Strategic implementation of HPV vaccination to eliminate cervical cancer in Georgia

Abstract

Objectives

Human Papillomavirus (HPV) is a prevalent sexually transmitted infection and a leading cause of cervical cancer. In Georgia, cervical cancer ranks as the fifth most common cancer among women, with approximately 330 new cases and 200 deaths reported annually. Despite the availability of effective HPV vaccines, national vaccination coverage remains low. This study aimed to evaluate HPV vaccination coverage, analyze cervical cancer incidence trends, and model the potential impact of increased vaccination uptake on cancer prevention outcomes in Georgia.

Study design

A retrospective observational study was conducted using national health registry data and modeling projections to assess the burden of cervical cancer and estimate the effect of scaled vaccination coverage.

Methods

National health databases were used to analyze HPV vaccination rates and cervical cancer incidence. Descriptive statistics, chi-square tests, and linear regression were applied to identify trends and disparities. Additionally, a dynamic transmission model was developed to simulate the 10-year impact of increasing HPV vaccination coverage on cervical cancer incidence.

Results

The crude cervical cancer incidence rate was 15.7 per 100,000 women, with an age-standardized rate of 10.6 per 100,000. In 2022, only 38 % of eligible girls aged 13–18 received the first HPV vaccine dose, and 26 % completed the second dose. Regional disparities in vaccination and screening were noted, and overall screening coverage declined to 13,890 women screened in 2022. Modeling showed that increasing vaccine coverage to 60 % could reduce cervical cancer incidence by 50 % (preventing ∼163 cases); coverage of 80 % and 90 % could reduce incidence by 70 % and 85 %, preventing 228 and 276 cases, respectively.

Conclusion

Low HPV vaccination uptake in Georgia (38 % first dose and 26 % dull coverage) and declining screening limit cervical cancer prevention. Modeling shows that increasing vaccination coverage to 60–90 % could prevent 163–276 cases over the next decade. Strengthening vaccination and screening strategies is essential to move forward elimination.

1. Introduction

Human Papillomavirus (HPV) is one of the most prevalent sexually transmitted infections globally and remains a primary cause of cervical cancer [1]. Globally, cervical cancer represents a major public health concern, and in Georgia, it is the fifth leading cause of cancer-related deaths among women. Approximately 330 new cases and over 200 cervical cancer–related deaths are reported annually [2]. The age-standardized incidence rate (ASR) in Georgia is 10.6 per 100,000 women, and the mortality rate is 5.8 per 100,000, which is comparable to the global average incidence of 13.3 per 100,000 women [3].

Despite the availability of effective prevention tools, including vaccination and screening, HPV vaccine coverage in Georgia remains suboptimal, necessitating a comprehensive strategic approach. As of 2022, only 38 % of eligible girls had received the first vaccine dose, and 26 % had completed the full series [4]. The national cervical cancer screening program, available free of charge to women aged 25 to 60, also shows limited uptake, with coverage rates hovering around 10–15 % of the target population annually [5].

This article provides a comprehensive overview of Georgia's HPV prevention landscape. It evaluates the current epidemiological trends, describes the barriers to vaccine uptake, and presents simulation-based projections of potential outcomes under improved vaccination and screening scenarios. In doing so, it aims to inform national policies aligned with the WHO's cervical cancer elimination targets.

HPV is a circular double-stranded DNA virus encased in an icosahedral capsid [6], transmitted primarily through sexual contact. Over 200 HPV types have been identified, of which types 16, 18, and 45 are considered the most oncogenic, accounting for the majority of cervical cancer cases [7]. HPV infection is also implicated in other anogenital and oropharyngeal cancers. The cumulative lifetime risk of cervical cancer in Georgian women is estimated at 1.10 % by age 75, underscoring the need for a more aggressive prevention strategy.

Georgia's national immunization program initially targeted girls aged 9–13, later expanding to include catch-up programs for girls aged 13–18 and women up to age 45. Recent policy revisions introduced structured “clean-up” vaccination rounds.

• •Girls under 15 years receive two doses (0 and ≥ 6 months).
• •Girls and women aged 15–45 years, including those 27–45 with a medical indication, are offered three doses (0, 2, 6 months), with minimum intervals of 1 month between doses 1–2 and 3 months between doses 2–3.

Boys have also been included in the national vaccination scheme.

• •Boys under 15 receive two doses (0 and ≥ 6 months).
• •Boys aged 15–26 receive three doses on the same schedule as for girls and women.

The vaccine currently used is Gardasil 4, which provides protection against HPV types 6, 11, 16, and 18.

