Human papillomavirus 9-valent vaccine for cancer prevention: a systematic review of the available evidence

Current status and future directions for the development of human papillomavirus vaccines

The development of human papillomavirus (HPV) vaccines has made substantive progress, as represented by the approval of five prophylactic vaccines since 2006. Generally, the deployment of prophylactic HPV vaccines is effective in preventing newly acquired infections and incidences of HPV-related malignancies. However, there is still a long way to go regarding the prevention of all HPV infections and the eradication of established HPV infections, as well as the subsequent progression to cancer. Optimizing prophylactic HPV vaccines by incorporating L1 proteins from more HPV subtypes, exploring adjuvants that reinforce cellular immune responses to eradicate HPV-infected cells, and developing therapeutic HPV vaccines used either alone or in combination with other cancer therapeutic modalities might bring about a new era getting closer to the vision to get rid of HPV infection and related diseases. Herein, we summarize strategies for the development of HPV vaccines, both prophylactic and therapeutic, with an emphasis on the selection of antigens and adjuvants, as well as implications for vaccine efficacy based on preclinical studies and clinical trials. Additionally, we outline current cutting-edge insights on formulation strategies, dosing schedules, and age expansion among HPV vaccine recipients, which might play important roles in addressing barriers to vaccine uptake, such as vaccine hesitancy and vaccine availability.

Screening for High-Risk Human Papillomavirus Reveals HPV52 and HPV58 among Pediatric and Adult Patient Saliva Samples

Previous research has demonstrated that the human papillomavirus (HPV) can infect a wide range of human tissues, including those within the oral cavity. High-risk oral HPV strains have been associated with the development and progression of oral cancers, including oral squamous cell carcinomas. Although many studies have examined the prevalence of the high-risk strains HPV16 and HPV18, far fewer have assessed the prevalence of other high-risk HPV strains. An approved study protocol was used to identify HPV52 and HPV58 among clinical samples (n = 87) from a saliva biorepository. Quantitative polymerase chain reaction (qPCR) and validated primers for HPV52 and HPV58 were used to facilitate this screening. This screening demonstrated that a total of n = 4/45 or 8.9% of adult saliva samples harbored high-risk HPV52, and n = 2/45 or 4.4% tested positive for high-risk HPV58. In addition, a total of n = 6/42 or 14.3% of the pediatric saliva samples tested positive for high-risk HPV, including n = 5/42 or 11.9% with HPV52 and n = 3/42 or 7.1% for HPV58. These data demonstrate the presence of the high-risk oncogenic HPV52 and HPV58 strains among both adult and pediatric clinical patient samples. More detailed longitudinal research must be conducted to determine whether this prevalence may be increasing or decreasing over time. In addition, these data strongly support public health prevention efforts, such as knowledge and awareness of the nine-valent HPV vaccine covering additional high-risk strains, including HPV52 and HPV58.

Screening for High-Risk Oral Human Papillomavirus (HPV31, HPV33, HPV35) in a Multi-Racial Pediatric and Adult Clinic Patient Population

Many human papillomavirus (HPV) strains induce cancer in the cervix and the oral cavity. Although high-risk strains including HPV16 and HPV18 are commonly known, additional high-risk strains including HPV31, HPV33, and HPV35 may also induce carcinogenesis, and much less is known about their prevalence. Using an approved protocol, samples from a salivary biorepository were screened to find pediatric and adult samples from a multi-ethnic, university-based patient clinic population. A total of N = 86 samples from the saliva biorepository met the quality and concentration standards and were screened for high-risk HPV. qPCR screening of adult samples revealed n = 10/45 or 22% were HPV31- or HPV33-positive. In addition, a total of n = 9/41 or 21.9% of pediatric samples were either HPV31- or HPV33-positive (or both). No samples harbored HPV35. Most samples were derived from patients within the recommended vaccination or catch-up age range (age 9-45 years). These results demonstrated that a significant percentage of patients harbor additional high-risk HPV strains within the oral cavity, including HPV31 and HPV33. These data support oral healthcare provider recommendations for the newer nine-valent vaccine, which includes both HPV31 and HPV33.

Parental perceptions of the HPV vaccine for prevention of anogenital and oropharyngeal cancers

Background and Objectives

Human papillomavirus (HPV) is implicated in the development of both anogenital and oropharyngeal cancers. Although HPV vaccination prevents the majority of anogenital and head and neck cancers (HNC), vaccination rates remain low, especially among males. Known barriers to vaccination are knowledge gaps and vaccine acceptability. The objective of this study is to explore parental knowledge, perceptions, and decision-making processes about HPV and HPV vaccination for both anogenital and HNC.

Methods

This qualitative study recruited parents of children and adolescents aged 8-18 to participate in semi-structured telephone interviews. Data were analyzed using thematic analyses, informed by an inductive approach.

