Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014

Disparities in HPV knowledge by race/ethnicity and socioeconomic position: Trusted sources for the dissemination of HPV information

PURPOSE

To examine the differences in HPV and HPV vaccine awareness, knowledge, and beliefs by race/ethnicity and socioeconomic position (SEP) among a national sample of non-Hispanic whites (NH-Whites), non-Hispanic Blacks (NH-Blacks), and Hispanics in the United States. We also examine differences in trusted health information sources by race/ethnicity and SEP.

METHODS

Data were obtained from the Health Information National Trends Survey, Cycle 1, conducted from January to April 2017. Descriptive statistics, bivariate analyses, multivariate logistic regression, and listwise deletion were used to examine HPV and HPV vaccine awareness and knowledge-related items, and trust in health information sources among NH-Whites, NH-Blacks, and Hispanics 18-49 years old.

RESULTS

HPV vaccine awareness was moderate with no significant differences across racial/ethnic groups. NH-Whites had significantly higher knowledge that HPV causes cervical cancer than NH-Blacks and Hispanics (p < 0.001). High SEP NH-Blacks (OR = 0.42, 95% CI = [0.24-0.73], p = 0.002]) and Hispanics (OR = 0.49, 95% CI = [0.31-0.79, p = 0.003]) had lower odds of knowing HPV causes a sexually transmitted disease than their white counterparts. Low SEP NH-Blacks (OR = 11.03, 95% CI = [3.05-39.86, p < 0.001]) had 11 times the odds of ever hearing about the HPV vaccine than low SEP NH-Whites. NH-Blacks had twice the odds of trusting health information from television (OR = 2.39, 95% CI = [1.52-3.78]. p < 0.001), and almost six times the odds of trusting health information from religious organizations than low SEP NH-Whites (OR = 5.76, 95% CI = [2.02-16.44, p < 0.001]).

CONCLUSION

Tailored communication strategies may address the low HPV knowledge among NH-Blacks and Hispanics from high and low SEP.

Prevalence and concordance of oral HPV infections with cervical HPV infections in women referred to colposcopy with abnormal cytology

BACKGROUND

Considering the shared aetiology of Human Papillomavirus infections in oropharyngeal and cervical cancers and the possible role for sexual transmission, several key aspects of the relationship between cervical and oral infections merit investigation, including prevalence of concomitant oral HPV infection and type-specific concordance with concurrent cervical infections.

METHODS

A cross-section study was performed on women referred to colposcopy clinics with cytological abnormalities and a cervical HPV infection. An oral rinse sample was taken from the participants at their baseline visit for HPV testing, and a demographic and risk factor questionnaire was also administered. HPV DNA testing was carried out on the Cobas 4800 platform and extended genotyping was carried out with the INNO-LiPA HPV Genotyping Extra II assay. HPV genotyping was also carried out on the concurrent cervical tissue samples on all women who had a positive oral HPV infection.

RESULTS

The prevalence of oral HPV infections was 10.0% (95%CI:5.9-13.7) in the study population. HPV18 was the most frequent genotype (7.0%). Concordant oral and cervical HPV infections were detected in 28.6% of women. Age (p = 0.005) and level of education (p = 0.02) were significantly associated with a prevalent oral HPV infection.

CONCLUSION

Concomitant oral HPV infections were present in 10.0% of women referred to colposcopy with a pre-existing cervical HPV infections and cytological abnormalities. Although mild type-specific concordance was observed between oral and cervical HPV infections, findings suggest that infections at these sites may not be independent of each other.

[HPV vaccination and the prevention of genital warts and precancerous lesions-current evidence and evaluation]

Human papillomaviruses (HPVs) can cause both benign and malignant tumors. To date, more than 200 HPV types have been discovered, of which 12 are currently classified as high risk for cervical cancer. HPV types that affect the anogenital tract are sexually transmitted. Since 2006, prophylactic HPV vaccines have been available and should be administered before first sexual contact.HPVs infect epithelial cells and are worldwide the most common sexually transmitted viruses. Apart from cervical cancer, HPVs cause other anogenital cancers such as vulvar, vaginal, and anal cancer but also oropharyngeal cancer (or head and neck cancers). HPV types 16 and 18 are also found at these sites. HPV types 6 and 11 are associated with genital warts; other HPV types can cause harmless skin warts.HPV vaccines are safe and highly effective, if they are administered before exposure to HPV. Systematic reviews and meta-analyses have shown that HPV vaccination effectively prevents HPV infection, but also precancerous lesions of the anogenital tract and genital warts. Recent vaccination data also demonstrate reductions in cervical cancer incidence.The uptake rates of HPV vaccination vary worldwide by program and acceptance. In comparison to other European countries, Germany has a low uptake rate. The Standing Committee on Vaccination (STIKO) recommends HPV vaccinations for all girls and boys ages 9 to 14 years in Germany. In 2018, only half of all 18-year-old girls in Germany were completely immunized against HPV.Organized vaccination programs, whether population-based or school-based, are necessary in order to increase vaccination uptake rates.

Concurrent and Concordant Oral and Genital High-Risk Human Papillomavirus in the United States: Results from the National Health and Nutrition Examination Survey

BACKGROUND

Oropharyngeal cancers associated with high-risk human papillomavirus (HR-HPV) infection are increasing in the United States, especially among men. We evaluated the prevalence and predictors of concurrent (genital and oral) and concordant (same-type) HR-HPV infections in the United States.

METHODS

We used the National Health and Nutrition Examination Survey from 2009 to 2016. Predictors were assessed via multivariable logistic regression.

RESULTS

Among 10 334 respondents, 172 (2.1%) had concurrent infections (109 [3.5%] men and 63 [0.76%] women]. Ninety-three (1.0%) had concordant infections (54 [1.6%] men and 39 [0.5%] women). Predictors of concurrence in men included the following: no longer married versus married (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.9), living with a partner versus married (3.0; 1.2-7.5), and having 2-5 lifetime oral sex partners (3.0; 1.2-7.5). In women they included the following: no longer married versus married (3.6; 1.3-10.3), ≥2 recent sex partners (4.6; 1.4-15.6 for 2-5 partners and 3.9; 1.1-14.3 for ≥6 partners), and marijuana use (2.2; 1.0-4.5). The predictor of concordance in men and women was no longer married versus married (3.5; 1.2-9.9 in men and 3.2; 1.1-9.4 in women).

CONCLUSIONS

Concurrent and concordant HR-HPV infections occur at a high rate, especially among men, and are associated with behavioral factors. This underscores the importance of HPV vaccination, screening, and education in men.

Interactive Session for Residents and Medical Students on Dermatologic Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients

INTRODUCTION

Despite increasing emphasis on LGBTQ health in medical education, evidence-based training on LGBTQ patient care in dermatology is lacking. We designed an interactive online didactic session on dermatologic care of LGBTQ patients for medical students and dermatology residents.

METHODS

Session content was based on continuing medical education articles and incorporated preexisting LGBTQ-inclusive policies, environments, and videos. We implemented the session via a web-based videoconferencing platform as part of a preexisting resident lecture series. We began with a 90-minute lecture on LGBTQ health care disparities and dermatologists' roles, best practices for providing inclusive care, and dermatologic health concerns and screening recommendations in LGBTQ populations. To solidify knowledge and promote practice of learned skills, a 30-minute interactive role-playing session followed where participants acted as observer, patient, or provider in three distinct clinical scenarios pertaining to dermatologic care of LGBTQ patients. Participants completed baseline and follow-up surveys, which included a psychometrically validated clinical skills scale and an ad hoc knowledge assessment.

RESULTS

Baseline and follow-up scores from the clinical skills scale increased overall (0.7; 95% CI, 0.5-0.9; p < .001), in self-reported clinical preparedness (1.1; 95% CI, 0.5-1.6; p = .001), and in basic knowledge (0.8; 95% CI, 0.3-1.4; p = .003).

DISCUSSION

An online interactive didactive session on dermatological care of LGBTQ patients increased participants' clinical preparedness and basic knowledge. Implementation of similar sessions at other institutions can improve gaps in preparing residents and medical students in dermatological care of LGBTQ patients.

