation for HPV vaccination, supported by evidence including statistics on the vaccine’s safety and highlighting the successful implementation and high uptake rates of the vaccine in other countries....
• Providing physicians, nurses, and other health care providers with accurate materials they can use with their patients to address concerns and questions....This information can be disseminated at schools, in doctors’ surgeries and clinics and online through websites similar to Australia’s cancer council and social media....
• Actively promoting HPV vaccination to parents (mothers in particular). Mothers are typically the family health care decisionmakers. They need to have their questions and concerns addressed in order to feel comfortable taking their daughters to be vaccinated.
• Advising that the HPV vaccine, like any other vaccine, may cause side effects but that these do not occur at a rate higher than other vaccine....
• Developing school-based vaccination programs, so that students do not have to miss class or find their own way to a medical clinic. School-based programs also allow for the engagement of parent-teacher associations, which can offer an important venue for dialogue and for cultivating parental buy-in....
• Establishing a system that allows the public to express concerns and receive swift, evidence-based answers."