Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis

Parents' uptake of human papillomavirus vaccines for their children: a systematic review and meta-analysis of observational studies

OBJECTIVE

To examine factors associated with parents' uptake of human papillomavirus (HPV) vaccines for their children.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Library, AIDSLINE, CINAHL, EMBASE, PsycINFO, Social Sciences Abstracts, Ovid MEDLINE, Scholars Portal, Social Sciences Citation Index and Dissertation Abstracts International from inception through November 2017.

METHODS

We included studies that sampled parents and assessed uptake of HPV vaccines for their children (≤18 years) and/or sociodemographics, knowledge, attitudes or other factors associated with uptake. Study risk of bias was assessed using the Effective Public Health Practice Project tool. We pooled data using random-effects meta-analysis and conducted moderation analyses to examine variance in uptake by sex of child and parent.

RESULTS

Seventy-nine studies on 840 838 parents across 15 countries were included. The pooled proportion of parents' uptake of HPV vaccines for their children was 41.5% (range: 0.7%-92.8%), twofold higher for girls (46.5%) than for boys (20.3%). In the meta-analysis of 62 studies, physician recommendation (r=0.46 (95% CI 0.34 to 0.56)) had the greatest influence on parents' uptake, followed by HPV vaccine safety concerns (r=-0.31 (95% CI -0.41 to -0.16)), routine child preventive check-up, past 12 months (r=0.22 (95% CI 0.11 to 0.33)) and parents' belief in vaccines (r=0.19 (95% CI 0.08 to 0.29)). Health insurance-covered HPV vaccination (r=0.16 (95% CI 0.04 to 0.29)) and lower out-of-pocket cost (r=-0.15 (95% CI -0.22 to -0.07)) had significant effects on uptake. We found significant moderator effects for sex of child.

CONCLUSIONS

Findings indicate suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents' positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs. Limitations of this meta-analysis include the lack of intervention studies and high risk of bias in most studies reviewed. Further studies should disaggregate HPV vaccine uptake by sex of child and parent.

Factors Associated with HPV Vaccine Refusal among Young Adult Women after Ten Years of Vaccine Implementation

In Italy, the Human Papillomavirus (HPV) vaccination was implemented for twelve years old girls in 2007, but its coverage was lower than the recommended level. Sicily is one of the Italian administrative regions with lower vaccination coverage, with a value of 59% for those born in 1996 increasing to 62% coverage for those born in 1999. The aim of the study was to investigate factors associated with the refusal of HPV vaccination among young adult women of Palermo, Italy. The study was approved by the Ethics Committee of the Policlinico “Paolo Giaccone” Hospital (Palermo 1) and the questionnaire was validated in a convenience sample representing 10% of the young women. A cross-sectional study was conducted through the administration of a telephone questionnaire, consisting of 23 items on HPV infection and vaccination knowledge based on the Health Belief Model framework. The eligible population were young women (18–21 years old) who had at least a vaccination among all included in the Sicilian vaccination schedule, without starting or completing HPV vaccination. Overall, 141 young women were enrolled (response rate 22%). Among them, 84.4% were unvaccinated and 15.6% had at least one dose of the HPV vaccine. In multivariate analysis, the factors associated with the refusal of the HPV vaccination were a bachelor’s as the education level (OR = 10.2, p = 0.041), lower participation at school seminar on HPV (OR = 0.2, p = 0.047) and lower perception of HPV vaccine benefits (OR = 0.4, p = 0.048). Public health educational program focusing and tailored on benefits perception of HPV vaccine and HPV disease severity, carried out at school or during medical visits, can be useful to improve HPV vaccination uptake.

Parental perspective on human papillomavirus (HPV) vaccination in Serbia: Knowledge, attitudes and practice

STUDY OBJECTIVE

Assessing knowledge and attitudes of parents towards human papillomavirus (HPV) vaccination of their children and estimating factors associated with parental positive attitude towards HPV immunization.

STUDY DESIGN

Cross-sectional.

SETTING

Two Community Health Centers. A total of 282 adult parents of boys and/or girls who presented at the pediatrician's office with their child aged ≤18 years from December 2015 to May 2016.

MAIN OUTCOME MEASURES

HPV vaccination coverage with one dose, knowledge and attitudes towards HPV vaccination. Parental knowledge was tested through a set of 10 items such as the infectious nature of HPV, mode of transmission, symptoms and its association with cervical cancer and circumstances surrounding HPV vaccine in Serbia. Answers were graded on a 5-point Likert scale from "strongly disagree" to "strongly agree".

RESULTS

Coverage with one dose of HPV vaccine was 2.0%. Majority of parents knew that the vaccine existed (71.0%). One quarter of parents confirmed that their child should be vaccinated against HPV. Parents expressed highest level of agreement with the statement that HPV vaccination in Serbia is not sufficiently promoted (4.17 ± 1.21 points). Having female child and more knowledge on HPV were independently associated with positive attitude towards vaccination among parents of children aged <9 years. Having received recommendation for HPV vaccination from a pediatrician was independently associated with positive attitude towards HPV vaccination among parents of children aged ≥9 years.

CONCLUSION

Coverage with one dose of HPV vaccine is low. Health-care authorities are urged to consider inclusion of HPV vaccination in immunization schedule.

The Relationship of Health Beliefs with Information Sources and HPV Vaccine Acceptance among Young Adults in Korea

Despite the HPV vaccine&rsquo;s efficacy in preventing cervical cancer, its coverage rates among Asians are very low. To increase immunization coverage among these populations, understanding the psychological factors that affect HPV acceptability is critical. To this end, this study examined the relationships between multidimensional health beliefs and HPV vaccine acceptance, and what information sources effectively foster HPV vaccination-related health beliefs. Data were collected using a survey of 323 undergraduate students in Korea. Results showed that perceived susceptibility, perceived severity, perceived benefits, and perceived vaccine safety concerns predicted vaccine acceptance. Multiple dimensions of perceived barriers showed differing impacts on vaccine acceptance. In addition, interpersonal information sources were effective in boosting various health beliefs for HPV vaccination. The Internet also was effective in reducing social barriers, but the effects were opposite to those of social media. Theoretical and practical implications are discussed.

Opportunities and challenges for human papillomavirus vaccination in cancer

The discovery of genotype 16 as the prototype oncogenic human papillomavirus (HPV) initiated a quarter century of laboratory and epidemiological studies that demonstrated their necessary, but not sufficient, aetiological role in cervical and several other anogenital and oropharyngeal cancers. Early virus-induced immune deviation can lead to persistent subclinical infection that brings the risk of progression to cancer. Effective secondary prevention of cervical cancer through cytological and/or HPV screening depends on regular and widespread use in the general population, but coverage is inadequate in low-resource settings. The discovery that the major capsid antigen L1 could self-assemble into empty virus-like particles (VLPs) that are both highly immunogenic and protective led to the licensure of several prophylactic VLP-based HPV vaccines for the prevention of cervical cancer. The implementation of vaccination programmes in adolescent females is underway in many countries, but their impact critically depends on the population coverage and is improved by herd immunity. This Review considers how our expanding knowledge of the virology and immunology of HPV infection can be exploited to improve vaccine technologies and delivery of such preventive strategies to maximize reductions in HPV-associated disease, including incorporation of an HPV vaccine covering oncogenic types within a standard multitarget paediatric vaccine.