Results

A total of 31 parents participated in the study. Six themes emerged: 1) knowledge about HPV vaccines, 2) perceptions and attitudes toward cancers, 3) role of child's sex in HPV vaccination, 4) decision-making processes around HPV vaccination, 5) communication with health care providers about HPV vaccines, and 6) influence of social networks. There were significant knowledge gaps about the vaccine's indications and effects, especially for males and HNC prevention. Parents had concerns related to risks of the HPV vaccine. They cited pediatricians as important sources of information about vaccination and critical to their decision-making.

Conclusions

This study identified many parental knowledge gaps related to HPV vaccination, with information about males, HNC prevention, and risks particularly lacking. As parents identified pediatricians as the most important sources of information regarding HPV vaccination, this should empower pediatricians to educate families about this important preventive health measure, with a focus on addressing concerns about vaccine risks.

Construction of a CCL20-centered circadian-signature based prognostic model in cervical cancer

BACKGROUND

Rather low vaccination rates for Human papillomavirus (HPV) and pre-existing cervical cancer patients with limited therapeutic strategies ask for more precise prognostic model development. On the other side, the clinical significance of circadian clock signatures in cervical cancer lacks investigation.

METHODS

Subtypes classification based upon eight circadian clock core genes were implemented in TCGA-CESC through k-means clustering methods. Afterwards, KEGG, GO and GSEA analysis were conducted upon differentially expressed genes (DEGs) between high and low-risk groups, and tumor microenvironment (TME) investigation by CIBERSORT and ESTIMATE. Furthermore, a prognostic model was developed by cox and lasso regression methods, and verified in GSE44001 by time-dependent receiver-operating characteristic curve (ROC) analysis. Lastly, FISH and IHC were used for validation of CCL20 expression in patients' specimens and U14 subcutaneous tumor models were built for TME composition.

RESULTS

We successfully classified cervical patients into high-risk and low-risk groups based upon circadian-oscillation-signatures. Afterwards, we built a prognostic risk model composed of GJB2, CCL20 and KRT24 with excellent predictive value on patients' overall survival (OS). We then proposed metabolism unbalance, especially for glycolysis, and immune related pathways to be major enriched signatures between the high-risk and low-risk groups. Then, we proposed an 'immune-desert'-like suppressive myeloid cells infiltration pattern in high-risk group TME and verified its resistance to immunotherapies. Finally, CCL20 was proved positively correlated with real-world patients' stages and induced significant less CD8⁺ T cells and more M2 macrophages infiltration in mouse model.

CONCLUSIONS

We unraveled a prognostic risk model based upon circadian oscillation and verified its solidity. Specifically, we unveiled distinct TME immune signatures in high-risk groups.

DSPE-PEG polymer enhanced berberine absorption specifically in the small intestine of rats through paracellular passway

OBJECTIVES

This study focuses on investigating the potential impact of DSPE-PEG polymers on intestinal absorption and related mechanism of berberine in rats.

METHODS

Effect of DSPE-PEG polymer on intestinal absorption of berberine was investigated with an in situ closed-loop method in rats. To confirm the safety of DSPE-PEG polymer, morphological observation of rat intestine and measurement of biological markers in the intestinal perfusion of rats was performed. Underling mechanism behind promoting action of DSPE-PEG polymer was explored from its impact on the P-gp function and tight junction using in vitro diffusion chamber system, Caco-2 monolayer cells and western blot.

KEY FINDINGS

DSPE-PEG polymer demonstrated significant enhancement action on the berberine absorption in rats without any obvious membrane toxicity. DSPE-PEG polymer (1.0%, w/v) induced the most significant promoting effect on berberine absorption specifically in the small intestine of rats. Results of mechanistic studies revealed that DSPE-PEG polymer might not regulate intestinal P-gp function, but significantly down-regulated the expression of tight junction-related proteins, which accordingly led to loosening the tight junctions of intestinal epithelium cells, and consequently increased paracellular absorption of berberine in rats.

CONCLUSIONS

DSPE-PEG polymer, as an excellent absorption enhancer, seems very promising in increasing oral bioavailability of berberine.

A Clinical Educational Intervention to Increase HPV Vaccination Rates Among Pediatric Patients Through Enhanced Recommendations

INTRODUCTION

The human papillomavirus (HPV) causes largely preventable cancers by completing a vaccination series. However, pediatric HPV vaccination rates remain low. Current evidence indicates that integrating five factors creates a high-quality recommendation associated with higher HPV vaccination rates. This quality improvement project aimed to evaluate the impact of an educational intervention to improve the quality of providers' recommendations and subsequent vaccination rates.

METHOD

Using the Squire 2.0 Guidelines, clinical staff were observed during well-child visits (aged 11-12 years) before and after the intervention across three Plan-Do-Study-Act cycles.

RESULTS

Thirty-nine encounters with mostly (n = 31; 80%) families of color. The quality of vaccine recommendations was improved after the intervention; however, vaccination rates did not increase for the 39 patients. Providers' delivery approach (presumptive vs. conversational) did increase vaccination rates.