Oral and laryngeal HPV infection: Incidence, prevalence and risk factors, with special regard to concurrent infection in head, neck and genitals

This review focuses on the importance of oral and laryngeal HPV infection which is present in majority of sexually active individuals at least once in their lifetime. Despite testing, still little is known about prevalence rates, determinants and, especially, the concurrent HPV infection in head and neck, and genitals. The purpose of this review is to clarify some issues of oral HPV incidence, prevalence, and to demonstrate the difficulties in identification of asymptomatic oral HPV carriers. The main premise to take up this topic is the high and still increasing risk for development of oropharyngeal cancer, and potential benefit from screening strategies, education programs and HPV vaccination. Transmission of HPV to the oral cavity and oropharynx is hypothesized to occur mainly through sexual contact. The exposure of oropharyngeal mucosa to HPV infection with consequence of increased risk for oropharyngeal carcinoma depends on specific sexual behavior. Male gender, older age, race or ethnicity, oral hygiene and current cigarette smoking are independently associated with any prevalent oral HPV infection.

Human Papilloma Virus vaccine and prevention of head and neck cancer, what is the current evidence?

OBJECTIVES

Human Papilloma Virus is associated with the development of cancers in the head and neck region. We have witnessed, in the last decades, an increase in number of cases directly related to HPV infection, in particular in the Western Countries. Recently the FDA expanded the indications for Gardasil-9® to include the prevention of head and neck cancer. Objective of this paper is to review the evidence supporting its use.

MATERIALS AND METHODS

Bibliographic review enquiring Medline, Web of Science and the Cochrane Library to assess the efficacy of vaccination against oncogenic HPV in the prevention of head and neck squamous cell carcinoma.

RESULTS

Two prospective and 4 retrospective studies have evaluated vaccination in prevention of head and neck cancer, using persistent oral infection as surrogate of efficacy. All studies showed lower prevalence of oral infection up to 4 years following vaccination. Vaccine efficacy was estimated between 88 and 93.3%. Because of low vaccine coverage the estimated population-level effect against oral HPV16/18/6/11 infections was only 17.0%.

CONCLUSIONS

Antibodies concentration in the oral fluid correlate with serum level, but the threshold to ensure protection is unknown. Duration of protection has not been established. HPV vaccination can provide protection from re-infection (at different mucosal sites) in previously exposed individuals, suggesting possible use of HPV vaccine later in life. Other studies should focus on confirming causal relationship between vaccination and prevention of persistent oral infection and investigate the duration of efficacy, which is crucial in its effectiveness against HNSCC.

Civic Learning, Science, and Structural Racism

Vaccine hesitancy is a major public health challenge, and racial disparities in the acceptance of vaccines is a particular concern. In this essay, we draw on interviews with mothers of Black male adolescents to offer insights into the reasons for the low rate of vaccination against the human papillomavirus among this group of adolescents. Based on these conversations, we argue that increasing the acceptance of HPV and other vaccines cannot be accomplished merely by providing people with more facts. Instead, we must address the pervasive racial discrimination in the United States that undermines trust in social institutions, including the health care system. In the short term, it may be helpful to increase the number of clinicians of color working in the health system, but more fundamental changes are required. The U.S. must adopt and implement policies that dismantle structural racism if it hopes to produce greater trust and community-oriented thinking on behalf of people who have been exploited for centuries.

New Insights into Oral Cancer-Risk Factors and Prevention: A Review of Literature

The oral cancer constitutes 48% of head and neck cancer cases. Ninety percent of oral cancer cases are histologically diagnosed as oral squamous cell carcinomas (OSCCs). Despite new management strategies, the 5-year survival rate of oral cancer is still below 50% in most countries. Head and neck cancers are heterogeneous tumors, and this characteristic of them provides a challenge to treatment plan. Due to the poor outcomes in oral cancer, prevention is a necessity. In this review, a relevant English Literature search in PubMed, ScienceDirect, and Google Scholar from 2000 to mid-2018 was performed. All published articles related to oral cancer and its prevention were included. The risk factors of oral cancer and strategies of oral cancer prevention will be discussed.

Updates in the cause of sinonasal inverted papilloma and malignant transformation to squamous cell carcinoma

PURPOSE OF REVIEW

The purpose of this study was to give an overview of recently published articles investigating the cause of inverted papilloma and possible mechanisms mediating malignant transformation into squamous cell carcinoma (SCCa).

RECENT FINDINGS

Inverted papilloma is a sinonasal tumour that is benign in nature, but has a tendency for local invasion, recurrence and malignant degeneration. Its pathogenesis has not been elucidated and the etiological role for human papillomavirus virus (HPV) has been controversial. Recent reports have varied in detection method (mRNA ISH, DNA ISH and PCR amplification of highly conserved regions of the viral genome), ranging from 0 to 100%. Advances in meta-genomics have permitted detection of HPV viral signatures that were previously cost-prohibitive, and there appears to be a potential role for both low-risk and high-risk in the cause of the disease. Activating EGFR mutations have also been identified to be correlated with malignant transformation, which may be exclusive of HPV infection. Furthermore, more comprehensive approaches in detecting genomic markers have been reported, with HOX-related genes and epithelial-mesenchymal-transition-related gene sets appear to be differentially upregulated.

SUMMARY

Sinonasal inverted papilloma is a diverse disease that is predominantly benign, but it harbours the potential for malignant degeneration in the SCCa with cause yet to be elucidated. Current evidence supports a potential role for high-risk HPV in a subset of SCCa, with the role of low-risk HPV yet to be defined. Historic studies of individual and small groups of molecular markers have not consistently adequate characterize signalling pathways underpinning the oncogenesis, and comprehensive genomic studies are needed to better understand the disease.

Quantitative Oral HPV16 and HPV18 Detection in Persons Attending Dental Clinics

OBJECTIVE

This study aimed to assess quantitative human papillomavirus (HPV) type 16 and HPV18 detection in oral rinses obtained in dental offices in Seattle, Washington.

METHODS

We evaluated oral rinses collected during dental visits from 2016 to 2018. Multiplex TaqMan quantitative polymerase chain reaction was used to determine HPV16 and HPV18 viral load (VL).

RESULTS

Of 15,313 persons, 152 (1%) had detectable oral HPV16/18. Men were at higher risk of oral HPV16/18 infection than women (1.6% vs. 0.6%; odds ratio, 3.2; 95% confidence interval, 2.1-4.4). Compared with women, men with HPV16 were older (median, 55 vs. 48 years; P < 0.001) and had higher VL (39.7 vs. 1.1 copies/mL, P < 0.001). Of 39 with HPV16 at baseline and a second oral rinse, 13 remained positive at subsequent rinse; of 8 with HPV18 at baseline, 2 remained positive at subsequent rinse. Persons with consecutive positive test results were all men and had higher baseline VL compared with those with first positive and second negative samples.

CONCLUSION

Oral rinse is an acceptable method of HPV testing, and persons are interested in testing. Overall HPV16/18 prevalence was low, and detection was more frequent among men than women, especially at higher copy numbers. HPV16 persistence was more common in men with high VL at baseline test. Future studies are needed to evaluate the feasibility of an effective secondary prevention strategy for oropharyngeal cancer using quantitative oral HPV detection.

No association between HPV-status in tonsillar tissue and sexual behavior of the patients in a northern German population - Critical view of the link between HPV natural history and HPV-driven carcinogenesis

HPV-infection in patients with HNSCC is reportedly correlated with sexual behavior, age, and tobacco/alcohol-consumption. HPV-infections of the oral cavity are regarded as sexually transmitted. Comparable data of patient populations outside the U.S. are sparse or missing. Questionnaires regarding sexual behavior, education tobacco- and alcohol-consumption, were given to 28 patients with tonsillar hyperplasia (H) and 128 patients with tonsillar carcinomas (CA), all with tissue-typed HPV-DNA-status performing PCR. Answers were correlated among groups and HPV-status. 106 questionnaires were analyzed. Comparisons between H- (n = 25) and CA- (n = 81) patients showed that CA-patients were older (61.1yrs ± 9.3) than H-patients (45.2yrs ± 11.9; p < 0.0001; Student's t-test); had a lower educational level (p = 0.0095); and lower number of sexual partners (p = 0.0222; Fisher's exact test). All groups showed a significant correlation between smoking and lack of HPV-DNA-positivity (p = 0.001). Further Fisher's exact tests and logistic regression analysis revealed in all 106 patients no significant correlations between tissue-HPV-status and the analyzed parameters. Despite the limited sample size, we were able to confirm the established correlation between smoking and tissue-HPV-status. The correlation between sexual behavior and HPV-infection was not confirmed. No consensus exists in the literature about the latter. Our data does not support the strict classification of oral HPV-infections and HPV-driven HNSCCs as STDs.