Human papillomavirus vaccination coverage in Luxembourg - Implications of lowering and restricting target age groups

BACKGROUND

In Luxembourg, a national Human Papillomavirus (HPV) vaccination programme was introduced in 2008, targeting 12-17 year old girls offering a choice of bivalent or quadrivalent vaccine free of charge. In 2015, the programme was changed offering the bivalent vaccine only to 11-13 year old girls. The aim of this study was to evaluate the HPV vaccination coverage, to assess the impact of age target changes and compare vaccination coverage to other European countries.

METHODS

Anonymous HPV vaccination records consisting of individual vaccine doses obtained free of charge in pharmacies between 2008 and 2016 were extracted from the Luxembourgish Social Security database. Additional aggregate tables by nationality and municipality were analysed.

RESULTS

Of the target cohort of 39,610 girls born between 1991 and 2003 residing in Luxembourg, 24,550 (62.0%) subjects obtained at least one dose, 22,082 (55.7%) obtained at least two doses, and 17,197 (43.4%) obtained three doses of HPV vaccine. The mean age at first dose was 13.7 years during 2008-14 and 12.7 years in 2016 after the age target change. Coverage varied significantly by nationality (p < 0.0001): Portuguese (80%), former Yugoslavs (74%), Luxembourgish (54%), Belgian (52%), German (47%), French (39%) and other nationalities (51%). Coverage varied also by geographical region, with lower rates (<50%) noted in some Northern and Central areas of Luxembourg (range: 38% to 78%).

CONCLUSION

Overall HPV vaccination coverage in Luxembourg is moderate and varied by nationality and region. The policy changes in 2015 did not have a substantial impact except lowering age at initiating vaccination. Options to improve coverage deserve further investigation.

HIV-positive women have higher risk of human papilloma virus infection, precancerous lesions, and cervical cancer

OBJECTIVE

HIV-positive women have higher human papillomavirus (HPV) prevalence and cervical cancer incidence than HIV-negative women, partly because of HIV's modifying effect on HPV pathogenesis. We synthesized the literature on the impact of HIV on HPV natural history.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched the literature for studies evaluating HPV acquisition and persistence or precancer progression by HIV status. Data on HPV natural history by HIV status, CD4 cell counts, viral load, and antiretroviral therapy (ART) were summarized using fixed effect models.

RESULTS

Overall, 38 of 1845 abstracts identified met inclusion criteria. HIV-positive women had higher HPV acquisition [relative risk (RRpooled) 2.64, 95% confidence interval (CI) 2.04-3.42] and lower HPV clearance (hazard ratiopooled 0.72, 95% CI 0.62-0.84) than HIV-negative women. HPV acquisition was higher with declining CD4 cell count and was lower in those virally suppressed on ART. HIV was associated with higher incidence of low-grade squamous intraepithelial lesions (LSIL; RRpooled 3.73, 95% CI 2.62-5.32) and high-grade squamous intraepithelial lesions (HSIL; hazard ratiopooled 1.32, 95% CI 1.10-1.58), largely because of increased HPV persistence. ART lowered progression from normal cytology to LSIL (hazard ratiopooled 0.65, 95% CI 0.52-0.82), but not HSIL. Cervical cancer incidence was associated with HIV positivity (RR 4.1, 95% CI 2.3-6.6), but not with ART.

CONCLUSION

HIV-positive women have higher risk of acquiring HPV, with risk inversely associated with CD4 cell count. ART lowered HPV acquisition, increased clearance, and reduced precancer progression, likely via immune reconstitution. Although some of our results are limited by small number of studies, our study can inform screening guidelines and mathematical modeling for cervical cancer prevention.

Assessing the acceptability of incentivising HPV vaccination consent form return as a means of increasing uptake

BACKGROUND

Uptake of human papillomavirus (HPV) vaccination is high overall but there are disparities in uptake, particularly by ethnicity. Incentivising vaccination consent form return is a promising approach to increase vaccination uptake. As part of a randomised feasibility trial we qualitatively assessed the acceptability of increasing uptake of HPV vaccination by incentivising consent form return.

METHODS

In the context of a two-arm, cluster randomised feasibility trial, qualitative free-text questionnaire responses were collected from adolescent girls (n = 181) and their parents (n = 61), assessing the acceptability of an incentive intervention to increase HPV vaccination consent form return. In the incentive intervention arm, girls who returned a signed consent form (regardless of whether consent was given or refused), had a 1-in-10 chance of winning a £50 shopping voucher. Telephone interviews were also conducted with members of staff from participating schools (n = 6), assessing the acceptability of the incentive. Data were analysed thematically.

RESULTS

Girls and parents provided a mix of positive, negative and ambivalent responses about the use of the incentive to encourage HPV vaccination consent form return. Both girls and parents held misconceptions about the nature of the incentive, wrongly believing that the incentive was dependent on vaccination receipt rather than consent form return. School staff members also expressed a mix of opinions on the acceptability of the incentive, including perceptions of effectiveness and ethics.

CONCLUSIONS

The use of an incentive intervention to encourage the return of HPV vaccination consent forms was found to be moderately acceptable to those receiving and delivering the intervention, although a number of changes are required to improve this. In particular, improving communication about the nature of the incentive to reduce misconceptions is vital. These findings suggest that incentivising consent form return may be an acceptable means of improving HPV vaccination rates, should improvements be made.

TRIAL REGISTRATION

ISRCTN Registry; ISRCTN72136061 , 26 September 2016, retrospectively registered.

Rural distribution of human papilloma virus in low- and middle-income countries

Cervical cancer rates in low- and middle-income countries (LMICs) are higher than in developed countries and account for 80% of an estimated 500,000 new cases annually. Factors that contribute to this are that diagnostic and prevention strategies designed for developed countries suffer from the combination of low vaccination rates and limitations due to lack of consistent access to both healthcare and supplies. Here we: 1) improve upon our LMIC deployable HPV test and 2) determine both the high and low-risk HPV genotype prevalence in an isolated Honduran population. We found an unexpected HPV distribution with an abundance of HPV 52 and HPV 72 infections. In this context, molecular testing using a LMIC deployable approach for the detection of HPV can aid in both the triage of HPV positive cytology-based follow up and provide information regarding HPV genotype distribution in support of vaccination strategies.

Global human papilloma virus vaccine implementation: An update

Human papillomavirus (HPV) infections continue to be one of the most common sexually transmitted infections worldwide. The oncogenic potential of this virus was well established in anogenital malignancies and oropharyngeal cancers. Even though a fall in cervical cancer rates has been reported worldwide, the subsequent rise in HPV-associated head and neck cancers among men and women have been reported from developed countries, necessitating the vaccination of adolescent boys as well. The objective of this narrative review is to provide an update on the current status of HPV vaccination worldwide. This will be helpful for clinicians in counseling parents and guardians as this vaccine mainly targets sexually naïve preadolescents. An electronic search of the databases was carried out to retrieve information concerning HPV vaccine implementation between July 2006 and 2017, with special emphasis on the current viewpoints, controversies and ethical issues. Globally, 74 countries have implemented the HPV vaccine in the national immunization schedule, and this vaccine is listed as an essential medicine by WHO. About 60% of the low- and lower-middle-income countries have implemented the vaccine with financial assistance from Gavi and WHO. The HPV vaccine is a safe vaccine with no serious adverse effects as per the data available from developed nations as well as low/lower middle/upper middle-income countries. However, long-term follow-up is essential to substantiate the impact of the vaccination programs in cancer prevention.