DISCUSSION

Providers' delivery style appears to be important when making HPV vaccine recommendations.

Prevention, diagnosis and treatment of cervical cancer: A systematic review of the impact of COVID-19 on patient care

Worldwide, the COVID-19 pandemic disrupted healthcare services, including cervical cancer management, and an increased burden for this condition is expected. This systematic review synthetizes the available evidence on the impact of the pandemic on prevention, diagnosis and treatment of cervical cancer. Searches were performed on PubMed, Embase, and Scopus for relevant studies on these topics with the purpose of comparing service access and care delivery before and during COVID-19 pandemic. Due to the methodological heterogeneity among the studies, findings were narratively discussed. Of the 715 screened titles and abstracts, 33 articles were included, corresponding to 42 reports that covered the outcomes of interest: vaccination against human papillomavirus (HPV) (6 reports), cancer screening (19), diagnosis (8), and treatment (8). Seven studies observed reductions in HPV vaccination uptake and coverage during COVID-19. Reports on cervical screening and cancer diagnosis activities showed a substantial impact of the pandemic on access to screening services and diagnostic procedures. All but one study that investigated cervical cancer treatment reported changes in the number of women with cervical lesions who received treatments, as well as treatment delay and interruption. With a major impact during the first wave in 2020, COVID-19 and restriction measures resulted in a substantial disruption in cervical cancer prevention and management, with declines in screening and delays in treatment. Taken together, findings from this systematic review calls for urgent policy interventions for recovering cervical cancer prevention and care.

HPV Vaccination during the COVID-19 Pandemic in Italy: Opportunity Loss or Incremental Cost

Objectives: Italy was the first European country to introduce universal vaccination of adolescents, for both males and females, against Human Papilloma Virus (HPV) starting in 2017 with the NIP 2017–2019′s release. However, vaccine coverage rates (VCRs) among adolescents have shown a precarious take-off since the NIP’s release, and this situation worsened due to the impact of the COVID-19 pandemic in 2020. The aim of this work is to estimate the epidemiological and economic impact of drops in VCRs due to the pandemic on those generations that missed the vaccination appointment and to discuss alternative scenarios in light of the national data. Methods: Through an analysis of the official ministerial HPV vaccination reports, a model was developed to estimate the number of 12-year-old males and females who were not vaccinated against HPV during the period 2017–2021. Based on previously published models that estimate the incidence and the economic impact of HPV-related diseases in Italy, a new model was developed to estimate the impact of the aggregated HPV VCRs achieved in Italy between 2017 and 2021. Results: Overall, in 2021, 723,375 girls and 1,011,906 boys born between 2005 and 2009 were not vaccinated against HPV in Italy (42% and 52% of these cohorts, respectively). As compared with the 95% target provided by the Italian NIP, between 505,000 and 634,000 girls will not be protected against a large number of HPV-related diseases. For boys, the number of the unvaccinated population compared to the applicable target is over 615,000 in the ‘best case scenario’ and over 749,000 in the ‘worst case scenario’. Overall, between 1.1 and 1.3 million young adolescents born between 2005 and 2009 will not be protected against HPV-related diseases over their lifetime with expected lifetime costs of non-vaccination that will be over EUR 905 million. If the 95% optimal VCRs were achieved, the model estimates a cost reduction equal to EUR 529 million, the net of the costs incurred to implement the vaccination program. Conclusion: Suboptimal vaccination coverage represents a missed opportunity, not only because of the increased burden of HPV-related diseases, but also in terms of economic loss. Thus, reaching national HPV immunization goals is a public health priority.

Implications of Persistent HPV52 and HPV58 Positivity for the Management of Cervical Lesions

Objective

This study aimed to compare the variability of HPV16/18/52/58 subtype infections in patients with different cervical lesions, to explore the guiding significance of persistent positive HPV subtypes 52 and 58 in the stratified management of cervical lesions, and to determine the appropriate management model.

Method

This study was conducted through a retrospective analysis of 244,218 patients who underwent HPV testing at the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from September 2014 to December 2020 to examine the distribution of different types of HPV infection. From March 2015 to September 2017, 3,014 patients with known HPV underwent colposcopy to analyze high-risk HPV infection for different cervical lesions. Meanwhile, from September 2014 to December 2020, 1,616 patients positive for HPV16/18/52/58 alone with normal TCT who underwent colposcopy in our hospital were retrospectively analyzed for the occurrence of cervical and vulvovaginal lesions, with colposcopic biopsy pathology results serving as the gold standard for statistical analysis.

