Primary Prevention of HPV through Vaccination: Update on the Current Global Status

A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs

The uptake of human papillomavirus (HPV) vaccine remains suboptimal despite being a part of routine vaccination within national immunization program(s). This indicates probable challenges with the implementation of HPV immunization program(s) in various countries. The objective of this systematic literature review (SLR) was to identify implementation strategies for HPV vaccination within national and regional immunization programs worldwide with an aim to provide guidance for countries targeting to increase their HPV vaccine coverage rate (VCR). A comprehensive literature search was conducted across Medline and Embase and included articles published between January 2012 and January 2022. Of the 2,549 articles retrieved, 168 met inclusion criteria and were included in the review. Strategies shown to improve HPV vaccination uptake in the reviewed literature include campaigns to increase community awareness and knowledge of HPV, health care provider trainings, integrating HPV vaccination within school settings, coordinated efforts via multi-sectoral partnerships, and vaccination reminder and recall systems. Findings may help national authorities understand key considerations for HPV vaccination when designing and implementing programs aiming to increase HPV VCR in adolescents.

Racial and ethnic disparities in human papillomavirus (HPV) vaccine uptake among United States adults, aged 27-45 years

In 2018, the Food and Drug Administration expanded the age of eligibility for the human papillomavirus (HPV) vaccine to 27 to 45 years. However, it is unclear if there are racial/ethnic disparities in HPV vaccine uptake for this age-group following this expanded recommendation. We aimed to identify any disparities in HPV vaccine in 27 to 45 year-olds based on sociodemographic factors. We analyzed nationally representative, cross-sectional data from the 2019 National Health Interview Survey (n = 9440). Logistic regression models estimated the odds of vaccine uptake (receipt of ≥1 vaccine dose) based on sociodemographic factors. Participants were mostly Non-Hispanic Whites (60.7%) and females (50.9%). In adjusted models, females had over three times greater odds of vaccine uptake compared to males (aOR = 3.58; 95% CI 3.03, 4.23). Also, compared to Non-Hispanic Whites, Non-Hispanic Blacks were 36% more likely (aOR = 1.36; 95% CI 1.09, 1.70), and Hispanics were 27% less likely (aOR = 0.73; 95% CI 0.58, 0.92) to receive the vaccine. Additionally, individuals without a usual place of care had lower odds of vaccine uptake (aOR = 0.72; 95% CI 0.57, 0.93), as were those with lower educational levels (aORhigh school = 0.62; 95% CI 0.50, 0.78; aORsome college = 0.83; 95% CI 0.70, 0.98). There are disparities in HPV vaccine uptake among 27 to 45 year-olds, and adult Hispanics have lower odds of receiving the vaccine. Given the vaccine's importance in cancer prevention, it is critical that these disparities are addressed and mitigated.

School Nurses' Experiences and Roles in Promoting and Administering the HPV Vaccine: A Systematic Review Using the Socioecological Framework

Understanding the school nurse's experience in human papillomavirus (HPV) vaccine promotion can reduce vaccine disparities. HPV vaccination is critical to cancer prevention. Despite the importance of the school nurse in vaccine promotion, there is a lack of understanding. This article aims to examine the knowledge, attitude, experience, and role of school nurses related to HPV vaccination and promotion in school settings. A systematic search for school nurses and their experiences related to HPV vaccination was conducted. A thematic synthesis was undertaken using the socioecological model. This review highlights the complexity of HPV vaccine promotion in schools over time. Multilevel factors impact nursing practice. Nurses have good vaccine knowledge and positive attitudes. Poor workflow processes, competing demands, and vaccine communication challenge school nurses. The themes that were synthesized informed the LEADS model. With the support of school nurses, reaching the goal of eliminating cervical cancer as a public health problem is possible.