Factors influencing intention to obtain the HPV vaccine in South East Asian and Western Pacific regions: A systematic review and meta-analysis

Since licensing in 2006, there has been poor uptake of the HPV vaccine among the targeted population in the South East Asia Region (SEAR) and Western Pacific Region (WPR). A systematic review was conducted to identify the studies exploring the relationship between factors and intention for HPV vaccination among women in SEAR and WPR countries. Nineteen studies were identified as suitable for qualitative synthesis, and three as suitable for meta-analysis. Most women had a positive intention to have an HPV vaccine (range 57%-85%). Having a positive intention to vaccinate was significantly higher among women not aware of HPV infection (OR: 1.34, 95% CI: 1.02-1.76) and HPV vaccine (OR: 1.57, 95% CI: 1.26-1.96). Lower knowledge level and less confidence in safety and efficacy of the vaccine, negatively affected intention to vaccinate. Perceiving the vaccine to be expensive, low perception of contracting HPV infection and cervical cancer, and lack of concrete recommendations from healthcare providers also negatively affected intention to vaccinate. This review suggests the decision-making processes of women in SEAR and WPR is influenced by the cost of vaccination, perceived efficacy and safety of vaccine, provision of information on vaccination, and the awareness about HPV infection and the HPV vaccine.

Human papillomavirus (HPV) vaccination and factors related to intention to obtain the vaccine among young college women in Thailand

Purpose

Most cervical cancers are caused by genital human papillomavirus (HPV). However, it can be prevented if females receive an HPV vaccine. Nevertheless, there is limited evidence of HPV vaccination and predictors of intention to obtain the vaccine among young women in Thailand. The paper aims to discuss this issue.

Design/methodology/approach

This cross-sectional study examined HPV vaccination and factors influencing intention to vaccinate among a convenient sample of college women in Thailand. The data collection was conducted via a self-administered “HPV and HPV vaccine-related knowledge, attitudes, and behaviors” questionnaire.

Findings

Out of 1,030 participants, 309 (30.0 percent) were aware of HPV and the HPV vaccine. Out of these, 257 participants reported that they had not obtained the vaccine and 18 participants were unsure if they had already obtained the vaccine or not. Only 34 participants confirmed that they had received the vaccine. Among those who were aware of HPV and the HPV vaccine, 56.4 percent of them did not know that most HPV-infected persons do not show any signs or symptoms, and 53.3 percent thought that the vaccine provided protection against other sexually transmitted infections as well. Most had positive attitudes toward vaccination and subjective norms. Among the participants who had not received the vaccine, the intention to obtain the vaccine was predicted by age, knowledge, attitudes toward vaccination, and subjective norms. The reasons for not being vaccinated included the cost of the vaccine, lack of knowledge, and perception of themselves being at low risk.

Originality/value

This study found low HPV vaccination among college women. However, those who had not received the vaccine intended to obtain the vaccine at some point in the future. An HPV vaccination campaign may be well tailored in order to increase the intention to obtain the vaccine which, in turn, may increase the HPV vaccination. Vaccination cost sharing should be discussed among Thai policy makers in order to alleviate the financial burden for women.

Impact of a website based educational program for increasing vaccination coverage among adolescents

Data regarding the use of technology to improve adolescent knowledge on vaccines are scarce. The main aim of this study was to evaluate whether different web-based educational programmes for adolescents might increase their vaccination coverage. Overall, 917 unvaccinated adolescents (389 males, 42.4%; mean age ± standard deviation, 14.0 ± 2.2 years) were randomized 1:1:1 into the following groups: no intervention (n = 334), website educational program only (n = 281), or website plus face to face lesson (n = 302) groups. The use of the website plus the lesson significantly increased the overall knowledge of various aspects of vaccine-preventable disease and reduced the fear of vaccines (p < 0.001). A significant increase in vaccination coverage was observed for tetanus, diphtheria, acellular pertussis and conjugated meningococcal ACYW vaccines in the 2 groups using the website (p < 0.001), and better results were observed in the group that had also received the lesson; in this last group, significant results were observed in the increase in vaccination coverage for meningococcal B vaccine (p < 0.001). Overall, the majority of the participants liked the experience of the website, although they considered it important to further discuss vaccines with parents, experts and teachers. This study is the first to evaluate website based education of adolescents while considering all of the vaccines recommended for this age group. Our results demonstrate the possibility of increasing vaccination coverage by using a website based educational program with tailored information. However, to be most effective, this program should be supplemented with face-to-face discussions of vaccines at school and at home. Thus, specific education should also include teachers and parents so that they will be prepared to discuss with adolescents what is true and false in the vaccination field.

Parents' knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-demographics and religious beliefs: A cross-sectional study in Thailand

Thailand has one of the world's highest prevalence of cervical cancer, mainly caused by the human papillomavirus (HPV). HPV infections can successfully be prevented by vaccination, which is available at a cost but not yet implemented in the national vaccination program. Parents play a critical role in deciding whether to vaccinate their child against HPV. Thus, the aim was to examine the association between parents' knowledge, beliefs, and acceptance of the HPV vaccination for their daughters, considering their socio-demographics and religious beliefs. A cross-sectional design was used among three schools in Thailand: Nakorn Phatom province (suburban) and Bangkok (urban). Parents of 9-12-year-old daughters completed the questionnaires, guided by the Health Belief Model. In total, 359 parents completed the questionnaires; of those, 301 were included in the final analyses. The ordinary least squares (OLS) regression analysis showed that background knowledge of HPV and the HPV vaccine was positively related to knowledge of HPV and cervical cancer. For beliefs, knowledge was positively associated with susceptibility (i.e., parents' perceived risk of an HPV infection/ related disease), severity, and benefit. However, knowledge was not significantly related to barriers. For acceptance, higher susceptibility and benefit were related to higher acceptance, and greater knowledge was associated with higher acceptance. Thus, we found associations between parents' knowledge, beliefs, and acceptance of the HPV vaccination for their daughters, considering their socio-demographics and religious beliefs. Parents, who reported religion as important, as opposed to those who did not, were more favorable toward the HPV vaccination. Four out of ten mothers had never undergone a cervical cancer screening, but most had accepted previous childhood vaccinations for their daughters. The overall acceptance of the vaccine was high, and we believe our results are promising for future implementation of the HPV vaccination in the national childhood vaccination program in Thailand.

Lack of school requirements and clinician recommendations for human papillomavirus vaccination

BACKGROUND

A strong recommendation from a clinician is one of the best predictors of human papillomavirus (HPV) vaccination among adolescents, yet many clinicians do not provide effective recommendations. The objective of this study was to understand how the lack of school entry requirements for HPV vaccination influences clinicians' recommendations.