Result

Analysis of 244,218 patients who had HPV tested revealed that the top 3 high-risk HPV types were HPV52, HPV58, and HPV16. Further analysis of 3,014 patients showed that 78.04% of patients referred for colposcopy had HPV16/18/52/58 alone. Among high-grade squamous intraepithelial lesions (HSIL) and cervical cancer, the most common is HPV16, followed by HPV58 and then HPV52 (p < 0.05). A total of 1,616 patients with normal TCT who were referred for colposcopy due to HPV16/18/52/58 infection were further analyzed. Based on pathological findings in lesions of HSIL and CC, HPV16 is the most common, followed by HPV58 and then HPV18 (p < 0.05). In the 1,616 patients analyzed, high-grade vulvovaginal lesions were detected, with HPV58 being the most common, followed by HPV16 and then HPV52 (p < 0.05).

Conclusion

1. In patients with positive HPV58 alone and normal TCT, the indications for colposcopy may be relaxed, with particular attention paid to the possibility of vulvar and vaginal lesions.2. Patients with a positive HPV type 52 alone and normal TCT may be considered for a follow-up review and, if necessary, a colposcopy.3. The development of a more suitable HPV vaccine for the Asian population, such as HPV16/18/52/58, may better protect women's health.

Anal and cervical human papillomavirus genotypes in women co-infected with human immunodeficiency virus: A systematic review

Human papillomavirus (HPV) and human immunodeficiency virus (HIV) infections are sexually transmitted. There are several HPV genotypes and clinical manifestations. Determining which genotypes circulate worldwide and/or in specific geographic areas can help with prevention programs and vaccine distribution. This systematic review aimed to investigate the most frequent anal and cervical HPV genotypes in women co-infected with HPV/HIV. The PubMed, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences databases were used to search for articles published between January 2015 and August 2021, and the included articles followed the defined selection criteria. Based on the 51 articles included, HPV16 was the most prevalent (41%) genotype, followed by HPV52 (17%) and HPV58 (14%). Based on the comparative analyses of the HIV-negative women with HPV and the HPV/HIV co-infected groups, HPV16 was frequent in both groups; HPV58, HPV31, and HPV52 were more frequent in the co-infected group; and HPV18 was more common in HIV-negative women with HPV. HPV/HIV co-infected women most frequently presented the HPV genotypes 16, 58, and 52, whereas HIV-negative women with HPV had a higher frequency of HPV16, HPV18, and HPV52 genotypes. The results indicate the importance of genotype surveillance as a strategy to improve preventive measures against HPV infection and its complications. International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42020220121.

Negative loop electrosurgical excision procedure (LEEP) following cervical biopsy diagnosis of high grade squamous intraepithelial lesion

CONTEXT

Loop Electrosurgical Excision Procedure (LEEP) is commonly performed after cervical biopsy diagnosis of high grade squamous intraepithelial lesion (HSIL/CIN2 or CIN 3). Histological and immunohistochemical assessments are made to differentiate reactive and metaplastic changes from dysplastic changes. A Human Papillomavirus (HPV) test is used for prognostic assessment after conization.

OBJECTIVE

We retrospectively reviewed cases where the cervical biopsy showed HSIL but the LEEP specimen was negative for high grade dysplasia. Our aim was to determine the cause of miscorrelation.

DATA

IRB approval was obtained and a search was made of all LEEP specimens received during 2018. We reviewed 25 of 137 LEEP specimens that did not correlate with the diagnosis of HSIL rendered on the cervical biopsy. These were from women between 25 to 54 years. All cases had positive high-risk HPV with 80% being non16/18 subtype. On review, 8/25 had HSIL with the remainder of cases falling short of HSIL diagnosis. Follow up cytology with HPV test after the LEEP procedure was negative in all but one case of LSIL with persistent non-16/18 HPV.

CONCLUSION

The study highlights the diagnostic difficulties of distinguishing HSIL from immature squamous metaplasia. The practical implication is that in cases with non-16/18 high risk HPV which have thin epithelium and fall short of definite morphologic criteria of HSIL, presence of immature squamous metaplasia should be carefully evaluated. The specific role of CK7 and CK17 which highlight squamocolumnar junctional cells and metaplastic cells, respectively, needs to be explored in these cases.

Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer

Human papillomavirus (HPV) is the most common sexually transmitted infection, with 15 HPV types related to cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancers. However, cervical cancer remains one of the most common cancers in women, especially in developing countries. Three HPV vaccines have been licensed: bivalent (Cervarix, GSK, Rixensart, Belgium), quadrivalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)), and nonavalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)). The current HPV vaccine recommendations apply to 9 years old and above through the age of 26 years and adults aged 27–45 years who might be at risk of new HPV infection and benefit from vaccination. The primary target population for HPV vaccination recommended by the WHO is girls aged 9–14 years, prior to their becoming sexually active, to undergo a two-dose schedule and girls ≥ 15 years of age, to undergo a three-dose schedule. Safety data for HPV vaccines have indicated that they are safe. The most common adverse side-effect was local symptoms. HPV vaccines are highly immunogenic. The efficacy and effectiveness of vaccines has been remarkably high among young women who were HPV seronegative before vaccination. Vaccine efficacy was lower among women regardless of HPV DNA when vaccinated and among adult women. Comparisons of the efficacy of bivalent, quadrivalent, and nonavalent vaccines against HPV 16/18 showed that they are similar. However, the nonavalent vaccine can provide additional protection against HPV 31/33/45/52/58. In a real-world setting, the notable decrease of HPV 6/11/16/18 among vaccinated women compared with unvaccinated women shows the vaccine to be highly effective. Moreover, the direct effect of the nonavalent vaccine with the cross-protection of bivalent and quadrivalent vaccines results in the reduction of HPV 6/11/16/18/31/33/45/52/58. HPV vaccination has been shown to provide herd protection as well. Two-dose HPV vaccine schedules showed no difference in seroconversion from three-dose schedules. However, the use of a single-dose HPV vaccination schedule remains controversial. For males, the quadrivalent HPV vaccine possibly reduces the incidence of external genital lesions and persistent infection with HPV 6/11/16/18. Evidence regarding the efficacy and risk of HPV vaccination and HIV infection remains limited. HPV vaccination has been shown to be highly effective against oral HPV type 16/18 infection, with a significant percentage of participants developing IgG antibodies in the oral fluid post vaccination. However, the vaccines’ effectiveness in reducing the incidence of and mortality rates from HPV-related head and neck cancers should be observed in the long term. In anal infections and anal intraepithelial neoplasia, the vaccines demonstrate high efficacy. While HPV vaccines are very effective, screening for related cancers, as per guidelines, is still recommended.

Social and behavioural research prospects for sexually transmissible infection prevention in the era of advances in biomedical approaches

In the past two decades, major advances in biomedical intervention approaches to prevent HIV and many sexually transmissible infections (STIs) have shown great promise. However, challenges to prevention remain in the area of achieving population-level impact for biomedical prevention approaches. In this paper we address what social and behavioural research approaches can contribute beyond well-known behaviour change and counselling interventions. We organise work into five areas. Adherence and disinhibition research is primarily into individual-level constructs pertaining to maximising intervention effectiveness. Coverage research represents a population-level construct germane to maximising efficient prioritisation for prevention. Research covering social determinants, a second population-level construct, contributes to both prioritisation and effectiveness. Finally, disparities and social inequities need to be incorporated into prevention, given the pervasive and persistent disparities found in rates of HIV and STIs and in their antecedents.

Nested PCR followed by NGS: Validation and application for HPV genotyping of Tunisian cervical samples

The most used methodologies for HPV genotyping in Tunisian studies are based on hybridization that are limited to a restricted number of HPV types and to a lack of specificity and sensitivity for same types. Recently, Next-Generation sequencing (NGS) technology has been efficiently used for HPV genotyping. In this work we designed and validated a sensitive genotyping method based on nested PCR followed by NGS. Eighty-six samples were tested for the validation of an HPV genotyping assay based on Nested-PCR followed by NGS. These include, 43 references plasmids and 43 positive HPV clinical cervical specimens previously evaluated with the conventional genotyping method: Reverse Line Hybridization (RLH). Results of genotyping using NGS were compared to those of RLH. The analytical sensitivity of the NGS assay was 1GE/μl per sample. The NGS allowed the detection of all HPV types presented in references plasmids. On the clinical samples, a total of 19 HPV types were detected versus 14 types using RLH. Besides the identification of more HPV types in multiple infection (6 types for NGS versus 4 for RLH), NGS allowed the identification of HPV types that were not detected by RLH. In addition, the NGS assay detected newly HPV types that were not described in Tunisia so far: HPV81, HPV43, HPV74, and HPV62. The high sensitivity and specificity of NGS for HPV genotyping in addition to the identification of new HPV types may justify the use of such technique to provide with high accuracy the profile of circulating types in epidemiological studies.

Colposcopic histopathology results of patients over 50: Is HPV genotyping useful?

BACKGROUND

To determine the rate of high-grade cervical intraepithelial lesion and cancer (HSIL+) diagnosis as a result of colposcopic histopathology in patients aged ≥50 years and to investigate the role of cytology, Human Papillomavirus (HPV) test positivity and HPV genotyping in predicting HSIL+.

MATERIAL AND METHOD

The study included 1102 patients aged ≥50 as study group and 2723 patients aged <50 as control group who were admitted to our colposcopy unit between January 1, 2015 and December 31, 2019 and underwent colposcopy for the first time. The patients with HSIL+ were compared as Cytology group and HPV group in the study group. To evaluate the impact of genotyping HPV positive group was compared in terms of HSIL+ results in subgroups with HPV16/18 and HPV other types positivity. Patients diagnosed with cancer in the same period were compared in terms of age, stage and histology as screening cancer group and symptomatic cancer groups.

RESULTS

The rate of cervical cancer in the study group was 2.2% and 1.2 % in the control group. In patients diagnosed with cancer, Federation of Gynecology and Obstetrics stage was ≥ stage IB2 in 57.4% of cases in the symptomatic cancer group and in 18.9% of cases in the screening cancer group. The HPV 16/18 positivity rate in HSIL+ patients were 75.0% and 79.5% in the study and control group, respectively.