Associations of Maternal Age, Education, and Marital Status with HPV Vaccine Uptake and Hesitancy among United States Youth: A Cross-Sectional Analysis of the 2020 National Immunization Survey

STUDY OBJECTIVE

Human papillomavirus (HPV) vaccination is proven to reduce the risk of HPV-associated cancers and lesions. Factors associated with HPV vaccine receipt or rejection have been studied, but specific maternal characteristics driving uptake among teens requires further investigation. The aim of this study was to examine maternal characteristics influencing teen vaccine uptake and intent to vaccinate.

STUDY DESIGN

Cross-sectional analysis METHODS: We analyzed data on 27,320 teens aged 13-17 using the 2020 National Immunization Survey-Teen. We constructed regression models to determine the associations, via relative risk, between child vaccination status and maternal characteristics.

RESULTS

Compared with mothers with less education, those with a college degree were significantly more likely to have their children receive HPV vaccination (RR = 1.18; 95% CI, 1.11-1.26). Compared to mothers under 35 years, those aged 35-44 (RR 1.07; 95% CI 1.01-1.14) and over 45 (RR = 1.13; 95% CI, 1.07-1.21) were more likely to provide HPV vaccination to their child. Among children not previously vaccinated (n = 12,098; N = 5,752,355), educated mothers were significantly less likely to report intent to vaccinate their child in the next year. There was no significant difference in vaccination rates in mothers who were married compared with never married (RR = 0.99; 95% CI, 0.97-1.02).

CONCLUSION

Maternal education was the strongest predictor of teens receiving the HPV vaccine. Among mothers with teens not previously vaccinated, intent to obtain the HPV vaccine for their child was higher among mothers with less education compared with college-level educated mothers. Understanding maternal characteristics driving HPV vaccine hesitancy can inform targeted approaches to improve vaccine uptake in children. Additionally, adequate and consistent health messaging on the safety, efficacy, and benefits of HPV vaccination from health providers and public health agencies could increase uptake among adolescents and teens of vaccine-hesitant mothers.

A Landscape of CRISPR/Cas Technique for Emerging Viral Disease Diagnostics and Therapeutics: Progress and Prospects

Viral diseases have emerged as a serious threat to humanity and as a leading cause of morbidity worldwide. Many viral diagnostic methods and antiviral therapies have been developed over time, but we are still a long way from treating certain infections caused by viruses. Acquired immunodeficiency syndrome (AIDS) is one of the challenges where current medical science advancements fall short. As a result, new diagnostic and treatment options are desperately needed. The CRISPR/Cas9 system has recently been proposed as a potential therapeutic approach for viral disease treatment. CRISPR/Cas9 is a specialised, effective, and adaptive gene-editing technique that can be used to modify, delete, or correct specific DNA sequences. It has evolved into an advanced, configurable nuclease-based single or multiple gene-editing tool with a wide range of applications. It is widely preferred simply because its operational procedures are simple, inexpensive, and extremely efficient. Exploration of infectious virus genomes is required for a comprehensive study of infectious viruses. Herein, we have discussed the historical timeline-based advancement of CRISPR, CRISPR/Cas9 as a gene-editing technology, the structure of CRISPR, and CRISPR as a diagnostic tool for studying emerging viral infections. Additionally, utilizing CRISPR/Cas9 technology to fight viral infections in plants, CRISPR-based diagnostics of viruses, pros, and cons, and bioethical issues of CRISPR/Cas9-based genomic modification are discussed.