These structured vaccination protocols are designed to ensure comprehensive age-appropriate immunization. However, the low uptake and persistent regional disparities — with uptake as high as 83 % in some regions and as low as 21 % in others — highlight critical gaps in implementation, accessibility, and public awareness. Addressing these challenges is essential to meet the WHO's cervical cancer elimination goal, defined as reducing incidence to fewer than 4 cases per 100,000 women.

2. Methods

Data Collection and Sources. Data for this study were obtained from national health information systems, including the National Cancer Registry, the National Immunization Management System, and datasets from the HPV Information Centre and WHO global repositories. These sources provided data on cervical cancer incidence, mortality, vaccination coverage by region and year, and population demographics.

Descriptive and Inferential Analysis. Descriptive statistics were used to summarize the epidemiological landscape, including.

• •Cervical cancer incidence and mortality
• •Age-specific distribution of cases
• •Vaccination uptake across regions and target age groups

Metrics such as mean, median, standard deviation, and percentages were calculated to describe the distribution and trends in key indicators.

To assess relationships between vaccination coverage and cervical cancer incidence, inferential statistical methods were applied. Specifically.

• •Chi-square tests were conducted to determine whether there were statistically significant differences in HPV vaccination rates across geographic regions and demographic groups.
• •p-values <0.05 were considered statistically significant.

Trend and Predictive Analysis. Time trend analyses were performed to examine changes in HPV vaccination uptake and cervical cancer screening participation from 2008 to 2022. Linear regression models were applied to identify patterns in these trends and to project future outcomes under current trajectories.

Simulation Model Design. To assess the epidemiological impact of improved vaccination coverage, we employed a dynamic transmission model, calibrated to pre-vaccination incidence and HPV prevalence data. This model simulates the natural history of HPV infection, including.

• •Transmission by age and sex
• •Progression through HPV infection → CIN1 → CIN2 → CIN3 → invasive cancer
• •Spontaneous regression and immunity
• •Effects of vaccination (with assumed efficacy) and screening detection

Model parameters were informed by published literature, Georgian surveillance data, and WHO/ICO sources. Scenarios included baseline vaccination (26 %) and expanded coverage targets (60 %, 80 %, 90 %). Screening intensity was also varied in sensitivity analyses. Credible intervals (95 % CIs) were calculated using probabilistic sampling of parameter distributions.

This approach enabled the estimation of future cervical cancer burden, the number of cases potentially averted, and the timeline for reaching elimination thresholds under different policy scenarios.

3. Results

Cervical cancer remains a significant public health challenge in Georgia. According to the most recent national data [[8], [9]], an estimated new cases and 204 death occured in 2022. The crude incidence rate was 15.7 per 100,000 women, and the age-standardized incidence rate (ASR) was 10.6 per 100,000, slightly below the global average of 13.3 per 100,000. The cumulative lifetime risk of developing cervical cancer by age 75 in Georgia was estimated at 1.10 % (Table 1).

Table 1.

Cervical cancer incidence in Georgia compared to global estimates (2022).

Indicator	Georgia	Global
Annual Number of New Cancer Cases	327	604,127
Uncertainty Interval (95 % UI)	[306−350]	[582,031–627,062]
Crude Incidence Rate (per 100,000 women)	15.7	15.6
Age-Standardized Incidence Rate (ASR)	10.6	13.3
Cumulative Risk by Age 75 (%)	1.10	1.39

HPV vaccination uptake remains low in Georgia. In 2022, 38 % of the eligible individuals received the first dose, and 26 % completed the two-dose schedule. Coverage varies across regions: for example, Tbilisi recorded 21 % first-dose coverage, whereas Adjara reached 83 % (Table 2). Cervicl cancer screening participation has also decreased in recent years. The number of women screened declined from 26,348 in 2016 to 13,890 in 2022,representing a reduction of approximately 47 % (Table 3). Linear regression analysis indicated a statistically significant downward screening trend (p < 0.001).

Table 2.

HPV vaccination coverage by region in Georgia (2019–2022).

Year	Region	Target Population	1st Dose (%)	2nd Dose (%)
2019	Tbilisi	12,700	43	27
2019	Adjara	6300	85	56
2019	Shida-Kartli	4100	27	N/A
2019	Georgia (total)	54,700	48	36
2020	Tbilisi	18,600	8	7
2020	Adjara	2050	56	36
2020	Shida-Kartli	2500	33	37
2020	Georgia (total)	50,400	23	23
2021	Tbilisi	15,800	16	12
2021	Adjara	1800	72	66
2021	Shida-Kartli	1200	29	34
2021	Georgia (total)	37,000	24	24
2022	Tbilisi	12,400	21	12
2022	Adjara	2700	83	72
2022	Shida-Kartli	3900	14	10
2022	Georgia (total)	32,800	38	26

Table 3.

Annual participation in cervical cancer screening in Georgia (women aged 25–60).