CONCLUSION

Cervical cancer rates were found to be high in the group aged ≥ 50 years. HPV genotyping is as effective in patients ≥50 years of age as in those aged < 50 years. Patients diagnosed as a result of screening are caught in the early stages and therefore with increased general life expectancy, the age at which screening is discontinued should be re-evaluated.

The efficacy of vaccination to prevent human papilloma viruses infection at anal and oral: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to review evidence on the effectiveness of vaccination in the prevention of human papilloma virus (HPV) infection at the cervix, anal, and oral.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The key search limitations are as follows: "Human Papilloma Virus", "Papilloma Virus, Human" "Human Papillomavirus Virus", "HPV" and "oral", "anus", "anal", "penis", "cervical," and "vaccine". Randomized controlled studies were searched and analyzed the risk ratio by Review Manager 5.3; funnel plot was adopted for publication bias analysis.

RESULTS

Five randomized controlled studies enrolling 13,686 participants were retrieved, analyzed, and showed that HPV vaccination can effectively block HPV infection at cervical, anal, and oral. Subgroup analysis, moreover, proved that HPV 16/18 is more effective than HPV 6/11/16/18 in preventing anal and oral infections.

CONCLUSION

HPV vaccine is efficacious in preventing HPV infection not only at cervical but also at anal and oral, as evidence supported by relevant studies.

The Role of Viruses in Carcinogenesis and Molecular Targeting: From Infection to Being a Component of the Tumor Microenvironment

About a tenth of all cancers are caused by viruses or associated with viral infection. Recent global events including the coronavirus disease-2019 (COVID-19) pandemic means that human encounter with viruses is increased. Cancer development in individuals with viral infection can take many years after infection, demonstrating that the involvement of viruses in cancer development is a long and complex process. This complexity emanates from individual genetic heterogeneity and the many steps involved in cancer development owing to viruses. The process of tumorigenesis is driven by the complex interaction between several viral factors and host factors leading to the creation of a tumor microenvironment (TME) that is ideal and promotes tumor formation. Viruses associated with human cancers ensure their survival and proliferation through activation of several cellular processes including inflammation, migration, and invasion, resistance to apoptosis and growth suppressors. In addition, most human oncoviruses evade immune detection and can activate signaling cascades including the PI3K-Akt-mTOR, Notch and Wnt pathways associated with enhanced proliferation and angiogenesis. This expert review examines and synthesizes the multiple biological factors related to oncoviruses, and the signaling cascades activated by these viruses contributing to viral oncogenesis. In particular, I examine and review the Epstein-Barr virus, human papillomaviruses, and Kaposi's sarcoma herpes virus in a context of cancer pathogenesis. I conclude with a future outlook on therapeutic targeting of the viruses and their associated oncogenic pathways within the TME. These anticancer strategies can be in the form of, but not limited to, antibodies and inhibitors.

Respective prevalence of high-risk HPVgenotypes in cervical neoplasia in Senegal

OBJECTIVES

With the perspective of prophylactic vaccination against high-risk human papillomavirus (HPV), we analyzed the viral epidemiology of cervical neoplasia in Senegal.

METHODS

All patients were treated at the Institut Joliot Curie du Cancer in Dakar. HPV genotypes were characterized using a real-time polymerase chain reaction-based approach and sequencing.

RESULTS

Histologically, there were 224 invasive carcinomas, 17 high-grade intraepithelial neoplasia (CIN), and five undetermined histologies. Molecular analysis was conclusive in 241 cases. HPV DNA was found in 207/241 (85.9%) cases while 34/241 (14.1%) remained HPV negative. There was one single genotype in 127/207 (61.4%) cases and several in 80/207 (38.6%) corresponding to 308 genotypes identified. Viral genotyping found HPV16 in 175 (56.8%) cases, HPV18 in 45 (14.6%), HPV45 in 40 (13.0%), HPV58 in 35 (11.4%), HPV33 in 6 (2.0%), HPV35 in 3 (1.0%), HPV31 in 2 (0.6%), HPV39 and HPV56 in one (0.3% each).

CONCLUSION

Our analysis showed that 98.4% of the HPV-positive cases were associated with viral genotypes covered by the 9-valent HPV vaccine. However, 14.1% of cases remained HPV negative. Therefore, prophylactic vaccination using a 9-valent vaccine should dramatically reduce the incidence of HPV-associated neoplasia but the detection and treatment of CIN remain necessary for the optimal prevention of cervical cancer.

