The Eight and a Half Years

If you were born in Japan between the late 1990s and the late 2000s, there is a reasonable chance that a vaccine which was legally free and legally available to you throughout your adolescence never reached you, and that nobody has ever explained to you why. This page is that explanation, and then the part that matters more: what is still available now.

Two things before it starts, because this subject has been argued about loudly and this page is not joining that argument. The symptoms reported after vaccination in this country were real experiences for the people who had them, and nothing here suggests otherwise. And the large epidemiological work done here afterwards did not find those symptoms to be more common among vaccinated girls than among unvaccinated ones. Both of those sentences are true at the same time. Holding both is the only honest position available, and it is the one this page takes.

And what this page is actually for is not the vaccine at all. It is screening — which is available to every reader of this page regardless of her age, regardless of whether she was ever vaccinated, regardless of her employer, and which catches this disease at a stage where it is curable. If you read one section, read that one.

In April 2013 HPV vaccination became a routine immunisation in Japan — the category that means free at public expense, with an individual notice sent to the families of eligible children. Two months later, on 14 June 2013, the ministry suspended the 積極的勧奨. That word is doing something very specific and almost everybody misreads it.

The vaccine was not withdrawn, was not banned, and did not stop being a routine immunisation. It remained free and available on request for the entire period. What was suspended was the recommendation — which in practice means the letter. The notice that tells a family their daughter is eligible, that says here is where to go and by when, simply stopped being sent.

Coverage then fell to something close to zero and stayed there for eight and a half years. That is worth sitting with, because it is one of the cleanest natural experiments modern Japanese public health has produced, and the finding is unambiguous: a programme that nobody is told about is a programme that does not exist. The entitlement was intact the whole time. Almost no one used it. Availability without notification is not availability, and this library has now made that observation about pensions, about allowances, about municipal screening and about three free government counselling doors — but nowhere is the demonstration as stark as here.

The recommendation resumed in April 2022. Nothing about the vaccine had changed in the interval; what had changed was the weight of evidence about the reported symptoms, and the accumulating cost of a decade of unvaccinated cohorts in a country whose cervical cancer burden in younger women had not been falling the way it had in countries with high vaccination and high screening coverage.

Because an entire cohort had passed through the gap, a catch-up programme was opened alongside the resumption: free vaccination for women born in the fiscal years 1997 through 2007, running from 1 April 2022 to 31 March 2025. A one-year extension then ran to the end of March 2026, for those who had already started the course inside that window and for the fiscal-2008 cohort that had aged out of routine eligibility.

Both of those windows are now closed. That is the plain position and there is no use softening it: if you are in that cohort and were never vaccinated, the free route is no longer open, and vaccination now means paying for it — three doses, at a cost that is genuinely significant. Some municipalities run subsidies of their own, independently of the national programme, and whether yours does is a question only your own city can answer. It is worth the phone call. It is not worth assuming either way.

It is also worth knowing what the vaccine does and does not do, because the answer shapes what follows. It works by preventing infection, which is why it is given before exposure and why the routine target is children rather than adults. It does not clear an infection somebody already has. And even the broadest formulation does not cover every oncogenic type — which is the reason, stated by every authority that recommends it, that a vaccinated woman still needs screening.

Which is the sentence this whole page turns on. If you were vaccinated, you still need screening. If you were not, screening is not a consolation prize — it is the intervention that actually catches this disease in individual women, it works at a stage where treatment is straightforward and fertility is usually preserved, and it is available to you now, this year, for very little money.

Cervical screening in Japan is a municipal programme, not a workplace one. It belongs to you as a resident, which means it does not depend on having an employer, does not depend on being insured through work, and continues if you stop working. This library’s essay on the annual health check makes the general version of that point; this is the specific case where it matters most.

Under the national guidance there are now two routes, and which one your city runs is a local decision made since 2024. The long-standing route is cytology — the smear — from the age of twenty, every two years. The newer route, where a municipality has adopted it, is an HPV test on its own from the age of thirty, every five years. A five-year interval sounds alarming next to a two-year one and is not: it is longer precisely because what it detects is the infection that would eventually cause the change, rather than the change itself, which gives it a much longer warning.

The practical failure is the same one that swallows the rest of municipal medicine. The coupon arrives with the tax paperwork, goes into a drawer, and the eligibility year passes without a decision ever having been made about it. Japan’s participation in cervical screening sits well below the level of comparable countries, and the reason is not that Japanese women have concluded it is unnecessary. It is that a decision never got made.

The honest obstacle for most women is not information and not cost. It is the chair, the position, the being looked at, and a suspicion — absorbed rather than taught — that this examination is somehow an account of how you have lived. So it is worth saying flatly what it consists of.

A smear takes under a minute of actual sampling. A soft brush or spatula collects cells from the surface of the cervix; most women describe pressure rather than pain, and it is over before the discomfort has finished registering. The HPV test uses the same sample. You are covered with a drape, the examiner is usually working from behind it, and in many clinics you can request a female doctor when you book — which is a normal request that reception staff hear constantly, not an imposition.