DESIGN AND METHODS

Semi-structured interviews with a purposive sample of 32 clinicians were conducted in 2015 in Connecticut USA. Data were analysed using an iterative thematic approach in 2016-2017.

RESULTS

Many clinicians described presenting HPV vaccination as optional or non-urgent because it is not required for school entry. This was noted to be different from how other required vaccines were discussed. Even strong recommendations were often qualified by statements about the lack of requirements. Furthermore, lack of requirements was often raised initially by clinicians and not by parents. Many clinicians agreed that requirements would simplify the recommendation, but that parents may not agree with requirements. Personal opinions about school entry requirements were mixed.

CONCLUSIONS

The current lack of school entry requirements for HPV vaccination is an important influence on clinicians' recommendations that are often framed as optional or non-urgent. Efforts are needed to strengthen the quality of clinicians' recommendations in a way that remains strong and focused on disease prevention yet uncoupled from the lack of requirements that may encourage delays. Additionally, greater support for requirements among clinicians may be needed to successfully enact requirements in the future.

Durability of Protection Afforded by Fewer Doses of the HPV16/18 Vaccine: The CVT Trial

Background

Previously, we demonstrated similar human papillomavirus (HPV)16/18 vaccine efficacy estimates and stable HPV16/18 antibody levels four years postvaccination in a nonrandomized analysis of women who received a varying number of doses of the bivalent HPV16/18 vaccine. Here we extend data to seven years following initial vaccination.

Methods

We evaluated HPV16/18-vaccinated women who received one (n = 134), two (n 0/1 = 193, n 0/6 = 79), or three doses (n = 2043) to a median of 6.9 years postvaccination. Cervical HPV DNA was measured with the SPF10- DEIA-LiPA PCR system; HPV16/18-specific antibody levels were measured using enzyme-linked immunosorbent assays (n = 486). Infection and immunological measures were compared across vaccine dose groups. Prevalent HPV infection at year 7 was also compared with an unvaccinated control group (UCG). All statistical tests were two-sided.

Results

Among women in the three-dose, two-dose 0/6 , two-dose 0/1 , and one-dose groups, cumulative incident HPV16/18 infection rates (No. of events/No. of individuals) were 4.3% (88/2036, 95% confidence interval [CI] = 3.5% to 5.3%), 3.8% (3/78, 95% CI = 1.0% to 10.1%), 3.6% (7/192, 95% CI = 1.6% to 7.1%), and 1.5% (2/133, 95% CI = 0.3% to 4.9%; P = 1.00, .85, .17 comparing the two-dose 0/6 , two-dose 0/1 , and one-dose groups to the three-dose group, respectively). The prevalence of other carcinogenic and noncarcinogenic HPV types, excluding HPV16/18/31/33/45, were high and not statistically different among all dose groups, indicating that the low incidence of HPV16/18 in the one- and two-dose groups was not due to lack of exposure. At seven years, 100% of participants in all dose groups remained HPV16 and HPV18 seropositive. A non-statistically significant decrease in the geometric mean of the HPV16 antibody levels between years 4 and 7 was observed among women in the three-dose group: -10.8% (95% CI = -25.3% to 6.6%); two-dose (0/6 months) group: -17.3% (95% CI = -39.3% to 12.8%), two-dose (0/1 month) group: -6.9% (95% CI = -22.1% to 11.2%), and one-dose group: -5.5% (95% CI = -29.7% to 27.0%); results were similar for HPV18.

Conclusions

At an average of seven years of follow-up, we observed similar low rates of HPV16/18 infections and slight, if any, decreases in HPV16/18 antibody levels by dose group.

Minor Capsid Protein L2 Polytope Induces Broad Protection against Oncogenic and Mucosal Human Papillomaviruses

The amino terminus of the human papillomavirus (HPV) minor capsid protein L2 contains a major cross-neutralization epitope which provides the basis for the development of a broadly protecting HPV vaccine. A wide range of protection against different HPV types would eliminate one of the major drawbacks of the commercial, L1-based prophylactic vaccines. Previously, we have reported that insertion of the L2 epitope into a scaffold composed of bacterial thioredoxin protein generates a potent antigen inducing comprehensive protection against different animal and human papillomaviruses. We also reported, however, that although protection is broad, some oncogenic HPV types escape the neutralizing antibody response, if L2 epitopes from single HPV types are used as immunogen. We were able to compensate for this by applying a mix of thioredoxin proteins carrying L2 epitopes from HPV16, -31, and -51. As the development of a cost-efficient HPV prophylactic vaccines is one of our objectives, this approach is not feasible as it requires the development of multiple good manufacturing production processes in combination with a complex vaccine formulation. Here, we report the development of a thermostable thioredoxin-based single-peptide vaccine carrying an L2 polytope of up to 11 different HPV types. The L2 polytope antigens have excellent abilities in respect to broadness of protection and robustness of induced immune responses. To further increase immunogenicity, we fused the thioredoxin L2 polytope antigen with a heptamerization domain. In the final vaccine design, we achieve protective responses against all 14 oncogenic HPV types that we have analyzed plus the low-risk HPVs 6 and 11 and a number of cutaneous HPVs.IMPORTANCE Infections by a large number of human papillomaviruses lead to malignant and nonmalignant disease. Current commercial vaccines based on virus-like particles (VLPs) effectively protect against some HPV types but fail to do so for most others. Further, only about a third of all countries have access to the VLP vaccines. The minor capsid protein L2 has been shown to contain so-called neutralization epitopes within its N terminus. We designed polytopes comprising the L2 epitope amino acids 20 to 38 of up to 11 different mucosal HPV types and inserted them into the scaffold of thioredoxin derived from a thermophile archaebacterium. The antigen induced neutralizing antibody responses in mice and guinea pigs against 26 mucosal and cutaneous HPV types. Further, addition of a heptamerization domain significantly increased the immunogenicity. The final vaccine design comprising a heptamerized L2 8-mer thioredoxin single-peptide antigen with excellent thermal stability might overcome some of the limitations of the current VLP vaccines.

Social determinants of community-level human papillomavirus vaccination coverage in aschool-based vaccination programme

OBJECTIVE

To assess social patterns in human papillomavirus (HPV) vaccine coverage in a school-based, government-funded vaccination programme located within a single-payer universal healthcare system.

DESIGN

We conducted a cross-sectional analysis of HPV vaccine uptake data for the 2013-2014 school year for 131 local authorities in England, and then evaluated the association between vaccine uptake and socioeconomic status at the aggregate level.

DATA SOURCES

HPV vaccination coverage data from Public Health England's vaccine uptake guidance and the UK's March 2011 Census.

MAIN OUTCOME MEASURES

We measured three-dose local authority-level vaccine series initiation to completion.