Cervical Cancer Immunotherapy: Facts and Hopes

It is a sad fact that despite being almost completely preventable through human papillomavirus (HPV) vaccination and screening, cervical cancer remains the fourth most common cancer to affect women worldwide. Persistent high-risk HPV (hrHPV) infection is the primary etiologic factor for cervical cancer. Upward of 70% of cases are driven by HPV types 16 and 18, with a dozen other hrHPVs associated with the remainder of cases. Current standard-of-care treatments include radiotherapy, chemotherapy, and/or surgical resection. However, they have significant side effects and limited efficacy against advanced disease. There are a few treatment options for recurrent or metastatic cases. Immunotherapy offers new hope, as demonstrated by the recent approval of programmed cell death protein 1-blocking antibody for recurrent or metastatic disease. This might be augmented by combination with antigen-specific immunotherapy approaches, such as vaccines or adoptive cell transfer, to enhance the host cellular immune response targeting HPV-positive cancer cells. As cervical cancer progresses, it can foster an immunosuppressive microenvironment and counteract host anticancer immunity. Thus, approaches to reverse suppressive immune environments and bolster effector T-cell functioning are likely to enhance the success of such cervical cancer immunotherapy. The success of nonspecific immunostimulants like imiquimod against genital warts also suggest the possibility of utilizing these immunotherapeutic strategies in cervical cancer prevention to treat precursor lesions (cervical intraepithelial neoplasia) and persistent hrHPV infections against which the licensed prophylactic HPV vaccines have no efficacy. Here, we review the progress and challenges in the development of immunotherapeutic approaches for the prevention and treatment of cervical cancer.

Cost-effectiveness analysis of the nonavalent human papillomavirus vaccine for the prevention of cervical cancer in Singapore

BACKGROUND

The nonavalent human papillomavirus (HPV) vaccine has been shown to extend protection against oncogenic HPV types 31/33/45/52/58 (HPV-OV) not covered by the bivalent and quadrivalent HPV vaccines. Besides its clinical benefit, evidence on the economic value of the nonavalent vaccine is required to inform local vaccination strategies and funding decisions. This study evaluated the cost-effectiveness of replacing the bivalent vaccine with the nonavalent vaccine in the national school-based HPV vaccination programme in Singapore.

METHODS

An existing age-structured dynamic transmission model coupled with stochastic individual-based simulations was adapted to project the health and economic impact of vaccinating 13-year-old girls with two doses of the nonavalent or bivalent HPV vaccines in Singapore. Direct costs (in Singapore dollars, S$) were obtained from public healthcare institutions in Singapore, while health state utilities were sourced from the literature. Incremental cost-effectiveness ratios (ICERs) were estimated over a lifetime horizon, from a healthcare system perspective. Probabilistic sensitivity analysis was performed to obtain the ICERs and corresponding variations across variable uncertainty. Particularly, this study tested the scenarios of lifelong and 20-year vaccine-induced protection, assumed 96.0% and 22.3% cross-protection against HPV-OV by nonavalent and bivalent vaccines respectively, and fixed vaccine prices per dose at S$188 for nonavalent and S$61.50 for bivalent vaccines.

RESULTS

Compared with the bivalent vaccine, the use of the nonavalent vaccine was associated with an ICER of S$61,629 per quality-adjusted life year gained in the base case. The result was robust across a range of plausible input values, and to assumptions regarding the duration of vaccine protection.

CONCLUSION

Given the high ICER, the nonavalent vaccine is unlikely to represent a cost-effective option compared with the bivalent vaccine for school-based HPV vaccination of 13-year old female students in Singapore. Substantial price reductions would be required to justify its inclusion in the school-based programme in the future.

[Immunisation schedule of the Pediatric Spanish Association: 2021 recommendations]

The CAV-AEP annually publishes the immunisation schedule considered optimal for all children and adolescent resident in Spain, taking into account the available evidence. The 2+1 schedule is recommended (2, 4, and 11 months) with hexavalent vaccines (DTPa-VPI-Hib-HB) and with 13-valent pneumococcal conjugate.A 6-year booster is recommended, preferably with DTPa (if available), with a dose of polio for those who received 2+1 schemes, as well as vaccination with Tdpa in adolescents and in each pregnancy, preferably between 27 and 32 weeks. Rotavirus vaccine should be systematic for all infants. Meningococcal B vaccine, with a 2+1 schedule, should be included in routine calendar. In addition to the inclusion of the conjugated tetravalent meningococcal vaccine (MenACWY) at 12 years of age with catch up to 18 years, inclusive, the CAV recommends this vaccine to be also included at 12 months of age, replacing MenC. Likewise, it is recommended in those over 6 weeks of age with risk factors or who travel to countries with a high incidence of these serogroups. Two-dose schedules for triple viral (12 months and 3-4 years) and varicella (15 months and 3-4 years) will be used. The second dose could be applied as a tetraviral vaccine. Universal systematic vaccination against HPV is recommended, regardless of gender, preferably at 12 years, and greater effort should be made to improve coverage. The 9 genotype extends coverage for both genders.