HPV Vaccination: An Underused Strategy for the Prevention of Cancer

Human papillomavirus (HPV) vaccination prevents cervical, head and neck, and anogenital cancers. However, global HPV vaccine coverage falls short of global targets and has seen unexpected and dramatic declines in some countries. This paper synthesizes the impact of HPV on the global burden of cancer and the potential benefit of HPV vaccination. Approximately 5% of the world's cancers are specifically attributed to HPV. While the greatest global burden of HPV is cervical cancers in low- and middle-income countries, HPV-associated head and neck cancers are increasing in high-income countries and have surpassed cervical cancer as the primary HPV-associated cancer in some countries. Therefore, it is also critical to improve gender-neutral HPV vaccination. Understanding the modifiable drivers of vaccine acceptance and uptake is important for increasing HPV vaccination. The Behavioural and Social Drivers of Vaccination framework is broadly applied to identify key factors associated with HPV vaccination including domains concerning practical issues, motivation, social processes, and thinking and feeling. Among the behavioural strategies available to reduce the incidence and mortality of cancer, increasing HPV vaccination stands out as having unrealized potential to prevent disease, financial cost, and psychological distress. An understanding of the shifting burden of HPV and the factors associated with vaccination can be leveraged to regularly measure these factors, develop interventions to promote vaccine uptake, and improve global HPV vaccine coverage. Future research in diverse contexts is necessary to investigate the barriers and facilitators of global HPV vaccination.

The impact of publicly funded immunization programs on human papillomavirus vaccination in boys and girls: An observational study

Background

Reaching and maintaining high global human papillomavirus (HPV) vaccine uptake has been challenging. The impact of publicly funded HPV immunization programs and the interplay of sociodemographic, psychosocial and policy factors in maximizing vaccination is poorly understood. This observational study examined the impact of introducing publicly funded school-based HPV vaccination programs for boys directly on uptake in boys and indirectly on uptake in girls, while concurrently examining other important sociodemographic and psychosocial factors.

Methods

Data were collected from a national, longitudinal sample of Canadian parents of children aged 9-16 years during August-September 2016 (T1) and June-July 2017 (T2). Participants completed an online questionnaire measuring sociodemographic characteristics, vaccine knowledge and attitudes, health care provider recommendation, and HPV vaccine uptake. Analyses were conducted separately for parents of boys and girls using logistic regression analyses at T1 and T2. Jurisdictions with HPV vaccine funding for boys at both time-points were compared to those with funding at neither time-points and those that introduced funding between time-points.

Findings

The sample included parents of boys (n = 716) and girls (n = 843). In multivariable analyses, jurisdictions with funding for boys at both time-points had higher odds of vaccination (adjusted odds ratio, T1 = 10.18, T2 = 11.42; 95% confidence interval, T1 = 3.08-33.58, T2 = 5.61-23.23) than jurisdictions without funding at both time-points; however, funded jurisdictions did not have higher odds of vaccination compared to jurisdictions that newly introduced funding for boys. Vaccination was associated with consistent determinants in boys and girls including child's age, health care provider recommendation, perceived vaccine harms, and perceived vaccine affordability.

Interpretation

This gender-sensitive analysis highlights the interplay of sociodemographic, psychosocial, and policy factors that can improve HPV vaccination. Publicly funded school-based programs are an impactful strategy to increase vaccine uptake.

Funding

This work was supported by the Canadian Cancer Society Research Institute (#704,036). GKS was supported by the Vanier Canada Graduate Scholarship and Queen Elizabeth II Diamond Jubilee Scholarship programs. The funders of this work had no role in the data collection, analysis, or interpretation, or any aspect pertinent to the study.

Design and Immunological Validation of Macaca fascicularis Papillomavirus Type 3 Based Vaccine Candidates in Outbred Mice: Basis for Future Testing of a Therapeutic Papillomavirus Vaccine in NHPs