RESULTS

We found that in local authorities where there are more high-income families, the vaccination rate is lower than in local authorities with more low-income families. Local authorities with a higher percentage of whites, compared with non-whites, had higher HPV vaccination rates. Additionally, local authorities with more non-migrants had higher rates of vaccination. Local authorities with more education deprivation had higher rates of vaccination. Local authorities' higher proportions of high-status occupations had worse vaccination coverage. In bivariate analyses across all the socioeconomic indicators, a 1 SD change in the indicators was associated with about a 2.25 percentage point decrease (for income, education and occupation) or increase (for race and migrant composition) in HPV dose coverage in the local authority. In multivariable analyses, only race remained as a significant predictor of HPV coverage at the local authority level.

CONCLUSIONS

Across all three doses, there are notable variations by socioeconomic status, with steep reverse gradients in three socioeconomic indicators. More quantitative and qualitative research needs to be conducted to determine the effects of the 2014 transition from a three-dose regimen to two-dose regimen on vaccination coverage, especially in groups that experience lower rates of vaccination.

Knowledge, attitudes, and practices regarding cervical cancer and screening among women visiting primary health care Centres in Bahrain

Background

Cervical cancer is one of the most common cancers among women, with 80% of the cases occurring in developing countries. Cervical cancer is largely preventable by effective screening programs. This has not been possible with opportunistic screening and its low use in the Kingdom of Bahrain. The objective of this study was to explore the knowledge, attitudes, and practices of women attending primary care health centres for cervical cancer screening.

Methods

This was a cross-sectional study of 300 women attending primary health care centres in Bahrain. We used a validated tool comprised of 45 items to collect data through face-to-face interviews between December 2015 and February 2016. Descriptive data are presented for demographic data, and frequency distributions with percentages are presented for each item of the knowledge and attitude questionnaire.

Results

The mean age ± SD of the participants was 37.24 ± 11.89 years, they were mostly married (221; 73.7%), and had a high school or higher education (261; 87%). Over 64% (194 participants) had never heard of a Pap smear procedure and only 3.7% (11 participants) had heard about the human papillomavirus (HPV) vaccine. Nearly 64% (192 participants) believed that a Pap smear was helpful in detecting pre-cancer and cancer of the cervix, and 44.3% (133 participants) believed that they should have a Pap smear at least every 3 years. Regarding the practice, only 40.7% (122 participants) had a Pap smear in their lifetime. The majority of participants felt embarrassed when examined by a male doctor (250, 83.3%) and few underwent a Pap smear screening if they were never married (69, 23.0%).

Conclusions

The participants demonstrated a wide range of knowledge and attitudes towards cervical cancer screening. However, the majority demonstrated positive attitudes towards the HPV vaccine.

Eradicating HPV-Associated Cancer Through Immunization: A Glass Half Full…

The human papillomavirus (HPV) is an important causal agent of premalignant cervical epithelial changes and cervical cancers. These cancers account for ∼5% of all cancers globally and kill more than a quarter million women annually. HPV infections also associate with certain anogenital and oropharyngeal cancers. Events leading to the development of HPV vaccines to prevent associated cancers are described, with a further discussion of goals that must be met to achieve full virus eradication.

Factors involved in human papillomavirus (HPV) vaccine hesitancy among women in the South-East Asian Region (SEAR) and Western Pacific Region (WPR): A scoping review

A scoping review was performed to identify factors that may lead to human papillomavirus (HPV) vaccine hesitancy among women in low- and middle-income countries in South East Asian Region (SEAR) and Western Pacific Region (WPR). A systematic search of English and non-English articles using Pubmed, EMBASE, PsycINFO, Cochrane, MEDLINE, and CINAHL plus was conducted. Only 63 studies conducted in SEAR and WPR were included from inception until December 2016. Results of these studies have shown that poor awareness and knowledge of practices on cervical cancer prevention was evident in both SEAR and WPR. Concerns on safety and efficacy of the vaccine, and costs in getting vaccinated were significant barriers. Most women stated that they needed more information, and strongly welcomed a physician's recommendation in both geographical regions. Women also felt they have a low risk of acquiring HPV infection and cervical cancer. Most women in SEAR and WPR were unable to decide on whether to accept HPV vaccination.

The role of human papillomavirus vaccines in cervical cancer: Prevention and treatment

Human papillomavirus (HPV) is the most common sexually transmitted disease, worldwide. Primary prevention thorough vaccination si able to reduce the burden of HPV-related lesions. Ten years ago the Food and drug Administration (FDA) approved the first vaccine against HPV. In the last decades, growing data on safety and effectiveness have been collected. In the present review we report the current knowledge on vaccine against HPV, highlighting the current value and prospective regarding the widespread diffusion of HPV vaccines. The role of emerging therapeutic vaccines is reviewed.

The Impact of Human Papillomavirus Catch-Up Vaccination in Australia: Implications for Introduction of Multiple Age Cohort Vaccination and Postvaccination Data Interpretation

We used transmission-dynamic modeling to estimate the added effectiveness of vaccinating multiple cohorts of females (12-26 years) in Australia compared with the theoretical introduction of routine-only (12-13 years) vaccination. Our results suggest that vaccinating multiple cohorts produced markedly faster direct/herd effects, and it added benefits that last for 20-70 years. Furthermore, the number needed to vaccinate to prevent 1 anogential warts (AGW) case or cervical cancer (CC) was similar for routine + catch-up (AGW = 9.9, CC = 678) and routine-only vaccination (AGW = 9.9, CC = 677), thus providing similar levels of efficiency per person vaccinated.

Mean medical costs associated with vaginal and vulvar cancers for commercially insured patients in the United States and Texas

OBJECTIVE

To estimate the average medical costs for vaginal and vulvar cancers in a commercially insured population in the U.S. and Texas.

METHODS

2011-2014U.S. MarketScan databases were used to estimate the average medical costs associated with vaginal and vulvar cancers. Women with newly diagnosed vaginal or vulvar cancer were matched to a comparison group without cancer using propensity score. Year 1 and year 2 costs after index diagnosis date were estimated. A generalized linear model was used to estimate the cost for censored months. The differential costs between groups were defined as the net costs associated with cancer diagnosis and treatment.

RESULTS

The analysis included 355 women with vaginal cancer and 997 with vulvar cancer in the U.S. The year 1 and year 2 costs for vaginal cancer were $86,995 and $51,107, respectively. The year 1 and year 2 costs for vulvar cancer were $37,657 and $19,139, respectively. The major factors associated with higher monthly vaginal and vulvar cancer costs were higher Charlson Comorbidity Index score and higher medical costs prior to cancer diagnosis. Monthly costs for vaginal and vulvar cancers decreased rapidly from month 1 to month 6 after diagnosis and then remained stable.

CONCLUSIONS

Seventy to 75% of all vaginal and vulvar cancers are due to HPV infections and mean medical costs associated with these cancers are substantial. These data will serve as key cost parameters in the economic evaluation of HPV vaccination dissemination and estimation of the long-term net economic benefit of promoting HPV vaccination.

Policies and processes for human papillomavirus vaccination in Latin America and the Caribbean

OBJECTIVES

Three highly effective vaccines are available to prevent human papillomavirus (HPV) infection, and they have been introduced in many countries around the world. This article describes advances and challenges in introducing HPV vaccines in the Expanded Program of Immunization (EPI) of countries in Latin America and the Caribbean (LAC).