And the thing nobody says out loud: this examination is not an audit of your history. HPV is a common virus, most sexually active people encounter it, most infections clear without ever doing anything, and the presence of one is not evidence about anybody’s conduct. A woman who has had one partner in her life is eligible for this screening on exactly the same terms as anybody else, for exactly the same reason, and the examination has no opinion about her.

Ask women why they have not gone and the stated reasons are time and embarrassment. The unstated one, which is doing most of the work, is what if they find something. So here is the ladder, in advance, because knowing its shape removes most of what makes the letter unopenable.

An abnormal cytology result is common and it is not a diagnosis of cancer. The report comes back in a graded system, and the milder grades — the ones that account for most abnormal results — describe cells that look slightly unusual, which in the great majority of cases reflects a current HPV infection doing what HPV infections mostly do. For the mildest grade the next step is often simply an HPV test on the same sample, or a repeat in several months, because a large share of these resolve on their own without anything being done.

If the grade is higher, or a repeat is still abnormal, the next step is 要精密検査 — which sounds alarming and means a closer look. That look is a colposcopy: the cervix is examined under magnification in an outpatient appointment, and a small tissue sample may be taken. It is not surgery and it is not an admission. What it produces is a grading of the tissue itself, and again the lower grades are usually followed over time rather than treated, because they frequently regress.

Only at the persistent high grades does treatment normally follow, and the standard one is a conisation — removal of a cone of tissue from the cervix, usually as a day procedure. It keeps the uterus. Fertility is usually preserved, though it does carry a raised risk of preterm birth in a later pregnancy, which is a real trade-off and one your obstetrician will want to know about. None of which is this page making a recommendation; it is simply the shape of the path, so that the phrase 要精密検査 arriving in an envelope stops meaning the worst thing you can imagine.

And the reason the ladder matters so much in this particular disease: it is slow at the start and it is caught at the start. This is the cancer that this country has long called a mother killer, because unlike most cancers it concentrates in women in their late twenties through their forties — exactly the years when a woman is least likely to think of herself as somebody cancer happens to, and exactly the years in which the early stages are most reliably curable with the uterus intact.

There is a version of avoidance that is not procrastination at all, and it deserves to be taken seriously rather than scolded. A woman who has quietly decided she would rather not find out is not being irrational. She is protecting something — a stretch of ordinary life, a year in which she does not have to be a patient — and the wish to keep that is a real, legitimate thing that this library has defended on other pages.

The trouble is only that in this specific disease the arithmetic runs the wrong way for that strategy, and it runs wrong sharply. Not knowing does not buy a year without the conversation. It buys the same conversation later, about a version of the thing that is harder to treat and more likely to cost the uterus. The early stage is the one where the intervention is small; the late stage is where it stops being small. So the avoidance protects this year at the direct expense of a later year, and unusually for a health decision, there is no version of the trade in which waiting improves the terms.

Which is not offered as an argument to win with. It is offered because the feeling and the fact can sit next to each other without either one having to lose: the reluctance is understandable and does not need to be argued away, and the appointment can be made anyway, by somebody who is still reluctant while she makes it. Most of the women who go are in exactly that state on the morning.

Since the chair is the barrier, it is worth knowing that a route exists which does not involve one: an HPV test on a sample the woman collects herself. It needs to be described accurately rather than enthusiastically, because its status here is specific.

It is not the official screening method. The national guidance adopts clinician-collected sampling, and self-collection sits outside it. What does exist is a set of municipal outreach programmes aimed specifically at women who have not been coming — Sapporo has run one — where a kit is sent to non-attenders, and a set of commercial kits sold privately, which are marketed as a risk check rather than as screening and should be read as exactly that.

The research on the outreach programmes found what you would expect and one thing you would not. Sending a kit does raise participation among women who were not coming, which is the point of it. But the follow-through is where it leaks: a substantial share of the women who test positive do not then go for the cytology that a positive result exists in order to trigger. Which makes the honest summary a short one. Self-collection is a way of finding out whether you need to go. It is not a way of not going.

The routine programme is running normally again, and its target is girls from roughly the sixth year of primary school to the first year of high school. The notice is being sent once more. If a girl in your family is inside that band, the thing that determines whether she is vaccinated is almost entirely whether somebody opened the envelope and made an appointment — which is the same mechanism that decided the outcome for the cohort above, operating in the other direction.

This page does not tell anybody what to decide for a child. It only points out that the decision deserves to be made rather than defaulted into, by reading what is currently recommended and by whom, and that the consequence of a decision never getting made is precisely the thing described in the section above — an entitlement that was intact the whole time and went unused.

The house has nothing to sell on this page, as with the one about the annual check. There is no hour here that touches any of it, and the whole recommendation is a call to a municipal office and a form you already have.

So the last thing is the only instruction: find out what your own city offers and when you are next eligible, and put it in the calendar on the day you find out. A generation of women in this country lost a free, available entitlement because the letter stopped arriving, and the letter that still arrives is the one in the drawer with the tax papers. That is a small thing to have learned from something that large, and it is enough.