Head and neck squamous cell carcinoma

Most head and neck cancers are derived from the mucosal epithelium in the oral cavity, pharynx and larynx and are known collectively as head and neck squamous cell carcinoma (HNSCC). Oral cavity and larynx cancers are generally associated with tobacco consumption, alcohol abuse or both, whereas pharynx cancers are increasingly attributed to infection with human papillomavirus (HPV), primarily HPV-16. Thus, HNSCC can be separated into HPV-negative and HPV-positive HNSCC. Despite evidence of histological progression from cellular atypia through various degrees of dysplasia, ultimately leading to invasive HNSCC, most patients are diagnosed with late-stage HNSCC without a clinically evident antecedent pre-malignant lesion. Traditional staging of HNSCC using the tumour-node-metastasis system has been supplemented by the 2017 AJCC/UICC staging system, which incorporates additional information relevant to HPV-positive disease. Treatment is generally multimodal, consisting of surgery followed by chemoradiotherapy (CRT) for oral cavity cancers and primary CRT for pharynx and larynx cancers. The EGFR monoclonal antibody cetuximab is generally used in combination with radiation in HPV-negative HNSCC where comorbidities prevent the use of cytotoxic chemotherapy. The FDA approved the immune checkpoint inhibitors pembrolizumab and nivolumab for treatment of recurrent or metastatic HNSCC and pembrolizumab as primary treatment for unresectable disease. Elucidation of the molecular genetic landscape of HNSCC over the past decade has revealed new opportunities for therapeutic intervention. Ongoing efforts aim to integrate our understanding of HNSCC biology and immunobiology to identify predictive biomarkers that will enable delivery of the most effective, least-toxic therapies.

Association of human papillomavirus vaccination with exposure to dental or medical visits

BACKGROUND

Human papillomavirus (HPV) infection is associated with oropharyngeal cancers. The Centers for Disease Control and Prevention (CDC) estimate that >15,000 new cases of HPV-associated oropharyngeal cancers are diagnosed in the United States annually. We evaluated an association between HPV vaccination and dental visits in the previous year.

METHODS

Data were analyzed from the 2012, 2014, and 2016 Massachusetts Behavioral Risk Factor Surveillance System (MA-BRFSS) datasets. We created four categories of exposures to healthcare services in the past 12 months: a) both medical and dental visits, b) medical visit only, c) dental visit only, d) neither. Outcomes were HPV vaccination ever or influenza vaccination within the past 12 months. Logistic regression, controlled for race and education, was used to measure the association between medical/dental visits and vaccination status. Separate models were generated by sex.

RESULTS

Crude and adjusted odds ratio of influenza and HPV vaccination were highest among males and females with both medical and dental visits. Women with both medical and dental provider visits had 3.7 times higher odds of being vaccinated for influenza and 1.7 times higher odds of being vaccinated for HPV. There were no differences in crude or adjusted odds among both males and females if the type of healthcare visits were only medical or only dental.

CONCLUSION

No difference in association between vaccination and medical or dental healthcare exposures suggests that oral health professionals might partner in promotion of positive health behaviors, including HPV vaccination. The type of provider did not affect the outcome as per this study.

Squamous cell carcinoma of head and neck: what internists should know

Squamous cell carcinoma of head and neck (SCCHN) is a group of cancer arising from mucosal surfaces of the head and neck. Optimal management of SCCHN requires a multidisciplinary team of surgical oncologists, radiation oncologists, medical oncologists, nutritionist, and speech-language pathologists, due to the complexity of anatomical structure and importance of functional outcome. Human papilloma virus (HPV)-related SCCHN represents a distinct subset from HPV negative SCCHN which is associated with carcinogen exposure such as cigarette smoking, betel nut use and alcohol. HPV related SCCHN responds better to concurrent chemoradiation and has better overall prognosis, compared to HPV negative SCCHN. Radiation therapy has been introduced to the treatment of SCCHN, administered concurrently with systemic chemotherapy for locoregional SCCHN, as well as a palliative measure for recurrent and/or metastatic (R/M) SCCHN. Recently, immune checkpoint inhibitors have been shown to improve overall survival in R/M-SCCHN and have been incorporated into the standard of care. Combination approaches with immune therapy and targeted therapy for biomarker enriched population based on genomics are being actively investigated and will shape the future of SCCHN treatment.

Parental intent to initiate and complete the human papillomavirus vaccine series in the USA: a nationwide, cross-sectional survey

BACKGROUND

Human papillomavirus (HPV) vaccine uptake among US adolescents is primarily dependent on the intent of their parents. To the best of our knowledge, an analysis quantifying parental intent to initiate and complete the HPV vaccine series in the USA at both the national and state level has not been done. We aim to estimate parental intent to initiate and complete the HPV vaccine series at the national-level and state-level and to identify reasons for lack of intent to initiate and complete the vaccine series.

METHODS

This cross-sectional study uses data from the adolescent component of the 2017-18 National Immunization Survey (NIS-Teen). Study participants were parents or caregivers of US adolescents aged 13-17 years, who were most knowledgeable about the immunisation status of the adolescents. The primary outcome was parental intent to vaccinate the adolescent in the next 12 months. The secondary outcomes were (1) the prevalence of reasons given for lack of intent to initiate and complete the HPV vaccine series, and (2) the relationship between receiving a recommendation from a health-care provider to vaccinate and intent to initiate the vaccination series. We computed national-level and state-level estimates for parental lack of intent to initiate and to complete the vaccine series; population-level estimates were derived using survey weights. A survey design-adjusted Wald F test was used for bivariate analysis. A multivariate logistic regression model was used to examine the association between health-care provider recommendation and parental intent to initiate the series. Analyses were stratified by history of health-care provider recommendation to initiate the HPV vaccine series.

FINDINGS

In 2017-18, the parent or caregiver of 82 297 US adolescents aged 13-17 years completed the NIS-Teen survey. 30 558 (37·1%) were unvaccinated and 9073 (10·8%) received only one HPV vaccine dose. Parents of 58·0% (17 171/29 086) of unvaccinated adolescents with data available on parental intent had no intention to initiate the HPV vaccine series. More than 65% of parents of unvaccinated adolescents in Idaho, Kansas, Michigan, Montana, Nebraska, North Dakota, Oklahoma, and Utah had no intention to initiate the HPV vaccine series. Parents of 23·5% (2166/9072) of initiators with data available on parental intent had no intention to complete the HPV vaccine series. More than 30% of parents in Arkansas, Florida, Georgia, Hawaii, Idaho, Utah, and West Virginia did not intend to complete the HPV vaccine series, whereas in the District of Columbia (11·2% [22/166]) and Rhode Island (20·4% [21/112]) parental lack of intent was relatively low (both regions have an HPV vaccine mandate). The most common reason for lack of intent among parents to initiate the vaccine for unvaccinated adolescents was safety concerns (22·8% [4182/16 455]); lack of a recommendation from a health-care provider (22·2% [440/1944]) was the most frequently cited reason for absence of intent to complete the series among parents of adolescents who received only one HPV vaccine dose. Receipt of a recommendation from a health-care provider was associated with greater odds of parental intent to initiate the HPV vaccine series (odds ratio 1·11, 95% CI 1·01-1·22). 45·5% (13 156/29 086) of parents of unvaccinated adolescents had reportedly received an HPV vaccine recommendation. Parents of 60·6% (7938/13 156) of unvaccinated adolescents with a recommendation from a health-care provider and data available on parental intent had no intention to initiate the series.

INTERPRETATION

Lack of parental intent to initiate and complete the HPV vaccine series for adolescents is a major public health concern in the USA. Combating vaccine safety concerns and strong recommendations from health-care providers could improve the currently suboptimal HPV vaccination coverage.

FUNDING

US National Cancer Institute.

