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On March 21st was held the webinar “HPV-related diseases and vaccine prophylaxis”. It was part of series “Vaccine school”- an Astra Forum Foundation initiative, in partnership with the Ministry of Health and UNICEF Bulgaria.

The lecturers at the event were:

  • Professor Dr. Mira Kozhuharova, epidemiologist
  • Tatiana Ralcheva, pediatrician
  • Miroslav Spasov, general practitioner
  • Momchil Baev, MD, Astra Forum Foundation


Professor Kozhuharova began the webinar, reminding the audience that the vaccination is the most efficient method for defeating infectious diseases, because they prevent their emergence. “Vaccination is an easy, safe and secure method for protection of development of dangerous diseases”, professor Kozhuharova said. She identified vaccination as the most rational approach for protection from infectious diseases. 

There are 14 high risk HPV types. They are the cause of different types of cancer – cervical, vulva, vaginal, anal, penile, oropharyngeal, as well as genital warts and recurring respiratory papillomatosis. The epidemiologist stated that vaccination against HPV is a universal tool, which protects effectively from every one of those different nosological units. She emphasized the importance of vaccine prophylaxis as the most accessible prophylactic measure. “Vaccine prophylaxis gives an opportunity to overcome the socially-economical inequality in this very important field of the healthcare system – protection from diseases, caused by pathogenic microorganisms.”

Bulgaria’s profile of disparities in oncology, published this year by the EU, shows that the average life expectancy in Bulgaria is relatively lower, compared to the other countries in the European Union. “This, in a way, is inequality”, said professor Kozhuharova.

It also became known that Bulgaria is the only EU country with increasing cancer mortality – in 2011 – 229 deaths out of 100 000 and in 2019 – 242 cases. The increase among men is 8% and among women – 5%.

In the words of the epidemiologist, the differences are not only between different countries. For example, in 2017 was received data for different regions in our country, reporting disparities in diseases.

Bulgaria is one of the countries in the EU with the lowest range for cervical cancer, and the highest social and economical inequality, regarding the participation of women in this screening. It appears that for 2019 only 45% of women over the age of 15 reported that they have been tested in the past 3 years. “These data show that we need to have a more-specific approach toward cervical cancer treatments”, said the professor.

Kozhuharova also presented the Global strategy by WHO for elimination of cervical cancer, which was accepted in 2020 by 194 countries. The primary purpose of the strategy is “90-70-90”.

“90% of young women to be vaccinated with HPV vaccines by the age of 15. 70% of women at the ages of 35 and 45 to be screened, using a highly specified examination. And 90% of women diagnosed with cervical disease to receive treatment and care.”


The next lecturer, Dr. Tatiana Ralcheva, presented the topic of “Real practice data for impact and efficiency of vaccination against HPV”.

“We talk a lot about vaccines, but let’s take a look at real practice”, she said”. It is known that the discovery of drinking water is one of the most important ones in medicine. The discovery of vaccination, which saved millions of lives around the world, takes a second place.

Dr. Ralcheva spoke about an Italian doctor, who noticed that nuns do not suffer from cervical cancer. He thought that the reason must be, that they are not having sex. Thanks to that discovery, many studies and researches began, until the HPV was discovered.

In her words, every year 624 000 people, who have been infected with HPV are discovered around the world. 510 000 annual cases of cervical cancer among women and 9 900 annual cases of anal carcinoma among men.

Ralcheva reminded that the 9-valent vaccine against HPV contributes to ensuring the wide protection against specific HPV-related carcinomas and other diseases.

“The uses of real practice by programs for vaccination against HPV become apparent over time”, the specialist stated. “With persistent HPV infections and anogenital warts, we can see results within a few months, while with cervical, vulval, vaginal and anal pre-cancerous lesions, results take years. That is why there are constant studies and data collections being done.”

Ralcheva explained that the multicohort vaccination and high vaccination coverage are increasing the protection from genital warts. She gave an example with a research, which states that the monocohort vaccination and/or low vaccination coverage with more than 50%, shows a decrease in diseased by only 5%. The research shows that with multicohort vaccination and high vaccination coverage, the decrease is with 63%.

“To summarize, the data from practice show that HPV vaccination contributes to the decrease in disease spread”, Dr. Ralcheva concluded.


Dr. Miroslav Spasov presented the “National program for primary cervical cancer prophylactic” and the role of the general practitioners.

“Unfortunately, general practitioners in their daily routine are forced to struggle with thousands of myths – about socially-relevant illnesses, and also about vaccines.”