Persistent human papillomavirus (HPV) infections are causative for cervical neoplasia and carcinomas. Despite the availability of prophylactic vaccines, morbidity and mortality induced by HPV are still too high. Thus, an efficient therapy, such as a therapeutic vaccine, is urgently required. Herein, we describe the development and validation of Macaca fascicularis papillomavirus type 3 (MfPV3) antigens delivered via nucleic-acid and adenoviral vectors in outbred mouse models. Ten artificially fused polypeptides comprising early viral regulatory proteins were designed and optionally linked to the T cell adjuvant MHC-II-associated invariant chain. Transfected HEK293 cells and A549 cells transduced with recombinant adenoviruses expressing the same panel of artificial antigens proved proper and comparable expression, respectively. Immunization of outbred CD1 and OF1 mice led to CD8+ and CD4+ T cell responses against MfPV3 antigens after DNA- and adenoviral vector delivery. Moreover, in vivo cytotoxicity of vaccine-induced CD8+ T cells was demonstrated in BALB/c mice by quantifying specific killing of transferred peptide-pulsed syngeneic target cells. The use of the invariant chain as T cell adjuvant enhanced the T cell responses regarding cytotoxicity and in vitro analysis suggested an accelerated turnover of the antigens as causative. Notably, the fusion-polypeptide elicited the same level of T-cell responses as administration of the antigens individually, suggesting no loss of immunogenicity by fusing multiple proteins in one vaccine construct. These data support further development of the vaccine candidates in a follow up efficacy study in persistently infected Macaca fascicularis monkeys to assess their potential to eliminate pre-malignant papillomavirus infections, eventually instructing the design of an analogous therapeutic HPV vaccine.

Adverse events following HPV vaccination: 11 years of surveillance in Australia

BACKGROUND

Australia was the first country to implement a fully funded vaccination program with quadrivalent human papillomavirus vaccine (4vHPV) in 2007, including males from 2013. We examined adverse events (AE) following vaccination with 4vHPV from 11 years of post-marketing data, focusing on a period of enhanced surveillance and adverse events of special interest (AESI).

METHODS

AE following 4vHPV doses administered between April 2007 and December 2017 reported to Australia's national regulator, the Therapeutic Goods Administration, were examined; reports collected during enhanced surveillance in 2013 and 2014 were analyzed separately. Age and sex-specific rates, using denominator data from the national HPV vaccination register, were determined. Pre-specified AESI were identified using Medical Dictionary for Regulatory Activities (MedDRA®) Preferred Terms and examined in detail.

FINDINGS

Following nine million doses of 4vHPV vaccine administered in Australia, 4551 AE reports were identified. The crude reporting rate was 39.8 per 100 000 doses in the funded cohorts, excluding the enhanced surveillance period. The reported rate of syncope in 12 to 13-year-old males and females was 29.6 per 100 000 doses during enhanced surveillance and 7.1 per 100 000 doses during the remaining study period; rates of syncope were higher in younger compared to older adolescents. The rate of anaphylaxis (0.32 per 100 000 doses) was consistent with published rates. Other AESI including autoimmune disease, postural orthostatic tachycardia syndrome, primary ovarian insufficiency, Guillain-Barré syndrome, complex regional pain syndrome and venous thromboembolism, were reported at low rates and analysis did not reveal unexpected patterns that would suggest causal association.

INTERPRETATION

AESI, apart from syncope, were reported rarely. The higher rate of syncope among younger adolescents highlights the need for management protocols to prevent syncope-related injury. Analysis of this large, longitudinal dataset in a country with high vaccine uptake, including a period of enhanced surveillance, affirms the safety profile of 4vHPV.

HPV vaccine, Twitter, and gay, bisexual and other men who have sex with men

This study aimed to quantify human papillomavirus (HPV) vaccine Twitter messaging addressing gay, bisexual and other men who have sex with men (GB+MSM) and describes messaging by vaccine sentiment (attitudes towards vaccine) and characteristics (topic of messaging). Between August 2014 and July 2015, we collected 193 379 HPV-related tweets and classified them by vaccine sentiment and characteristics. We analysed a subsample of tweets containing the terms 'gay', 'bisexual' and 'MSM' (N = 2306), and analysed distributions of sentiment and characteristics using chi-square. HPV-related tweets containing GB+MSM terms occupied 1% of our sample. The subsample had a largely positive vaccine sentiment. However, a proportion of 'gay' and 'bisexual' tweets did not mention the vaccine, and a proportion of 'gay' and 'MSM' tweets had a negative sentiment. Topics varied by GB+MSM term-HPV risk messaging was prevalent in 'bisexual' (25%) tweets, and HPV transmission through sex/promiscuity messaging was prevalent in 'gay' (18%) tweets. Prevention/protection messaging was prevalent only in 'MSM' tweets (49%). Although HPV vaccine sentiment was positive in GB+MSM messaging, we identified deficits in the volume of GB+MSM messaging, a lack of focus on vaccination, and a proportion of negative tweets. While HPV vaccine promotion has historically focused on heterosexual HPV transmission, there are opportunities to shape vaccine uptake in GB+MSM through public health agenda setting using social media messaging that increases knowledge and minimizes HPV vaccine stigma. Social media-based HPV vaccine promotion should also address the identities of those at risk to bolster vaccine uptake and reduce the risk of HPV-attributable cancers.