Educational Interventions on Human Papillomavirus for Oral Health Providers

The aim of this study was to evaluate the effectiveness of an educational intervention on HPV infection, HPV-related cancers and prevention modalities to improve Oral Health Care Providers (OHPs) knowledge and awareness about these topics, considering the rise of HPV-related malignancies in the USA. Educational sessions on HPV were offered to OHPs between 2016 and 2018 in the New England area. Participants were asked to fill out a questionnaire both before and after each session. Responses from the pre-questionnaire were compared to those from the post-questionnaire to evaluate the effectiveness of the lectures in increasing HPV-related knowledge of the OHPs. Among 277 participants, 263 completed both the pre- and post-questionnaire. A significant improvement was observed for the following categories: epidemiology of HPV infections, HPV-related diseases, and HPV vaccination and prevention. After the educational intervention, OHPs also indicated an increased comfort level in regard to educating their patients about the importance of HPV vaccination. Educational lectures can be effective in increasing OHPs knowledge and awareness about HPV, HPV-related cancers, and vaccination. More educational sessions on HPV are needed to reach a larger number of OHPs. OHPs may be the first to identify signs and symptoms of HPV-related oropharyngeal cancers. In addition, they may encourage their patients to take advantage of the HPV vaccine.

Human Papillomavirus Vaccines: An Updated Review

Human papillomavirus (HPV) vaccines, which were introduced in many countries in the past decade, have shown promising results in decreasing HPV infection and related diseases, such as warts and precancerous lesions. In this review, we present the updated information about current HPV vaccines, focusing on vaccine coverage and efficacy. In addition, pan-gender vaccination and current clinical trials are also discussed. Currently, more efforts should be put into increasing the vaccine’s coverage, especially in low- and middle-income countries. Provision of education on HPV and vaccination is one of the most important methods to achieve this. Vaccines that target HPV types not included in current vaccines are the next stage in vaccine development. In the future, all HPV-related cancers, such as head and neck cancer, and anal cancer, should be tracked and evaluated, especially in countries that have introduced pan-gender vaccination programs. Therapeutic vaccines, in combination with other cancer treatments, should continue to be investigated.

Considerations in Human Papillomavirus-Associated Oropharyngeal Cancer Screening: A Review

Importance

The incidence of human papillomavirus (HPV)-positive oropharyngeal cancer (OPC) is anticipated to rise over the next few decades until the effects of prophylactic vaccination are realized, which highlights the potential importance of secondary prevention. The objective of this review is to evaluate the evidence associated with screening for HPV-positive OPC.

Observations

Evaluation of a potential clinical preventive screening service requires characterization of the disease burden, the at-risk target screening population, screening tests, treatment, and screening benefits and harms. The lifetime risk of OPC is 0.7% for men and 0.2% for women and is expected to increase. The disease burden of HPV-positive OPC is substantial; most patients undergo morbid multimodality treatment and incur high costs in the process. Middle-aged and older adult men with elevated number of lifetime vaginal or oral sex partners are at highest risk. Patients may benefit from early detection of the disease-the 4-year overall survival of patients with stage I HPV-positive OPC is 87%, a considerable portion of whom are eligible for less morbid single-modality therapy. However, available screening tests are insufficiently sensitive and specific considering the current HPV-positive OPC incidence rates in the most at-risk patients. Further, the benefits and harms of screening for HPV-positive OPC are unknown.

Conclusions and Relevance

The current and projected future population-level burden of HPV-positive OPC supports further exploration of secondary preventive interventions. However, screening for HPV-positive OPC is not currently justified. Advances in biomarker discovery and improved characterization of (1) a highly at-risk, target screening population and (2) the benefits and harms of screening will be necessary. Large-scale clinical trials and rigorous evaluation of how to best implement this service into clinical practice will also be needed.

Gender Differences in Sexual Health Knowledge Among Emerging Adults in Acute-Care Settings

Context

Emerging adults (aged 18-25 years) are increasingly seeking evaluation in acute-care clinics for sexual health-related concerns to receive treatment and education.

Objective

To assess the sexual health knowledge of emerging adult patients by gender at acute-care health centers.

Methods

A prospective, self-administered survey was distributed from August 2014 through May 2016 to patients aged 18 to 24 years who presented to 1 of 4 acute-care locations in a university town in a mid-Atlantic state. Analyses included descriptive statistics, as well as χ2 and Fisher exact test crosstabulations to determine differences between genders.

Results

A total of 388 patients aged 18 to 24 years responded to the survey, with 81% of the sample identifying themselves as students and 64% identifying as female. Women were more likely than men to state that they sought sexual health advice at an urgent-care or walk-in clinic (70.3% vs 52.1%; P<.05). Human papillomavirus knowledge among women was significantly greater than among men (P<.0001). Open-ended responses were widespread and often incorrect, specifically with regard to the human papillomavirus vaccine and routine testing for sexually transmitted infections.

Conclusion

Women were more knowledgeable about sexual health than men. However, both genders were not as knowledgeable overall on sexual health topics as hypothesized. A stronger emphasis on gender-specific programming for sexual health education via community- and school-based programs throughout adolescence, supplemented with greater emphasis on routine preventive health care during adolescence and emerging adulthood, is encouraged.

High prevalence of human papillomavirus and European variants of HPV 16 infecting concomitantly to cervix and oral cavity in HIV positive women

OBJECTIVE

Identify the prevalence of HPV infections in the uterine cervix and oral cavity and HPV16 variants in HIV+ women.

METHODS

A total of 174 HIV+ women attended an HIV+ specialized clinic in Mexico City. Cells were obtained from the oral cavity and cervix to extract DNA. Polymerase chain reaction (PCR) was used to amplify the HPV sequence with generic primers. We detected specific HPV types using the INNO-LiPA HPV Genotyping Extra II Kit (INNOGENETICS). The identification of variants was studied by sequencing the E6 gene with a Big Dye Terminator Kit and an Applied Biosystems 3500/3500xL genetic analyzer.

RESULTS

HPV infection was very high in the uterine cervix (168/174, 96.6%) and oral cavity (161/174, 92.5%). The prevalence of HPV concurrent infections in the cervix and oral cavity was 155/174 (89.1%). We found hrHPVs to be more prevalent than low-risk HPVs (lrHPVs) in the oral cavity (90.2% versus 45.4%) and that infections simultaneously affected the cervix (94.3% versus 36.2%) and oral cavity (85.1% versus 20.1%). Surprisingly, only European variants of HPV type 16 were found in the uterine cervix of women and the oral cavity of all tested samples (52 oral cavity samples and 52 uterine cervix samples).

CONCLUSIONS

The high prevalence of HPV, multiple infections and presence of the EP350G intravariant in both anatomical regions are strongly related to the persistence of the virus, which is fundamental for the development of cancer. Therefore, it is very important to control and monitor this high-risk population as well as implement programs for the early detection of HPV and vaccination.

Awareness of oral and genital human papillomavirus (HPV) infection in young adolescents prior to gender-neutral vaccination

INTRODUCTION

Oral human papillomavirus (HPV) and oropharyngeal cancer prevalence are increasing, particularly in men. Raising greater awareness of male HPV disease is perceived as an important intervention strategy. This study investigated the effectiveness of HPV education on adolescents' perception of HPV disease and the impact of HPV vaccination on their sexual health.

METHODS

An HPV questionnaire was completed by 357 UK-based adolescents, aged 12-13 years.

RESULTS

Most adolescents knew HPV causes cervical cancer and HPV vaccination prevents this. A minority acknowledged HPV causes other genital cancers, with under one-fifth knowing HPV causes genital warts. Adolescents' awareness of HPV transmission activities were limited. There was very poor awareness of oral HPV infection or HPV-induced oropharyngeal cancer. Half of the participants stated HPV vaccination reduced their concerns about sexually transmitted infection contraction. Over half the males said they may take more sexual risks following vaccination, while a similar proportion of females did not expect their partner to take more risks.

CONCLUSIONS

Adolescents had little awareness of male HPV infection and the role HPV vaccination can play in preventing these diseases. With variable rates of HPV vaccination uptake in males reported worldwide, this study indicates that in the UK greater emphasis on male HPV disease within educational information is required, to raise better awareness of how HPV affects both genders. As both genders preferred to receive education via healthcare professionals, educating a wider range of healthcare professionals on oral HPV could help facilitate awareness of HPV's role in head and neck cancer.