METHODS

We reviewed national and regional sources of information to identify LAC countries with and without universal HPV vaccination, along with the year of introduction, type of HPV vaccine, vaccination scheme, age groups targeted, and coverage level reached. Incidence rates of cervical cancer were compared across countries with and without an HPV vaccination program, in order to identify inequities in access to HPV vaccines.

RESULTS

So far, 10 LAC countries have supplied data on their vaccination policies and vaccination coverage rates to the Pan America Health Organization. The majority of those 10 started their vaccination programs using quadrivalent vaccine. Only Chile, Ecuador, and Mexico started their programs using a two-dose scheme. However, by the end of 2016, most of the other countries had switched from a three-dose to a two-dose scheme. Different age groups are targeted in the various programs. Some countries vaccinate one-year birth cohorts, while others vaccinate multiple-year birth cohorts. By the end of 2014, coverage with at least two doses ranged from a low of 2% to a high of 86%. With the exception of Venezuela, the LAC countries with the largest populations introduced universal HPV vaccination between 2010 and 2014. Despite the progress that has occurred in some LAC countries, there are still 10 LAC nations with cervical cancer rates above the LAC average (21.2 cases per 100 000) that have not introduced an HPV vaccine in their EPI.

CONCLUSIONS

With several key adjustments, HPV vaccination programs across Latin America and the Caribbean could be substantially strengthened. Ongoing monitoring of HPV infection outcomes is needed in order to assess the impact of different vaccination policies.

Declines in Anogenital Warts Among Age Groups Most Likely to Be Impacted by Human Papillomavirus Vaccination, United States, 2006-2014

OBJECTIVES

To detect decreases in anogenital warts (AGW) among sex and age groups likely to be affected by human papillomavirus vaccination.

METHODS

We estimated annual AGW prevalence during 2006 to 2014 using health care claims among US private health insurance enrollees aged 15 to 39 years. We derived AGW diagnoses using 1 of the following: (1) condylomata acuminata diagnosis, (2) viral wart diagnosis combined with a benign anogenital neoplasm diagnosis or destruction or excision of an anogenital lesion, or (3) AGW medication combined with a benign anogenital neoplasm diagnosis or destruction or excision of an anogenital lesion.

RESULTS

Prevalence decreased during 2008 to 2014 among females aged 15 to 19 years (annual percentage change [APC] = -14.1%; P < .001) and during 2009 to 2014 among women aged 20 to 24 years (APC = -12.9%; P < .001) and among women aged 25 to 29 years (APC = -6.0%; P = .001). We observed significant declines among men aged 20 to 24 years (APC = -6.5%; P = .005). Prevalence increased or was stable in all other sex and age groups.

CONCLUSIONS

We observed AGW decreases among females in the age groups most likely to be affected by human papillomavirus vaccination and decreases in men aged 20 to 24 years. Decreased prevalence in young men is likely attributable to herd protection from vaccination among females.

The early impact of human papillomavirus vaccination on anogenital warts in Québec, Canada

In Québec province in Canada, a public school-based and catch-up HPV vaccination programs with the quadrivalent vaccine have been introduced in September 2008 for girls aged 9-17 years. We assessed the early impact of the HPV vaccination program on the incidence of anogenital warts (AGW) in the Quebec general population. We used the provincial health administrative data of the Régie de l'assurance maladie du Québec (RAMQ). AGW were identified either through a prescription of podofilox, or a medical procedure code specific to AGW, or a diagnostic code for viral warts followed by a prescription of imiquimod or fluorouracil. Sex- and age-specific incidence rates were calculated for pre-vaccination (2004-2007) and vaccination (2009-2012) periods. We found a significant decline of 45% and 19% in the incidence of AGWs among females aged 15-19 and 20-24 years, respectively. A decline of 21% was also seen among males aged 15-19 years. The median age at an episode of AGW increased from 27 years in 2004 to 31 years in 2012 among females and remained stable in males. Our findings indicate that the HPV public vaccination program is associated with an important reduction in the incidence of AGW among young females and males. The benefit is more pronounced among females 15-19 years of age, who were eligible for the public vaccination program. The observed decline among young males could be due to herd immunity and/or privately paid vaccination.

Fraction of high-grade cervical intraepithelial lesions attributable to genotypes targeted by a nonavalent HPV vaccine in Galicia, Spain

Background

Human papillomavirus (HPV) bivalent and quadrivalent vaccines have been widely implemented in worldwide organized immunization programs. A nonavalent HPV vaccine is now available in several countries. The objective was to describe the fraction of squamous non-invasive high-grade cervical intraepithelial lesions attributable to genotypes targeted by bi-quadrivalent vaccines and by nonavalent vaccine according to age and diagnosis in women living in the city of Vigo (Galicia, Spain).

Methods

Cervical scrapings (2009–2014) of women with histological diagnosis of cervical intraepithelial neoplasia grade 2 (CIN2, n = 145) and grade 3-carcinoma in situ (CIN3-CIS, n = 244) were tested with Linear Array HPV Genotyping test (Roche diagnostics, Mannheim, Germany). Hierarchical estimation of the fraction attributable to HPV 16/18 or HPV 31/33/45/52/58 detected alone or in combination was calculated. Absolute additional fraction attributable to genotypes targeted by nonavalent vaccine compared to genotypes targeted by bi-quadrivalent vaccines was calculated as the increment of attributable cases with respect to all studied cases. Age group 1, 2 and 3 included women 18 to 34, 35–44 and ≥45 years old, respectively. EPIDAT 3.1 was used.

Results

Fraction attributable to genotypes targeted by bi-quadrivalent vaccines was 59% CIN2 vs. 69% CIN3-CIS (p < 0.001). It was 63/51/50% of CIN2 and 78/66/45% of CIN3-CIS in age group 1, 2, 3, respectively. Fraction attributable to genotypes targeted by nonavalent vaccine was 86% CIN2 and 86% CIN3-CIS. It was 87/91/75% of CIN2 and 90/86/76% of CIN3-CIS in age group 1, 2, 3, respectively. Fraction attributable to genotypes targeted by these vaccines tended to decrease as age increased (p-trend <0.05). Globally, absolute additional attributable fraction was 16%, 26% and 29% in age group 1, 2 and 3, respectively (p < 0.005).

Conclusions

Absolute additional fraction of CIN2 and CIN3-CIS attributable to genotypes targeted by nonavalent vaccine was observed in women of any age, especially in those over 35 years old.

Strengthening global vaccine access for adolescents and adults

Global immunization efforts to date have heavily focused on infants and children, with noted success on public health. Healthy adolescents and adults contribute to the economic growth and development of countries but efforts to ensure vaccine coverage for these groups receive inadequate global attention and resources. Emerging epidemics for a number of infectious diseases including Ebola, Zika, dengue, malaria and the continuing epidemics of tuberculosis and several sexually transmitted infections, including HIV, HPV and Hepatitis B, have high incidence and prevalence in adolescents and adults. New vaccines under development for these diseases and under-used vaccines such as for human papilloma virus will have the greatest health and economic impact in these populations. Global consensus, political will, policies, global and country infrastructure, and financing mechanisms are needed to accelerate access for the billions of adolescents and adults living under the threat of devastating infectious disease outbreaks and epidemics, especially in lower income countries. The global health community and countries cannot afford to delay planning for implementation of adolescent and adult vaccine programs that will potentially save millions of lives and strengthen global and national economies. The article examines this next challenge and suggests a research agenda and a framework for action to galvanize global and national policy decision-makers to begin preparations for future immunization challenges.