Human papillomavirus vaccination and sexual practices among men who have sex with men in Melbourne, Australia: a cross-sectional study

The aim of this study was to explore the factors associated with self-reported receipt of human papillomavirus (HPV) vaccine among men who have sex with men (MSM). MSM aged 16–40 years attending the Melbourne Sexual Health Centre, Australia, for their first visit in 2016 were included in the analysis. Multivariable logistic regression analyses were performed to examine the association between self-reported HPV vaccination and sexual practices: one examining the sexual practices. A total of 1332 MSM with a mean age of 27.6 (standard error [SE] = 0.1) were included in the analysis. The mean number of reported male partners in the last 3 and 12 months was 4.0 (SE = 0.1) and 8.9 (SE = 0.4), respectively. Six percent ( n =  81) of MSM reported receiving the HPV vaccine. There was no significant association between sexual practices (the number of partners or condomless anal sex) and self-reported HPV vaccine receipt after adjusting for confounding factors such as human immunodeficiency virus (HIV) status and pre-exposure prophylaxis (PrEP). HIV-negative MSM taking PrEP were three times more likely to be vaccinated against HPV compared with HIV-negative MSM not taking PrEP in both multivariable analyses. Our findings suggest that there is no association between HPV vaccination and sexual risk practices in MSM.

The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent?

Background: A National human papilloma virus (HPV) Vaccination Programme for the prevention of HPV infection and associated disease using the quadrivalent HPV vaccine (4vHPV) has been funded and implemented in Australia since 2007, initially for girls only and extended to boys in 2013, with uptake rates among the highest observed worldwide. Aim: We report on the impact of this national programme on HPV prevalence and associated disease burden and estimate the potential impact of adopting a nonavalent HPV (9vHPV) vaccine. Methods: We performed a non-systematic literature review of studies measuring the burden of HPV-associated disease and infection in Australia before and after introduction of HPV vaccination. We also included key national reports with estimates of HPV-related disease burden. Results: Substantial declines in high-grade cervical disease and genital warts among vaccine-eligible women have been observed. Reductions in genital warts incidence and HPV prevalence among heterosexual men of similar age were observed before introduction of the male vaccination programme, indicating a substantial herd effect. 9vHPV vaccine is expected to prevent up to 90% of cervical and 96% of anal cancers. Of an estimated 1,544 HPV-associated cancers in 2012, 1,242 would have been preventable by the 4vHPV vaccine and an additional 187 anogenital cancers by the 9vHPV vaccine. Conclusions: Vaccination using 4vHPV vaccine has had a large demonstrable impact on HPV-related disease in Australia. A switch to 9vHPV could further reduce the HPV-associated cancer burden. With continued high coverage among both males and females, elimination of vaccine-type HPV disease seems achievable in Australia.

Japanese physicians' attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines

INTRODUCTION

Japan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents' vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV.

METHODS

We conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians' reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations.

RESULTS

Valid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation.

CONCLUSIONS

Although Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.