HPV-associated oropharyngeal cancer

Exposure of the oral cavity and oropharynx to human papillomavirus (HPV) often results in an asymptomatic, transient oral infection that is cleared by the body's immune system; however, a small percentage of these oral infections can persist in a dormant state. Depending on the HPV genotype, a persistent oral infection may lead to benign or malignant disease. High-risk HPV types 16 and 18, which cause most cervical and anal cancers, also are the cause of the rising rate of oropharyngeal squamous cell carcinoma (SCC) in the United States. This article focuses on the epidemiology, transmission, risk factors, and clinical presentation of HPV-associated oropharyngeal SCC, and provides an update on HPV vaccination in the context of the new head and neck cancer epidemic.

Identification of human papillomavirus in oral rinse specimens from women with and without cervical intraepithelial lesions

Objectives

The objective of this study was to evaluate the frequency of human papillomavirus (HPV) in the oral cavity of women with and without abnormal cervical cytology and to determine whether there is an association of oral HPV infection with infection of the cervix or with cervical cancer precursor lesions.

Methods

The present study was conducted among 406 women, aged 18–82 years, who attended the Prevention Department of Barretos Cancer Hospital (HCB), Brazil due to a previous altered cervical cytology result. Oral rinse, cervical cytology and biopsy were collected at the same day. The participants also answered a questionnaire about socioeconomic characteristics and risk factors for cervical cancer. Molecular screening for HPV16, HPV18 and 12 other high-risk HPV types was performed on cervical and oral rinse specimens using Cobas 4800 (Roche Molecular Systems, USA).

Results

HPV was detected in the oral rinse of 3.9% of participants. Infection of the oral cavity with a non-HPV16 or 18 type was most frequent (81.2%), followed by HPV16 (18.7%). Infection with HPV in the cervix and oral cavity was present in 11 (2.7%) of participants. There were no differences observed in the smoking status (p value 0.62), mean age of first sexual intercourse (p value 0.25), mean age of the first oral sex (p value 0.90) or mean lifetime number of sexual partners (p value 0.08) between the participants with oral HPV infection or not.

Conclusion

The presence of HPV infection in the oral cavity was low in the group of women with abnormal cervical cancer screening findings and a high rate of cervical HPV infection.

Predicted prevalence of oral human papillomavirus (HPV) by periodontitis status and HPV vaccination status

OBJECTIVES

The purpose of the present study was to examine differences in oral human papillomavirus (HPV) prevalence among adults based on HPV vaccination status and periodontitis status.

METHODS

Data from 2011 to 2012 and 2013 to2014 National Health and Nutrition Examination Surveys (n = 822) were retrieved in order to predict the prevalence of oral HPV in 24 separate demographic groups (age by sex by race) based on the following characteristics: HPV vaccination status and periodontitis status. A multiple logistic regression model, controlling for gender, age, race, smoking behavior, alcohol consumption, and sexual partners, was calculated in order to generate prevalence estimates.

RESULTS

Median predicted oral HPV prevalence rates per 1,000 in 2011-2012 were highest among nonvaccinated individuals with periodontitis [median ( x ˜ ) = 31.62, interquartile range (IQR) = 102.97], followed by nonvaccinated individuals without periodontitis ( x ˜ = 24.63, IQR = 81.84), vaccinated individuals with periodontitis ( x ˜ = 18.40, IQR = 62.27), and vaccinated individuals without periodontitis ( x ˜ = 14.29, IQR = 48.96). Median predicted oral HPV prevalence rates per 1,000 in 2013-2014 were highest among nonvaccinated individuals with periodontitis ( x ˜ = 9.50, IQR = 33.02), followed by nonvaccinated individuals without periodontitis ( x ˜ = 7.37, IQR = 25.76), vaccinated individuals with periodontitis ( x ˜ = 5.48, IQR = 19.27), and vaccinated individuals without periodontitis ( x ˜ = 4.25, IQR = 14.98).

CONCLUSIONS

Interventions that integrate primary care and dental care are needed, given increased risk for oral HPV among unvaccinated individuals with periodontitis.

Cannabinoids Promote Progression of HPV-Positive Head and Neck Squamous Cell Carcinoma via p38 MAPK Activation

PURPOSE

Human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) is associated with daily marijuana use and is also increasing in parallel with increased marijuana use in the United States. Our study is designed to define the interaction between cannabinoids and HPV-positive HNSCC.

EXPERIMENTAL DESIGN

The expression of cannabinoid receptors CNR1 and CNR2 was analyzed using The Cancer Genome Atlas (TCGA) HNSCC data. We used agonists, antagonists, siRNAs, or shRNA-based models to explore the roles of CNR1 and CNR2 in HPV-positive HNSCC cell lines and animal models. Cannabinoid downstream pathways involved were determined by Western blotting and analyzed in a primary HPV HNSCC cohort with single-sample gene set enrichment analysis (ssGSEA) and the OncoGenome Positioning System (Onco-GPS).

RESULTS

In TCGA cohort, the expression of CNR1 and CNR2 was elevated in HPV-positive HNSCC compared with HPV-negative HNSCC, and knockdown of CNR1/CNR2 expression inhibited proliferation in HPV-positive HNSCC cell lines. Specific CNR1 and CNR2 activation as well as nonselective cannabinoid receptor activation in cell lines and animal models promoted cell growth, migration, and inhibited apoptosis through p38 MAPK pathway activation. CNR1/CNR2 antagonists suppressed cell proliferation and migration and induced apoptosis. Using whole-genome expression analysis in a primary HPV HNSCC cohort, we identified specific p38 MAPK pathway activation signature in tumors from HPV HNSCC patients with objective measurement of concurrent cannabinoid exposure.

CONCLUSIONS

Cannabinoids can promote progression of HPV-positive HNSCC through p38 MAPK pathway activation.

Adolescent HPV vaccination: empowerment, equity and ethics

Despite the great promise offered by human papillomavirus (HPV) vaccines to reduce disease burden and promote socioeconomic and gender equality, their implementation into national programmes has been slow. The vaccination of adolescents against a disease that may have serious consequences much later in life requires special consideration to the principles and processes of informed consent. Accumulating experiences from implementations in many countries indicate a need to examine ethical considerations related to adolescent vaccination. However, frameworks that integrate legal, development- and rights-based considerations in adolescent vaccination policies, while taking into account practical realities of HPV vaccination programmes, are currently lacking. We argue that principles of autonomy, social justice and gender equality have impacts on adolescent immunization that go beyond mere acceptance of vaccination and place greater demands on what constitutes meaningful informed consent, with implications for the provision of age- and context-appropriate information, vaccine financing and gender-based vaccination policies. Independent of cost-effectiveness considerations, we find a strong case to support universal HPV vaccination of girls that is free at the point of use and, where feasible, to extend vaccination to boys under the same financing schemes.

ABBREVIATIONS

HPV: Human papillomavirus; STI: Sexually transmitted infections; WHO: World Health Organization.

Feasibility and acceptance of oral human papillomavirus detection in the dental office: Results from The National Dental Practice-Based Research Network

BACKGROUND

Oral human papillomavirus (HPV) infection is the principal underlying cause of a dramatic increase in oropharyngeal cancer. Dentistry can play an important role in developing clinical algorithms for secondary prevention.

METHODS

The authors conducted this cross-sectional pilot study with practices of The National Dental Practice-Based Research Network. The authors evaluated the feasibility and acceptability of screening and testing procedures as judged by practitioners and patients. The authors used tablet devices for patient screening, obtaining consent, and administering a confidential oral HPV risk factor survey.

RESULTS

Most patients (85%) were comfortable being asked about their cigarette use and their sexual behavior (69%) and were interested in participating again (79%). More than 90% of practitioners were comfortable with study procedures except the extra time required for patient participation (75% comfortable). There were no problems with oral rinse collection as reported by patients or practitioners.

CONCLUSIONS

It is feasible in community dental offices to collect oral rinses for HPV detection and to ask patients explicit questions about sexual history when using a tablet device for confidentiality.

PRACTICAL IMPLICATIONS

Discussing high-risk types of HPV and appropriately assessing that risk are a challenge for oral health care professionals. These results are positive from a research perspective but do not address the advisability of routine HPV screening in dentistry.

