22 Chapter 1 issued a global call in May 2018 for the implementation of evidence-based interventions, including HPV vaccination, cervical cancer screening and management of disease, with the goal of eliminating cervical cancer as a public health problem. In August 2020, the World Health Assembly adopted the Global Strategy for cervical cancer elimination, with the aim of achieving and maintaining an incidence rate of less than four per 100,000 women in all countries 67. To achieve this, countries must meet the 90-70-90 targets by 2030 to be on the path towards cervical cancer elimination: 1. 90% of girls fully vaccinated with the HPV vaccine by the age of 15; 2. 70% of women screened with a high-performance test by the age 35 and again by the age of 45; 3. 90% of women identified with cervical disease receive treatment, with 90% of women with precancer treated, and 90% of women with invasive cancer managed. 1.3.1 PRIMARY PREVENTION: PROPHYLACTIC VACCINES Prophylactic HPV vaccines are designed to prevent initial HPV infection and thereby HPVassociated lesions. These vaccines consist of virus-like particles (VLPs) that resemble native virus particles, but are non-infectious and lack viral DNA 68. Currently, three highly efficacious licensed HPV vaccines are available: 1. The bivalent Cervarix® vaccine (GlaxoSmithKline) targeting HPV16 and HPV18 69, 70; 2. The quadrivalent Gardasil® vaccine (Merck), directed against HPV16, HPV18, HPV6 and HPV11 71, 72; 3. The nonavalent Gardasil-9® vaccine (Merck) targeting HPV16, HPV18, HPV31, HPV33, HPV45, HPV52, HPV58, HPV6 and HPV11 73. While type-specific, these vaccines, in particular the bivalent vaccine, also offer some crossprotection 74, 75. HPV vaccines have been available since 2006, and in the Netherlands, HPV vaccination with the bivalent vaccine was introduced in the Dutch National Immunisation program in 2009 for girls aged 12, with a coverage rate of 54.8% in 2021 76-78. From 2022 onwards, the Dutch HPV vaccination program is gender-neutral, vaccinating children at the age of 9 years 79. In 2023, a catch-up campaign was launched for unvaccinated boys and girls up to age 26. All strategies aim to increase HPV vaccine uptake and thereby contributing to herd immunity to protect the population against HPV-related cancer. 1.3.2 SECONDARY PREVENTION: CERVICAL SCREENING The goal of population-based cervical screening is to reduce mortality from cervical cancer by detecting and treating early cancers and cervical precursor lesions. Due to the long
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