HPV-vaccination and cancer cervical screening in 53 WHO European Countries: An update on prevention programs according to income level

Human papillomavirus (HPV) is the most common sexually transmitted disease in the world. The aim of our study is to describe the differences in HPV‐vaccination coverage and screening programs in WHO European Countries notably according to income levels. Multiple correspondence analysis was applied to examine the association among the following variables: Gross National Income (GNI) levels (Lower‐Middle Income, LMI; Upper‐Middle Income, UMI; and High Income, HI); type of CC screening program (coverage; opportunistic/organized); vaccination payment policies (free or partial or total charge); mortality rates/100 000 (≤3; >3‐6; >6‐9; >9); incidence rates/100 000 (≤7; >7‐15; >15‐21; >21). Data HPV‐vaccination start (years) (2006‐2008; 2009‐2011; 2012‐2014; >2014; no program); coverage HPV‐vaccination percentage (≤25; 26‐50; 51‐75; >75); data screening start (years) (<1960; 1960‐1980; 1981‐2000; >2000); primary screening test (HPV, cytology), and screening coverage percentage (≤25; >25‐50; >50‐75; >75). A high income is associated with: start of screening before 1960, medium‐high screening coverage, organized screening, start of vaccination in the periods 2009‐2011 and 2012‐2014 and high immunization coverage. On the other hand, lower‐middle income is associated with: late start of vaccination and screening programs with cytology as primary test, high mortality and incidence rates and lower‐medium vaccination coverage. Our results show a useful scenario for crucial support to public health decision‐makers. Public health authorities should monitor the HPV‐vaccinated population in order to determine more precisely the effects on short‐ and long‐term incidence and mortality rates. In fact, the greater the vaccination coverage, the greater will be the efficacy of the program for the prevention of CC and other HPV‐related diseases.

Cervical Cancer Screening Programs in Europe: The Transition Towards HPV Vaccination and Population-Based HPV Testing

Cervical cancer is the fourth most frequently occurring cancer in women around the world and can affect them during their reproductive years. Since the development of the Papanicolaou (Pap) test, screening has been essential in identifying cervical cancer at a treatable stage. With the identification of the human papillomavirus (HPV) as the causative agent of essentially all cervical cancer cases, HPV molecular screening tests and HPV vaccines for primary prevention against the virus have been developed. Accordingly, comparative studies were designed to assess the performance of cervical cancer screening methods in order to devise the best screening strategy possible. This review critically assesses the current cervical cancer screening methods as well as the implementation of HPV vaccination in Europe. The most recent European Guidelines and recommendations for organized population-based programs with HPV testing as the primary screening method are also presented. Lastly, the current landscape of cervical cancer screening programs is assessed for both European Union member states and some associated countries, in regard to the transition towards population-based screening programs with primary HPV testing.

Making HPV vaccination available to girls everywhere

Cervical cancer is currently the fourth leading cause of cancer death among women worldwide, with most cases occurring in low- and middle-income countries. Safe, highly effective vaccines against HPV have been on the market since 2006, yet only 6% of girls worldwide have received this life-saving cancer prevention intervention. International organizations, including PATH, Gavi, and the pharmaceutical companies Merck and GlaxoSmithKline, have provided support to eligible low- and middle-income countries to implement national HPV vaccination programs. Still, glaring disparities in the availability of national HPV vaccination programs and the coverage of the primary target population between the global north and south persist. We illustrate worldwide HPV vaccine implementation and coverage using an online data visualization, which is publicly available and can be used to gain unique insights. We also present three emerging solutions to transform future HPV vaccine delivery in low- and middle-income countries: low-cost generics, single-dose vaccination, and co-administration with other adolescent vaccines. By rapidly expanding access to HPV vaccination to girls everywhere, vaccine-type HPV infections can be virtually eliminated. At high vaccination-coverage levels, more than 80%-or approximately 230 000-of the cervical cancer deaths that occur each year can be averted.