Exploring lay public and dental professional knowledge around HPV transmission via oral sex and oral cancer development

Background

Human papillomavirus (HPV) has been associated with certain types of oropharyngeal cancers and yet, the level of knowledge that dental professionals and the lay public have in terms of HPV transmission, oral sexual activities, and oral cancer development needs exploration. The aim of this study was to assess the knowledge held by practicing dental professionals as well as the lay public regarding Human Papillomavirus (HPV) transmission through oral sex and subsequent oropharyngeal cancer development.

Methods

Textual data were collected from a public forum with dental professionals in.

Vancouver, who discussed the HPV-oral sex-oral cancer triad, and from survey data gathered from 212 lay public participants (also in Vancouver) who answered a 13-item questionnaire on the perceived risks of oral sex in terms of HPV infection and oropharyngeal cancer development. The data were analyzed statistically by age group, gender, and sexual orientation using descriptive statistics, while an ANOVA test was used to compare variation in the responses to the survey (p-value = 0.05).

Results

The forum engaged 46 health care professionals, many of whom were aware of the potential risks for head and neck cancer development due to HPV infection, while also questioning “how to effectively talk about HPV with patients.” The survey revealed that 34.5% of the participants believed that oral sex is an activity with no or low risk for the transmission of HPV, while 84% of participants believed the same sexual practices were of low or no-risk for HIV (Human Immunodeficiency Virus) transmission. Most participants (82%) never discussed oral sexual activities with their physicians or dentists/dental hygienists.

Conclusions

The general public remains mostly unaware of the potential links between HPV infection and oropharyngeal cancer. Physicians and dental providers should discuss oral sexual practice with their patients to raise awareness.

Occupational exposure of oropharyngeal human papillomavirus amongst otolaryngologists

OBJECTIVES/HYPOTHESIS

Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure.

STUDY DESIGN

Animal and human laboratory model.

METHODS

Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16-negative tumors and three with p16-positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm.

RESULTS

Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively.

CONCLUSIONS

There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2366-2371, 2020.

HPV Knowledge and Attitudes Among American Indian and Alaska Native Health and STEM Conference Attendees

American Indian and Alaska Native women had approximately twice the incidence of cervical cancer as white women. Preventive measures for cervical cancer rely on screening and HPV vaccination. However, vaccine series completion and catch-up vaccinations for eligible adults are low across all racial/ethnic groups. Therefore, the aim of this study was to identify gaps in knowledge and evaluate the attitudes toward HPV and the vaccine among AIANs with various levels of training in the STEM and health-related fields. A survey was used to collect data from audience members at two national conferences geared towards American Indian and Alaska Natives in health and STEM fields in September 2017. A vignette study was administered via a live electronic poll to test knowledge (true/false questions), attitudes, and to collect demographic information. Respondents self-identified as primarily American Indian and Alaska Native (74%), pursuing or completed a graduate degree (67%), and female (85%). Most respondents (86%) were aware of HPV-associated cancer in men. However, most (48-90%) answered incorrectly to detailed true/false statements about HPV and available vaccines. After educational information was provided, opinions collected via vignettes highlighted mainly positive attitudes toward vaccination; specifically, that vaccines are safe and all eligible community members should be vaccinated (75% and 84%, respectively). We observed that our respondents with higher educational attainment still lacked accurate knowledge pertaining to HPV and the vaccine. Overall, continued education about HPV and the vaccine is needed across all levels of education including American Indian and Alaska Native community members and health professionals.

Immunological tolerance of low-risk HPV in recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is characterized by benign exophytic lesions of the respiratory tract caused by the human papillomavirus (HPV), in particular low-risk HPV6 and HPV11. Aggressiveness varies greatly among patients. Surgical excision is the current standard of care for RRP, with adjuvant therapy used when surgery cannot control disease recurrence. Numerous adjuvant therapies have been used to control RRP with some success, but none are curative. Current literature supports a polarization of the adaptive immune response to a T helper type 2 (Th2)-like or T regulatory phenotype, driven by a complex interplay between innate immunity, adaptive immunity and HPV6/11 proteins. Additionally, certain immunogenetic polymorphisms can predispose individuals to an HPV6/11-tolerant microenvironment. As a result, immunomodulatory efforts are being made to restore the host immune system to a more balanced T cell phenotype and clear viral infection. Literature has shown exciting evidence for the role of HPV vaccination with Gardasil or Gardasil-9 as both primary prevention, by decreasing incidence through childhood vaccinations, and secondary prevention, by treating active RRP disease. Multi-institution randomized clinical trials are needed to better assess their efficacy as treatment for active disease. Interestingly, a DNA vaccine has recently shown in-vitro success in generating a more robust CD8⁺ T cell response. Furthermore, clinical trials for programmed death 1 (PD-1) inhibitors are under investigation for RRP management. Molecular insights into RRP, in particular the interplay between RRP and the immune system, are needed to advance our understanding of this disease and may lead to the identification of immunomodulatory agents to better manage RRP.

A Randomized, Placebo-Controlled Trial of the Quadrivalent Human Papillomavirus Vaccine in Human Immunodeficiency Virus-Infected Adults Aged 27 Years or Older: AIDS Clinical Trials Group Protocol A5298

Background

Adults living with human immunodeficiency virus (HIV) are at increased risk for anal and oropharyngeal cancer caused by human papillomavirus (HPV). The efficacy of HPV vaccines in this population is unknown.

Methods

In this phase 3, double-blind, randomized, controlled trial, we assigned HIV-infected adults aged ≥27 years to the quadrivalent HPV (types 6, 11, 16, 18) vaccine or placebo (1:1) stratified by sex and presence of anal high-grade squamous intraepithelial lesions on biopsy (bHSIL). The primary endpoint was vaccine efficacy against incident persistent anal infection with quadrivalent vaccine types or single detection at the final visit that were not present at baseline. Secondary endpoints included vaccine efficacy for anal bHSIL after week 52, persistent oral HPV infection.

Results

A total of 575 participants were randomized. The Data and Safety Monitoring Board stopped the study early due to futility. Vaccine efficacy was 22% (95.1% confidence interval [CI], -31%, 53%) for prevention of persistent anal infection or single detection at the final visit, 0% (95% CI -44%, 31%) for improving bHSIL outcomes and 88% (95.1% CI 2%, 98%) for preventing persistent oral HPV infection, but was 32% (95.1% CI -80%, 74%) for 6-month persistent oral HPV infection or single detection at the final visit.

Conclusions

These results do not support HPV vaccination of HIV-infected adults aged ≥27 years to prevent new anal HPV infections or to improve anal HSIL outcomes. However, our data suggest a role for prevention of oral HPV infections, but this finding should be confirmed in future studies.

Clinical Trials Registration

NCT01461096.

Evaluating the Effectiveness of Human Papillomavirus Educational Intervention among Oral Health Professionals

This study aims to evaluate the effectiveness of an educational intervention that was designed to increase human papillomavirus (HPV) awareness and knowledge among oral health providers (OHPs). HPV educational lectures and a dental information toolkit on HPV were offered to OHPs in New England in 2016-2017. OHPs included dentists and dental hygienists. Post intervention surveys were distributed 1 month later. A total of 230 participants attended the educational lectures and received the toolkit. Descriptive statistics were used to compare the difference in knowledge and preparedness about HPV before and after the intervention. Eighty-nine OHPs completed the surveys. The response rate was 38.7%; however, for each question, the number of responses varied. Fifty-four (54%) (n = 26) of survey respondents were between 55 and 75 years of age with 73.5% (n = 36) being female and 55% (n = 45) working in private practice. Post intervention, 67.5% (n = 27) of the respondents felt more prepared, 82.6% (n = 38) reported clarity of their roles in educating their patients about HPV, and 91.6% (n = 44) reported an increase in knowledge about HPV. The HPV educational intervention was well received and successful at improving self-reported knowledge, comfort level, and preparedness of OHPs in discussing HPV with their patients. OHPs have the great opportunity to educate their patients about HPV and HPV vaccination. Further continuing education efforts may improve OHPs' participation in HPV prevention.

Human Papillomavirus (HPV) Vaccine Effectiveness and Potential Herd Immunity for Reducing Oncogenic Oropharyngeal HPV-16 Prevalence in the United Kingdom: A Cross-sectional Study

BACKGROUND

Oropharyngeal cancer incidence is rapidly rising due to human papillomavirus (HPV) type 16 infection. The dearth of data on effectiveness of national female-only vaccination programs in preventing oral HPV infection and potential herd immunity in unvaccinated males has resulted in considerable controversy regarding the need to vaccinate males, especially in countries with high female vaccination coverage.