Cervical cancer is the second leading cancer-related cause of death among women between the ages of 15 and 44 in Bulgaria. According to the National Statistical Institute, the spread of cervical cancer in Bulgaria is increasing – 15 691 cases in 2017 and 16 006 in 2019. Dr. Spasov stated that cervical cancer morbidity in Bulgaria is twice as high as the average for Europe (28.7 out of 100 000 women in Bulgaria, with an average of 13.4 out of 100 000 women for Europe).

“It has been proven that bad hygiene among men, creates carcinogenic substances, which are responsible for the development of cervical cancer. Statistics show that Middle Eastern countries, where genital hygiene is praised, have significantly fewer HPV cases, compared to European countries”, said Dr. Spasov.

In his words, Bulgaria has only 3% HPV vaccination coverage, compared to 30% in average for Europe. Dr. Spasov appealed to the general practitioners for more intensive work and aiming towards higher vaccination coverage.

He presented the target groups according to the National program for primary cervical cancer prophylactics for 2021-2024. The main target group are young girls between the ages of 10 and 13. In their cases, two doses of HPV vaccines are used with a 6-month interval before receiving the second. Another target group are parents and young women under the age of 25.


Momchil Baev, MD, founder and chairman of Astra Forum Foundation, presented the topic of “Establishing an HPV coalition in Bulgaria and good practices around the world with battling HPV-related diseases”. He reminded the audience that on March 9th was created a national, expert, non-governmental coalition for active prevention of diseases, related to human papillomavirus.

The coalition is supported by the World Health Organization, National Network for Children and Patient Portal. Some of the participators to the cause were AP Antoaneta Tomova, AP Ilia Karagiozov, AP Mihail Okoliyski, Professor Radka Argirova, Dr. Hristiana Batselkova and others.

The reason for the establishment of the coalition is an alarming tendency – every day in Bulgaria, a woman dies from cervical cancer and 44 women are diagnosed with HPV. It appears that our country takes the third place in morbidity and fourth in mortality in Europe, regarding this type of cancer, caused by HPV.

“During the meeting, some possible solutions were discussed”, Baev said.

One of them is to consider an expansion of vaccinations against HPV, in order to reach young girls, as well as young boys. Currently, only young girls are entitled to the vaccine, but immunization of young boys could have a large impact on decreasing the HPV morbidity cases.

Another proposal was for the HPV coalition to request a summary from the Ministry of Health annually, for the implementation of the program for vaccination against human papillomavirus.

Another solution was to improve the mindset of medical workers towards the vaccines. Doctors who disagree with something related to medicine, or do not have enough information about it, must seek more information, instead of denying it without justification.

And last, but not least, the media, who write about the funds for health prophylaxis – to describe it as an investment, not an expense.

Momchil Baev, MD, paid attention to the vaccination of young boys.

“More and more countries already recommend the vaccination of young boys”, he stated. Up until 2020, some of the countries, who included boys in the vaccinations are Austria, Belgium, Croatia, Czech Republic, Denmark, Finland, France, Germany, Hungary, Ireland, Israel, Italy and Luxembourg, Netherlands, Norway, Portugal, Sweden, Switzerland, Turkmenistan and UK. This is shown by the graphics of the European cancer organization in 2022.

In the USA also accepted the vaccination of boys. However, the percentage of vaccinated people is still under 50% in the USA. Since September 2019 both boys and girls at the ages of 12/13 in the UK can be vaccinated (girls have been getting the vaccines since 2008).

Slovenia also decided to expand their range to a gender-neutral vaccination earlier this year (September 2021) and Greece is also undergoing the same process in 2022.

Baev emphasized that Australia is on the way to become the first country in the world which eliminated cervical cancer in 2028 – 2035, according to a study by Cancer Council NSW.

“A country without cervical cancer – that can be achieved using a combination of three primary steps – vaccination against HPV, screening and treatment of precancerous and invasive cancerous diseases, studies show.”

Momchil Baev, MD, presented statistics by The Lancet, which shows the basic evaluations for age standardized annual morbidity by invasive cervical cancer and the resulting mortality from 2015 until 2100. “These evaluations are calculated with approximate continuing high vaccination coverage and the use of screening.

Elimination of cervical cancer (four new cases of every 100 000 women every year) is expected to happen in 2028. If the existing screening continues, the cervical cancer frequency will reach the point of 0.57 cases out of 100 000 women in 2100, which is 91% lower, compared to 2006.

The founder of Astra Forum Foundation concluded with the necessity of communication between doctor and patient for expanding the immunization, presenting “Interpersonal communication for immunization – Guidebook for healthcare workers”.

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