Using an integrated conceptual framework to investigate parents' HPV vaccine decision for their daughters and sons

Despite being an effective cancer prevention strategy, human papillomavirus (HPV) vaccination in Canada remain suboptimal. This study is the first to concurrently evaluate HPV vaccine knowledge, attitudes, and the decision-making stage of Canadian parents for their school-aged daughters and sons. Data were collected through an online survey from a nationally representative sample of Canadian parents of 9-16 year old children from August to September 2016. Measures included socio-demographics, validated scales to assess HPV vaccine knowledge and attitudes (using the Health Belief Model), and parents' HPV vaccination adoption stage using the Precaution Adoption Process Model (PAPM; six stages: unaware, unengaged, undecided, decided not, decided to, or vaccinated). 3779 parents' survey responses were analyzed (1826 parents of sons and 1953 parents of daughters). There was a significant association between child's gender and PAPM stage of decision-making, with parents of boys more likely to report being in earlier PAPM stages. In multinomial logistic regression analyses parents of daughters (compared to sons), parents of older children, and parents with a health care provider recommendation had decreased odds of being in any earlier PAPM stage as compared to the last PAPM stage (i.e. vaccinated). Parents who were in the 'decided not to vaccinate' stage had significantly greater odds of reporting perceived vaccine harms, lack of confidence, risks, and vaccine conspiracy beliefs. Future research could use these findings to investigate theoretically informed interventions to specifically target subsets of the population with particular attention towards addressing knowledge gaps, perceived barriers, and concerns of parents.

HPV vaccine implementation and monitoring in Latin America

OBJECTIVE

To describe HPV vaccine program implementation, monitoring and evaluation experiences in Latin America.

MATERIALS AND METHODS

We reviewed published articles in peer-reviewed journals and reports from government web- sites, as well as the PAHO/WHO/UNICEF Joint Reporting form and the ICO/IARC HPV Information Centre database.

RESULTS

By December 2016, 13 countries/territories in Latin America (56%) have introduced HPV vaccines. The majority have done so in the past three years, targeting 10- 12 year old girls with a two dose schedule, through school programs. Vaccine coverage ranges from 30 to 87%. Safety monitoring is well established, but monitoring vaccine impact is not, and data are not available.

CONCLUSIONS

. Although Latin America is the most advanced developing region with HPV vaccine introduction, systems for its monitoring are weak and there is a paucity of consistently available coverage data for this vaccine. Challenges remain to introduce HPV vaccines in several countries, to achieve high coverage, and to strengthen monitoring, evaluation and reporting.

Safety of Human Papillomavirus Vaccines: An Updated Review

Human papillomavirus (HPV) vaccines are now included in immunisation programmes in 71 countries. Unfortunately, uptake has been impacted in some countries by reduced confidence in the safety of the HPV vaccine. In 2013, we published an extensive review demonstrating a reassuring safety profile for bivalent (2vHPV) and quadrivalent (4vHPV) vaccines. A nonavalent (9vHPV) vaccine is now available and HPV immunisation programmes have been extended to males in 11 countries. The aim of this updated narrative review was to examine the evidence on HPV vaccine safety, focusing on the 9vHPV vaccine, special populations and adverse events of special interest (AESI). The previous searches were replicated to identify studies to August 2016, including additional search terms for AESI. We identified 109 studies, including 15 population-based studies in over 2.5 million vaccinated individuals across six countries. All vaccines demonstrated an acceptable safety profile; injection-site reactions were slightly more common for 9vHPV vaccine than for 4vHPV vaccine. There was no consistent evidence of an increased risk of any AESI, including demyelinating syndromes or neurological conditions such as complex regional pain or postural orthostatic tachycardia syndromes. The risk-benefit profile for HPV vaccines remains highly favourable.

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.

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.

Parents' involvement in the human papillomavirus vaccination decision for their sons

OBJECTIVES

Parents are critical to ensure sufficient human papillomavirus (HPV) vaccine coverage. No studies to date have examined how mothers and fathers perceive their own, their partners' and their sons' involvement in HPV vaccination decision-making process.

METHODS

An online survey methodology was used to collect data from a national sample of Canadian parents (33% fathers, 67% mothers, M_age=44) who had a 9-16years old son (n=3117).