METHODS

Subjects aged 0-65 years undergoing tonsillectomy for nonmalignant indications were recruited in 6 hospitals in the United Kingdom. Oral samples were collected as follows: oral rinse, tongue base, and pharyngeal wall brushes, then tonsil tissue (tonsillectomy). Vaccination data were obtained from regional health authorities. All samples were centrally tested for HPV DNA by polymerase chain reaction.

RESULTS

Of 940 subjects, 243 females and 69 males were aged 12-24 years (median age, 18.6 years), with 189 (78%) females and no males vaccinated against HPV. Overall, oropharyngeal HPV-16 prevalence was significantly lower in vaccinated versus unvaccinated females (0.5% vs 5.6%, P = .04). In contrast, prevalence of any oropharyngeal HPV type was similar in vaccinated and unvaccinated females (19% vs 20%, P = .76). Oropharyngeal HPV-16 prevalence in unvaccinated males was similar to vaccinated females (0% vs 0.5%, P > .99), and lower than unvaccinated females (0% vs 5.6%, P = .08).

CONCLUSIONS

Our findings indicate that the UK female-only vaccination program is associated with significant reductions in oropharyngeal HPV-16 infections. These are also the first data to suggest potential herd immunity from female-only vaccination against oropharyngeal HPV infection in contemporaneously aged males.

Dermatologic care of sexual and gender minority/LGBTQIA youth, Part 2: Recognition and management of the unique dermatologic needs of SGM adolescents

Sexual and gender minority (SGM) individuals, including lesbian, gay, bisexual, transgender/gender diverse, questioning/queer, intersex, and asexual (LGBTQIA) persons, represent a historically underserved population within the field of medicine, though their unique health needs are increasingly recognized. Part 2 of this two-part review will address unique concerns regarding acne, tanning behavior, sexually transmitted infections, and other health disparities among SGM adolescents. A more comprehensive understanding of the dermatologic needs of SGM youth will better allow pediatric dermatologists to actively and compassionately care for this health disparity population.

Oral HPV prevalence and HPV vaccination among special needs population in the US

Introduction

Special needs population have barriers accessing healthcare, higher incidence of sexual assaults and lower sexual education. Due to the above this study was conducted- 1) To assess the current prevalence of oral HPV infection among individuals with SHCN (special health care needs) as compared to the general population and 2) To compare the prevalence of HPV vaccination in SHCN individuals (within the recommended age groups) to general population.

Methods

This data was obtained from NHANES 2013-14 and included 665 individuals with special needs. Weighted prevalence estimates and prevalence ratios (PR) were calculated for oral HPV infection by gender, age (18–59 years), race, smoking history, economic status, and sexual behavior. Prevalence rates were calculated for HPV vaccination.

Results

Oral HPV was detected in 9% (7.1–11.5; p = 0.05) of special needs adults. High-risk HPV genotypes prevalence was also higher among adults with special needs [5.56% (3.9–7.9) vs 3.87% (2.7–5.4)]. The HPV vaccination rates among 9–26 years special needs females (33.5% vs 37%) and males aged 9–21 years (16.7% vs 21.2%) with special needs was lower than non-special needs individuals.

Conclusion

There is higher burden of oral HPV infection among adults with special needs compared to general population. Contrastingly, lower vaccination rates were observed among them within the recommended age groups. Further studies are required to determine the barriers to HPV vaccination among individuals with special needs.

•

The prevalence of Oral HPV infection is higher among the adults with special health care needs.

•

Individuals with Special health care needs have lower uptake of HPV vaccination with in the recommended age groups, compared to the general population.

•

Males are more likely to have high-risk Oral HPV infection and lower vaccination rates compared to females.

ATR inhibition sensitizes HPV- and HPV+ head and neck squamous cell carcinoma to cisplatin

OBJECTIVES

Cisplatin is commonly used in the treatment of head and neck squamous cell carcinoma (HNSCC), and the repair of cisplatin-induced DNA damage involves activation of the DNA damage response protein ataxia telangiectasia and Rad3-related (ATR). Resistance to cisplatin therapy exacerbates adverse toxicities and is associated with poor outcomes. Since repair of cisplatin-induced DNA damage contributes to resistance, we hypothesized that inhibition of ATR using AZD6738, a well-tolerated and orally-bioavailable inhibitor, would enhance the sensitivity of HNSCC cells and tumors to cisplatin.

MATERIALS AND METHODS

A panel of human papilloma virus-negative (HPV^-) and HPV⁺ HNSCC cell lines were treated with cisplatin in the absence or presence of AZD6738, and effects on cell viability, colony formation, apoptosis signaling, and DNA damage were assessed. The impact of co-treatment with cisplatin plus AZD6738 on the growth of HPV^- and HPV⁺ cell line- and patient-derived xenograft tumors was also examined.

RESULTS

Inhibition of ATR with AZD6738 enhanced cisplatin-induced growth inhibition of HNSCC cell lines and tumors, in association with increased apoptosis signaling and DNA damage. Both HPV^- and HPV⁺ models were sensitized to cisplatin by ATR inhibition.

CONCLUSION

Inhibition of ATR promotes sensitization to cisplatin in preclinical in vitro and in vivo models of HPV^- and HVP⁺ HNSCC, supporting clinical evaluation of this strategy in this disease.

Multisite HPV infections in the United States (NHANES 2003-2014): An overview and synthesis

HPV is the most common sexually transmitted infection in the U.S., infecting both anogenital and oral sites. Nationally representative data are collected through the National Health and Nutrition Examination Survey (NHANES). However, changing designations of HPV genotypes as high or low risk and varying underlying populations as new results are reported have made direct comparison of results difficult. We reanalyzed HPV data from NHANES derived from self-collected cervicovaginal swabs (women ages 18-59, 2003-14), penile swabs (men ages 18-59, 2013-14), and oral rinses (men and women ages 18-69, 2009-14), using consistent populations and definitions across NHANES cycles. These data strengthen our understanding of age trends in HPV prevalence: cervicovaginal prevalence decreases with age, penile prevalence increases with age, and oral prevalence is bimodal but with an earlier first peak in women. There is strong evidence for reduced prevalence of vaccine genotypes (6, 11, 16, 18) in vaccinated men and women (ages 18-24) at both genital (RR 0.2 (0.1-0.3) in women and 0.7 (0.1-5.4) in men) and oral sites (RR 0.1 (0.0-1.3) in women; no infections detected in vaccinated men). A more complete picture of the burden of HPV in the U.S. is emerging, including evidence for reduced HPV genital and oral prevalence in vaccinated individuals.

Epidemiology of Head and Neck Squamous Cell Carcinomas: Impact on Staging and Prevention Strategies

OPINION STATEMENT

The epidemiology of head and neck squamous cell carcinoma (HNSCC) has shifted dramatically over the last 50 years, as smoking-related HNSCCs decrease in incidence while human papillomavirus (HPV)-related cancers rise. The shift in HNSCC risk factors has changed patient demographics, the distribution of affected anatomical subsites, and prognosis of this illness. As such, the medical community has responded by devising novel staging systems and prevention strategies. The medical community will require continued vigilance in reducing HNSCC traditional risks factors for HNSCC, such as cigarette use, and emerging risk like HPV infection.

Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention

Lesbian, gay, bisexual, and transgender (LGBT) persons face important health issues relevant to dermatologists. Men who have sex with men (MSM) are at higher risk of certain infectious diseases, including HIV, syphilis and other sexually transmitted diseases (STDs), methicillin-resistant Staphylococcus aureus infections, and invasive meningococcal disease, and might be at higher risk of non-infectious conditions, including skin cancer. Recommendations for preventive health care, including screening for HIV and other STDs, sexual health-related vaccinations, and HIV pre-exposure prophylaxis, differ for MSM compared with non-MSM. Women who have sex with women experience disparities in STDs, including chlamydia and HPV. Transgender patients have unique, and often unmet, dermatologic needs during gender transition (also called gender affirmation), related to hormonal therapy and gender-affirming surgery. Familiarity with LGBT health issues and disease-prevention guidelines can enable dermatologists to provide medically appropriate and culturally competent care to LGBT persons.