Catch-up HPV vaccination status of adolescents in relation to socioeconomic factors, individual beliefs and sexual behaviour

In 2012, human papillomavirus (HPV) vaccination was introduced free of charge in the Swedish national school-based vaccination programme for 10-12-year-old girls, and as catch-up vaccination for young women. In Sweden, there is an ongoing discussion about including boys in the national vaccination programme. Few studies are undertaken about adolescents’ knowledge, beliefs and HPV vaccination status in relation to socioeconomic status and sexual experience. Thus, the aim was to examine HPV catch-up vaccination status in adolescents in relation to 1) socioeconomic factors, 2) beliefs and knowledge about HPV prevention, and 3) sexual behaviour. The Health Belief Model was used as a theoretical framework. Upper secondary school students (n = 832) aged 16, randomly chosen from a larger sample, were invited to participate in conjunction with the general health interview with the school nurse. A total of 751/832 (90.3%), girls (n = 391, 52%) and boys (n = 360, 48%) completed the questionnaire. HPV vaccination was associated with ethnicity and the mothers’ education level; i.e. girls with a non-European background and girls with a less educated mother were less likely to have received the vaccine (p<0.01 and p = 0.04 respectively). Vaccinated girls perceived HPV infection as more severe (p = 0.01), had more insight into women’s susceptibility to the infection (p = 0.02), perceived more benefits of the vaccine as protection against cervical cancer (p<0.01) and had a higher intention to engage in HPV-preventive behaviour (p = 0.01). Furthermore, boys and girls were almost equally sexually experienced, although fewer girls had used condom during first intercourse with their latest partner (p = 0.03). Finally, HPV vaccinated girls were less likely to have unprotected sex (p<0.01). In summary, catch-up HPV vaccination among young girls was associated with a European background and high maternal education level, as well as more favourable beliefs towards HPV prevention and less sexual risk-taking. Further preventive measures should therefore be directed at the migrant population.

Human Papillomavirus Vaccination Rates in Young Cancer Survivors

Purpose

Cancer survivors are at high risk for human papillomavirus (HPV)-related morbidities; we estimated the prevalence of HPV vaccine initiation in cancer survivors versus the US population and examined predictors of noninitiation.

Methods

Participants included 982 cancer survivors (9 to 26 years of age; 1 to 5 years postcompletion of therapy); we assessed HPV vaccine initiation, sociodemographic and clinical characteristics, and vaccine-specific health beliefs; age-, sex-, and year-matched US population comparisons were from the National Immunization Survey-Teen and the National Health Interview Survey (2012-2015).

Results

The mean age at the time of the study was 16.3 ± 4.7 years; the mean time off therapy was 2.7 ± 1.2 years; participants were 55% male and 66% non-Hispanic white; 59% had leukemia/lymphoma. Vaccine initiation rates were significantly lower in cancer survivors versus the general population (23.8%; 95% CI, 20.6% to 27.0% v 40.5%; 95% CI, 40.2% to 40.7%; P < .001); survivors were more likely to be HPV vaccine-naïve than general population peers (odds ratio [OR], 1.72; 95% CI, 1.41 to 2.09; P < .001). Initiation in adolescent survivors (ages 13 to 17 years) was 22.0% (95% CI, 17.3% to 26.7%), significantly lower than population peers (42.5%; 95% CI, 42.2% to 42.8%; P < .001). Initiation in young adult survivors and peers (ages 18 to 26 years) was comparably low (25.3%; 95% CI, 20.9% to 29.7% v 24.2%; 95% CI, 23.6% to 24.9%). Predictors of noninitiation included lack of provider recommendation (OR, 10.8; 95% CI, 6.5 to 18.0; P < .001), survivors' perceived lack of insurance coverage for HPV vaccine (OR, 6.6; 95% CI, 3.9 to 11.0; P < .001), male sex (OR, 2.9; 95% CI, 1.7 to 4.8; P < .001), endorsement of vaccine-related barriers (OR, 2.7; 95% CI, 1.6 to 4.6; P < .001), and younger age (9 to 12 years; OR, 3.7; 95% CI, 1.8-7.6; P < .001; comparison, 13 to 17 years).

Conclusion

HPV vaccine initiation rates in cancer survivors are low. Lack of provider recommendation and barriers to vaccine receipt should be targeted in vaccine promotion efforts.

Ending cervical cancer: A call to action

The outlook for elimination of the scourge of cervical cancer is bright, because we now have the tools to achieve this goal. In recent years human papillomavirus (HPV) vaccination in high-income countries has resulted in dramatic decreases in HPV infection and associated cervical disease. If all countries with a substantial burden of disease introduce the vaccine nationally, we can protect the vast majority of women and girls most at risk. For women who are beyond the vaccination target age, progress has been made in screening and treatment for cervical precancer, but we must accelerate this momentum to reduce incidence and mortality worldwide to the very low rates found in wealthier countries. Human and financial resources must be increased and directed to programs that follow best practices and reach all women, including the marginalized or disadvantaged. Seven key actions are recommended. Now is the time for action at national, regional, and global levels.

Why Human Papillomavirus Acute Infections Matter

Most infections by human papillomaviruses (HPVs) are `acute', that is non-persistent. Yet, for HPVs, as for many other oncoviruses, there is a striking gap between our detailed understanding of chronic infections and our limited data on the early stages of infection. Here we argue that studying HPV acute infections is necessary and timely. Focusing on early interactions will help explain why certain infections are cleared while others become chronic or latent. From a molecular perspective, descriptions of immune effectors and pro-inflammatory pathways during the initial stages of infections have the potential to lead to novel treatments or to improved handling algorithms. From a dynamical perspective, adopting concepts from spatial ecology, such as meta-populations or meta-communities, can help explain why HPV acute infections sometimes last for years. Furthermore, cervical cancer screening and vaccines impose novel iatrogenic pressures on HPVs, implying that anticipating any viral evolutionary response remains essential. Finally, hints at the associations between HPV acute infections and fertility deserve further investigation given their high, worldwide prevalence. Overall, understanding asymptomatic and benign infections may be instrumental in reducing HPV virulence.

Advocacy, communication, and partnerships: Mobilizing for effective, widespread cervical cancer prevention

Both human papillomavirus (HPV) vaccination and screening/treatment are relatively simple and inexpensive to implement at all resource levels, and cervical cancer screening has been acknowledged as a "best buy" by the WHO. However, coverage with these interventions is low where they are needed most. Failure to launch or expand cervical cancer prevention programs is by and large due to the absence of dedicated funding, along with a lack of recognition of the urgent need to update policies that can hinder access to services. Clear and sustained communication, robust advocacy, and strategic partnerships are needed to inspire national governments and international bodies to action, including identifying and allocating sustainable program resources. There is significant momentum for expanding coverage of HPV vaccination and screening/preventive treatment in low-resource settings as evidenced by new global partnerships espousing this goal, and the participation of groups that previously had not focused on this critical health issue.