MAIN OUTCOME MEASURES

Parent's perception of their self-involvement, partner-involvement and son's involvement in the decision to get their son the HPV vaccine were measured on a Likert scale and were classified as 'no involvement', 'moderate involvement' and 'high involvement'.

RESULTS

Mothers and fathers both perceive that they themselves and their partners should be highly involved in their son's HPV vaccination decision. Son's involvement was reported as moderate and influenced by age. Significant gender differences were found for self and partner involvement, but the effect sizes were small.

CONCLUSION

Mothers and fathers both perceive that they themselves and their partners should be significantly involved in their son's HPV vaccination decision. A dyad decision-making model involving both parents for HPV vaccine decision-making is suggested with a stronger recommendation for a triad decision-making model involving both parents as well as the child/adolescent. Gender stereotypes of females perceiving themselves as the sole decision-maker or fathers not wanting to be involved in their children's health decision were not supported.

A Multiple Streams analysis of the decisions to fund gender-neutral HPV vaccination in Canada

In Canada, the human papillomavirus (HPV) vaccine is licensed and recommended for females and males. Although all Canadian jurisdictions fund school-based HPV vaccine programs for girls, only six jurisdictions fund school-based HPV vaccination for boys. The research aimed to analyze the factors that underpin government decisions to fund HPV vaccine for boys using a theoretical policy model, Kingdon's Multiple Streams framework. This approach assesses policy development by examining three concurrent, but independent, streams that guide analysis: Problem Stream, Policy Stream, and Politics Stream. Analysis from the Problem Stream highlights that males are affected by HPV-related diseases and are involved in transmitting HPV infection to their sexual partners. Policy Stream analysis makes clear that while the inclusion of males in HPV vaccine programs is suitable, equitable, and acceptable; there is debate regarding cost-effectiveness. Politics Stream analysis identifies the perspectives of six different stakeholder groups and highlights the contribution of government officials at the provincial and territorial level. Kingdon's Multiple Streams framework helps clarify the opportunities and barriers for HPV vaccine policy change. This analysis identified that the interpretation of cost-effectiveness models and advocacy of stakeholders such as citizen-advocates and HPV-affected politicians have been particularly important in galvanizing policy change.

Knowledge and beliefs about HPV among college students in Vietnam and the United States

Any sexually active person has the possibility of contracting the human papillomavirus (HPV) sometime in their lifetime. HPV vaccines are effective in preventing HPV if obtained prior to viral exposure. Research on knowledge and beliefs of HPV and HPV vaccination among college students in Vietnam is significantly scarce. The purpose of this study is to examine the knowledge and beliefs about HPV among college students in Vietnam compared to college students in the US. This cross-cultural comparison will fill a void in current research on this subject. Over 900 college students (N=932: n=495 in Vietnam and n=437 in the US) participated in a self-administered survey on the knowledge and beliefs about HPV in September and October 2016. Vietnamese participants reported lower levels of knowledge and experiences with the HPV virus and vaccines (p<0.01). Additionally, Vietnamese participants also exhibited more barriers in obtaining the vaccination, as well as, HPV risk denial (p<0.01). The level of knowledge is an important predictor of barriers (p<0.01; η_p²=0.022) and risk denial (p<0.01; η_p²=0.116). On average, both Vietnamese and US participants could correctly answer less than half of the survey questions regarding HPV knowledge. Additionally, provider recommendations are potentially more important than informal connections (e.g. friends, family) to reduce barriers to HPV vaccination (p<0.01; η_p²=0.035) and denial of HPV risks (p<0.05; η_p²=0.008). The increase of knowledge about HPV prevention, including and vaccination, has the potential to be improved through provider interventions. Vietnam could take action toward promoting HPV vaccinations not only at an individual level but also at a national or local level. Further research may examine the effects of a lack of knowledge on HPV-related health outcomes.

Vaccination to prevent human papillomavirus infections: From promise to practice

In an essay, Paul Bloem and Ikechukwu Ogbuanu discuss the public health implications of HPV vaccination.