Prevalence of human papillomavirus in oral rinse samples from healthy individuals in northern Thailand

BACKGROUND

The incidence of oral cancers associated with human papillomavirus (HPV) has been increasing in recent years. Therefore, it is necessary to elucidate HPV prevalence in oral cells and exposure to risk factors in various age groups.

METHODS

Oral rinse samples from healthy individuals in northern Thailand were investigated for HPV prevalence and genotyped using the polymerase chain reaction (GP5+/6+ primers) and DNA sequencing of the PCR products.

RESULTS

Samples were collected from 594 participants between 4 and 60 years of age. HPV was detected in 3.7% of samples. The prevalence of HPV-positive cases was 8.6% in the 31-50 age group. HPV prevalence increased with age and was the highest (9.2%) in the 41-50 age group, but decreased (to 3%) in the 51-60 age group. Risk factors significantly associated with HPV-positive cases included alcohol consumption, coffee drinking, sexual activity, and having children. HPV 16 and 18 were common genotypes, especially in the 31-50 age group, and were associated with having sexual activity (odds ratio 19.0 [95% CI: 2.5-142.5]). At follow-up of some individuals in the 4-10 age group, a 9-year-old child was found to be positive for HPV18.

CONCLUSIONS

These results suggest that HPV can be acquired at a young age and the prevalence peaks in the middle age class among healthy individuals in northern Thailand, especially in the 31-50 age group.

Human papillomavirus prevalence and behavioral risk factors among HIV-infected and HIV-uninfected men who have sex with men in Taiwan

Human papillomavirus (HPV) infection is associated with cancer and can be prevented through vaccination. Few studies from Taiwan have reported on HPV infection among human immunodeficiency virus (HIV)-infected subjects. The aim of this study was to examine the prevalence of HPV infection among men who have sex with men (MSM) with and without HIV infection in Taiwan, and explore the behavioral risk factors thereof.We conducted a cross-sectional study in Taiwan during 2013 to 2016 to collect data on MSM aged 20 years or older. We used a questionnaire in a face-to-face interview, and subsequently collected oral, anal, and genital specimens from HIV-infected and HIV-uninfected subjects. Multivariate analysis was performed to predict factors associated with high-risk HPV (HR-HPV) positivity.Overall, 279 subjects, including 166 (59.5%) HIV-uninfected and 113 (40.5%) HIV-infected men were enrolled. Compared to HPV-negative subjects, HPV-positive subjects had significantly higher rates of receptive anal sex (91.3% vs 75.6%), substance use (22.6% vs 11%), history of sexually transmitted infections (75.7% vs 38.4%), anogenital or oral warts (39.1% vs 6.72%), syphilis (32.2% vs 11.6%), and HIV infection (69.6% vs 20.1%). We detected 489 HPV deoxyribonucleic acid (DNA) types (through 379 viable specimens), of which 43.6%, 5.7%, 56.4%, and 10.4% were HR-HPV type, HPV type 16, low-risk HPV types, and HPV type 6, respectively. In multivariate analysis, HIV-infected subjects had a significantly higher prevalence of HR-HPV infection (adjusted odds ratio, 5.80; 95% confidence interval, 2.57-13.11), compared to HIV-uninfected subjects.These results suggest that the prevalence of HPV infection was high among HIV-infected MSM. Additionally, anal HPV infection was observed to be common among both HIV-infected and HIV-uninfected MSM in Taiwan. The prevalence of oral and genital HPV infection, HR-HPV DNA types, and multiple HPV types was higher in HIV-infected subjects than in HIV-uninfected subjects. As only 35% of subjects practiced safe sex, we recommend routine HPV vaccination with 4-valent HPV or 9-valent HPV vaccines for both MSM, and HIV-infected subjects.

Dynamics and Determinants of HPV Infection: The Michigan HPV and Oropharyngeal Cancer (M-HOC) Study

INTRODUCTION

Human papillomavirus (HPV) is the primary cause of cervical and other anogenital cancers and is also associated with head and neck cancers. Incidence of HPV-related oropharyngeal squamous cell cancers (OPSCCs) is increasing, and HPV-related OPSCCs have surpassed cervical cancer as the most common HPV-related cancer in the USA. Given the multisite nature of HPV, there is strong interest in collecting data from both genital and oral sites, as well as associated data on social and sexual behaviours. The overarching goal of this study is to evaluate patterns of oral HPV infection incidence, clearance and persistence and their relationship to sexual behaviour history.

METHODS AND ANALYSIS

Participants are recruited from two populations: college students at a large public university and general population from the surrounding area. At the first study visit, participants complete a detailed sexual history, health and behaviour questionnaire. Follow-up visits occur every 3-4 months over 3 years, when participants complete an abbreviated questionnaire. All participants provide a saliva sample at each visit, and eligible participants may provide a cervicovaginal self-swab. Genetic material isolated from specimens is tested for 15 high-risk and 3 low-risk HPV types. Statistical analyses will examine outcome variables including HPV prevalence, incidence, persistence and clearance. Logistic regression models will be used to estimate odds ratios and 95% confidence intervals for associations between the outcomes of interest and demographic/behavioural variables collected in the questionnaires. The longitudinal HPV infection data and detailed sexual history data collected in the questionnaires will allow us to develop individual-based network models of HPV transmission and will be used to parameterise multiscale models of HPV-related OPSC carcinogenesis.

ETHICS AND DISSEMINATION

This study has been approved by the University of Michigan Institutional Review Board. All participants are consented in person by trained study staff. Study results will be disseminated through peer-reviewed publications.

Trends in Risks for Second Primary Cancers Associated With Index Human Papillomavirus-Associated Cancers

IMPORTANCE

In the last 4 decades, survival among patients with human papillomavirus (HPV)-associated cancers has improved, while the incidence of these cancers has increased among younger cohorts. Among survivors of HPV-associated cancers, persistent HPV infection may remain a risk factor for preventable HPV-associated second primary cancers (HPV-SPCs).

OBJECTIVES

To investigate the risk of HPV-SPCs among survivors of HPV-associated index cancers and to test the hypothesis that the HPV-SPC risk among these persons has increased over the last 4 decades.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 9 cancer registries of the Surveillance, Epidemiology, and End Results (SEER) database was conducted to identify patients with HPV-associated (cervical, vaginal, vulvar, oropharyngeal, anal, and penile) cancers diagnosed from January 1, 1973, through December 31, 2014. The dates of analysis were July 1, 2017, to January 31, 2018.

MAIN OUTCOMES AND MEASURES

The HPV-SPC risk was quantified by calculating standard incidence ratios (SIRs) and excess absolute risks (EARs) per 10 000 person-years at risk (PYR). The HPV-SPC risk by time was estimated using Poisson regression.

RESULTS

From 113 272 (73 085 female and 40 187 male) survivors of HPV-associated cancers, 1397 women and 1098 men developed HPV-SPCs. The SIRs for HPV-SPCs were 6.2 (95% CI, 5.9-6.6) among women and 15.8 (95% CI, 14.9-16.8) among men. The EARs were 18.2 per 10 000 PYR for women and 53.5 per 10 000 PYR for men. Among both women and men, those who had index oropharyngeal cancers had the highest HPV-SPC risk (SIR, 19.8 [95% CI, 18.4-21.4] and EAR, 80.6 per 10 000 PYR among women; SIR, 18.0 [95% CI, 16.9-19.1] and EAR, 61.5 per 10 000 PYR among men). Women who had index cervical cancers and men who had index anal cancers had the lowest HPV-SPC risk (SIR, 2.4 [95% CI, 2.2-2.7] and EAR, 4.5 per 10 000 PYR among women; SIR, 6.5 [95% CI, 4.7-8.8] and EAR, 18.5 per 10 000 PYR among men). Both women and men who had index HPV-associated cancers of any kind had a significantly higher risk of oropharyngeal HPV-SPCs. Over the last 4 decades, the risk of developing most types of HPV-SPCs after index cervical, vaginal, and vulvar cancers increased.

CONCLUSIONS AND RELEVANCE

According to this study, the HPV-SPC risk among survivors of HPV-associated cancers is significant, implying that persistent HPV infection at multiple sites may be associated with HPV-SPCs. These findings have the potential to inform surveillance recommendations for survivors of HPV-associated cancers.