Optimizing secondary prevention of cervical cancer: Recent advances and future challenges

Although human papillomavirus (HPV) vaccines offer enormous promise for the ultimate control and possible elimination of cervical cancer, barriers to uptake and coverage of the vaccine both in high- and low/middle-income settings mean that advances in secondary prevention continue to be essential to prevent unnecessary deaths and suffering from cervical cancer for decades to come. While cytology (the Pap smear) has reduced cervical cancer incidence and prevalence in jurisdictions where it has been systematically implemented in population-based programs-mainly in high-income settings-limitations inherent to this method, and to program delivery, leave many women still vulnerable to cervical cancer. Recent evidence has confirmed that screening based on HPV testing prevents more invasive cervical cancer and precancerous lesions, and offers innovative options such as self-collection of specimens to improve screening uptake broadly. In this paper, we review key advances, future opportunities, and ongoing challenges for secondary prevention of cervical cancer using HPV-based testing.

College women, HPV genotyping and sexual behavior before HPV vaccination: Results from samples stored for a long time

HPV is the sexually transmitted agent most common among young people, like college students. The aim of study was to associate sexual behavior characteristics of women with HPV, detected in genital samples taken before the introduction of the HPV vaccine. Female students during 2001-2005 donated genital samples and the samples were re-analyzed in 2013 for HPV genotyping by RT-PCR. The frozen storage of the students' genital samples allowed the detection of HPV DNA and its genotyping after years of sample collection. HPV prevalence was 22%, HPV16 3.9%, and HPV18 1.1%. Age, multiple sexual partners and the partner's age at first sexual intercourse were significantly associated to HPV. Students with ≥ 3 sexual partners and who did not use condom had 12.8 higher odds of being HPV positive. These results made possible the analysis of HPV prevalence changes, before HPV vaccine introduction.

Burden of HPV-caused cancers in Denmark and the potential effect of HPV-vaccination

BACKGROUND

Denmark is one of the countries where Human papillomavirus (HPV)-vaccination at present includes only girls. However, the burden of HPV-related cancer in men is increasing, which would argue for gender-neutral vaccination. The aim of this study was to examine the burden of HPV-caused cancers in women and men, and to evaluate the potential of HPV-vaccination in cancer control.

METHODS

Data were retrieved from the literature on population prevalence of high risk (HR) HPV, on HR HPV-prevalence and genotypes in HPV-related cancers, and on number of cytology samples in cervical screening. Data on annual biopsies and conisations were retrieved from the Danish National Health Service Register and the Danish National Patient Register. Incidences of HPV-related cancers in Denmark were extracted from NORDCAN. Number of HPV-caused cancers was calculated from number of HPV-related cancers and the proportion known to be caused by high-risk (HR) HPV.

RESULTS

In cross-sectional surveys in Denmark, one fifth of women and almost one third of men were found to be positive for HR HPV. Per year, 548 HPV-caused cancer cases were diagnosed in women and 234 in men, and twice as many cancers in women as in men were preventable with HPV vaccination. However, including screening prevented cervical cancers, the burden of cancers caused by HPV-infection would be 1300-2000 in women as compared to 234 in men.

CONCLUSION

Taking screening prevented cervical cancers into account, the cancer control potential of HPV-vaccination is considerably higher in women than in men. HPV-vaccination could reduce the burden of screening on women and on health care resources.

Cost-effectiveness of HPV vaccination in the context of high cervical cancer incidence and low screening coverage

BACKGROUND

Estonia has high cervical cancer incidence and low screening coverage. We modelled the impact of population-based bivalent, quadrivalent or nonavalent HPV vaccination alongside cervical cancer screening.

METHODS

A Markov cohort model of the natural history of HPV infection was used to assess the cost-effectiveness of vaccinating a cohort of 12-year-old girls with bivalent, quadrivalent or nonavalent vaccine in two doses in a national, school-based vaccination programme. The model followed the natural progression of HPV infection into subsequent genital warts (GW); premalignant lesions (CIN1-3); cervical, oropharyngeal, vulvar, vaginal and anal cancer. Vaccine coverage was assumed to be 70%. A time horizon of 88years (up to 100years of age) was used to capture all lifetime vaccination costs and benefits. Costs and utilities were discounted using an annual discount rate of 5%.

RESULTS

Vaccination of 12-year-old girls alongside screening compared to screening alone had an incremental cost-effectiveness ratio (ICER) of €14,007 (bivalent), €14,067 (quadrivalent) and €11,633 (nonavalent) per quality-adjusted life-year (QALY) in the base-case scenario and ranged between €5367-21,711, €5142-21,800 and €4563-18,142, respectively, in sensitivity analysis. The results were most sensitive to changes in discount rate, vaccination regimen, vaccine prices and cervical cancer screening coverage.

CONCLUSION

Vaccination of 12-year-old girls alongside current cervical cancer screening can be considered a cost-effective intervention in Estonia. Adding HPV vaccination to the national immunisation schedule is expected to prevent a considerable number of HPV infections, genital warts, premalignant lesions, HPV related cancers and deaths. Although in our model ICERs varied slightly depending on the vaccine used, they generally fell within the same range. Cost-effectiveness of HPV vaccination was found to be most dependent on vaccine cost and duration of vaccine immunity, but not on the type of vaccine used.

Attitudes towards Human Papilloma Virus Vaccination in the Latin American Andean Region

This commentary explores the distribution of human papilloma virus (HPV) and HPV-related diseases, and factors affecting attitudes towards HPV, HPV-related diseases, and HPV vaccination in the Latin American Andean region. Lack of knowledge of HPV, known negative attitudes or incorrect assumptions about HPV, HPV-related diseases, and HPV vaccination provide a basis upon which to develop targeted HPV awareness and preventive health media campaigns. For maximal effect, media campaigns should use the internet, radio, and television to address health care providers, parents, and students. Additional programming can be developed for clinics to use in-house with their clients. Ministries of Education, Finance, and Health all have roles to play to increase national HPV, HPV-related diseases, and HPV vaccination awareness.

Population-based HPV vaccination programmes are safe and effective: 2017 update and the impetus for achieving better global coverage

Persistent oncogenic human papillomavirus (HPV) is the cause of cervical cancer, as well as cancers of the anus, penis, vulva, vagina and oropharynx. There is good evidence that prophylactic HPV vaccines are immunogenic and effective against targeted-type HPV infections and type-specific genital lesions, including high-grade cervical intraepithelial neoplasia (CIN), when administered prior to HPV infection. There is good evidence that HPV vaccines are safe in population usage, with the most frequent adverse event being injection-site reactions. There is evidence to support some cross-protection against non-targeted types occurring following the administration of HPV vaccines. There is limited evidence suggesting that HPV vaccines may be beneficial in preventing future disease in women treated for high-grade CIN. This chapter focuses on the accumulated evidence regarding the global use of the three licensed HPV vaccines including safety, immunogenicity, duration of protection, effectiveness, coverage to date and barriers to higher coverage.