Year	Number of Women Screened
2016	26,348
2017	22,281
2018	23,999
2019	18,047
2020	17,695
2021	15,712
2022	13,890

Model projections indicated that increased HPV vaccination coverage would lead to reductions in future cervical cancer incidence. Compared with the current baseline of 26 % coverage, increasing coverage to 60 % was estimated to reduce incidence by 50 % over the next decade, preventing approximately 163 cases. Increasing coverage to 80 % was projected to reduce incidence by 70 %, preventing about 228 cases. Coverage of 90 % was estimated to reduce incidence by 85 %, corresponding approximately 276 cases prevented (Table 4, Table 5). The projections were based on current vaccination and screening participation levels.

Table 4.

Estimated impact of HPV vaccination coverage on cervical cancer incidence.

Coverage Scenario	Estimated Reduction in Incidence (%)	Predicted Cases Prevented (Next Decade)
Current Coverage (26 %)	Baseline	N/A
Increased to 60 %	50 %	163
Increased to 80 %	70 %	228
Increased to 90 %	85 %	276

Table 5.

HPV vaccination coverage and projected incidence reduction (simulation outputs).

Vaccination Coverage (%)	Reduction in Incidence (%)	Cumulative Cases Prevented (10 Years)
60 %	50 %	163
80 %	70 %	228
90 %	85 %	276

4. Discussion

The findings from this study highlight both the pressing challenges and significant opportunities for strengthening cervical cancer prevention in Georgia. Despite the availability of effective HPV vaccines and screening infrastructure, implementation gaps remain wide, and uptake levels are insufficient to achieve population-level impact.

The national HPV vaccination program, introduced in 2018 and targeting children aged 9–13 (with a catch-up scheme for girls aged 13–18), has shown limited reach. By 2022, only 38 % of the eligible population had received the first dose, and just 26 % had completed the full course. These national averages conceal stark regional disparities: for example, first-dose uptake was only 21 % in Tbilisi, while Adjara reported a remarkable 83 % coverage. This contrast suggests unequal program implementation and varying levels of community engagement and health service accessibility. To address this, targeted interventions are urgently needed to reduce regional disparities and ensure more equitable vaccine delivery across the country [[10], [11], [12]].

Alongside low vaccination coverage, screening participation is also in decline. From 26,348 screened women in 2016, the number dropped to 13,890 by 2022. This steady reduction poses a significant barrier to early detection and treatment. Possible contributing factors include lack of awareness, service availability, social stigma, and competing healthcare priorities. Public education campaigns, community outreach, and integration of screening into routine primary care services could improve uptake, particularly in underserved rural populations [13,14].

The results of our dynamic simulation model support the conclusion that improvements in HPV vaccination could yield substantial epidemiological benefits. Increasing coverage to 60 % could reduce cervical cancer incidence by 50 %, preventing ∼163 cases in the next decade. Reaching 80 % coverage could reduce incidence by 70 %, averting approximately 228 cases, while 90 % coverage could yield an 85 % reduction, equating to 276 cases prevented over ten years. These modeled outcomes confirm the critical role of vaccination in altering the trajectory of cervical cancer and align with international findings from comparable studies [15,16].

However, these projections are contingent upon sustained policy commitment, cross-sectoral collaboration, and effective public health messaging. Furthermore, without a parallel effort to increase screening coverage—especially among women aged 25–60—the full benefit of vaccination may be delayed, particularly for cohorts already beyond vaccine-eligible age. As such, a dual strategy involving vaccination scale-up and revitalized screening is essential to achieve WHO's cervical cancer elimination target of fewer than 4 cases per 100,000 women.

In summary, Georgia stands at a pivotal moment. With improved outreach, equitable vaccine distribution, and reinforced screening efforts, it is feasible to significantly reduce cervical cancer incidence and approach global elimination benchmarks. Continued investment in prevention, coupled with community engagement and evidence-based planning, will be key to realizing this goal.

5. Conclusion

Low HPV vaccination uptake in Georgia (38 % first dose and 26 % dull coverage) and declining screening limit cervical cancer prevention. Modeling shows that increasing vaccination coverage to 60–90 % could prevent 163–276 cases over the next decade. Strengthening vaccination and screening strategies is essential to move forward elimination.

Human ethics and consent to participate

All data used in this study were collected from national health databases, which compile de-identified information from routine healthcare practices and public health surveys. No direct contact with patients or additional data collection from individuals was undertaken for this study, thus minimizing the risk to human subjects.

Authors contribution

All authors equally contributed to this article preparation.

Data availability

The datasets (HPV Information Centre, Module of Immunization Management, Cancer Registry) used and/or analysed during the current study available online, links are provided in references.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the author(s) used ChatGPT to improve readability and language. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Funding

N/A.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.