Plant-Derived Natural Compounds in Genetic Vaccination and Therapy for HPV-Associated Cancers

Simple Summary

DNA vaccination represents a useful approach for human papillomavirus (HPV) cancer therapy. The therapeutic potential of plant-based natural compounds for control of HPV- associated cancers has been also widely explored. Genetic vaccines for HPV-associated tumors that include plant protein-encoding gene sequences, used alone or in combinations with plant metabolites, are being investigated but are still in their infancy. Main focus of this paper is to provide an overview of the current state of novel therapeutic strategies employing genetic vaccines along with plant-derived compounds and genes. We highlight the importance of multimodality treatment regimen such as combining immunotherapy with plant-derived agents.

Abstract

Antigen-specific immunotherapy and, in particular, DNA vaccination provides an established approach for tackling human papillomavirus (HPV) cancers at different stages. DNA vaccines are stable and have a cost-effective production. Their intrinsic low immunogenicity has been improved by several strategies with some success, including fusion of HPV antigens with plant gene sequences. Another approach for the control of HPV cancers is the use of natural immunomodulatory agents like those derived from plants, that are able to interfere in carcinogenesis by modulating many different cellular pathways and, in some instances, to reduce chemo- and radiotherapy resistance of tumors. Indeed, plant-derived compounds represent, in many cases, an abundantly available, cost-effective source of molecules that can be either harvested directly in nature or obtained from plant cell cultures. In this review, an overview of the most relevant data reported in literature on the use of plant natural compounds and genetic vaccines that include plant-derived sequences against HPV tumors is provided. The purpose is also to highlight the still under-explored potential of multimodal treatments implying DNA vaccination along with plant-derived agents.

Human papillomavirus genotyping as a tool for cervical cancer prevention: from commercially available human papillomavirus DNA test to next-generation sequencing

The biological importance of human papillomavirus (HPV) in the field of medicine – related to cervical carcinogenesis – has been extensively reported in the last decades. For the first time, a direct correlation between cause and effect to explain a cancer development was completely achieved in medical research. Consequently, the Nobel Prize was awarded to HZ Hausen in 2008 for his efforts to understand the effects of persistent infection of oncogenic types of HPV and malignancy transformation. The aim of the present review was to summarize the principal elements of HPV characteristics and their importance in oncology.

It is established that HPV is the main etiologic agent for the development of cervical cancer. With the evolution of diagnosis and molecular biology, many tools have become essential for an early diagnosis and thereby, considerably reducing mortality. Molecular biology continues to advance and provide new perspectives with the use of reverse-transcription PCR in automation and genotyping through next-generation sequencing. This article aims to provide an overview of what is currently used in HPV diagnostic and research and future perspectives with the help of technologies such as next-generation sequencing for screening and vaccination.

Natural and vaccine-induced B cell-derived systemic and mucosal humoral immunity to human papillomavirus

Introduction: Human papillomavirus (HPV) are the causative agent of mucosal neoplasia. Both cervical, anal and oropharyngeal cancers incidence is constantly increasing, making the HPV infection, a significant worldwide concern. Together, the CD8+ T cytotoxic cell-mediated response and the HPV-specific antibody response control most of the HPV infections before the development of cancers.Areas covered: We searched the MEDLINE and EMBASE databases and identified 228 eligible studies from 1987 to 2019 which examines both naturally acquired and vaccine induced humoral immunity against HPV infection in female and male subjects from worldwide origin. Herein, we synthesize current knowledge on the features of systemic and mucosal humoral immunity against HPV. We discuss the issues of the balance between the viral clearance or the escape to the host immune response, the differences between natural and vaccine-induced HPV-specific antibodies and their neutralizing capability. We also discuss the protection afforded after natural infection or following prophylactic vaccination.Expert opinion: Understanding the antibody response induced by HPV infection has led to the design of first-generation prophylactic vaccines. Now, prophylactic vaccination induces protective and long-lasting antibody response which would also strengthened the natural moderate humoral response in people previously exposed to the virus.

Efficacy and immunogenicity of a single dose of human papillomavirus vaccine compared to no vaccination or standard three and two-dose vaccination regimens: A systematic review of evidence from clinical trials

OBJECTIVES

This study aimed to systematically review the literature on the efficacy and immunogenicity of single-dose HPV vaccination compared to no vaccination or multi-dose schedules among vaccine trial participants.

METHODS

Medline, EMBASE, Global Health Database and Cochrane Central Register of Controlled Trials were searched for publications and conference abstracts (dated January 1999-August 2018) using MeSH and non-MeSH terms for human papillomavirus AND vaccines AND (immunogenicity OR efficacy/effectiveness) AND dosage. Search results were screened against pre-specified eligibility criteria. Data were extracted from included articles, and a narrative synthesis conducted on efficacy against HPV16/18 infection and humoral immunogenicity.

RESULTS

Seven of 6,523 unique records identified were included in the review. Six were nested observational studies of participants randomised to receive two or three doses in three large HPV vaccine trials, in which some participants did not complete their allocated schedules. One small pilot study prospectively allocated participants to receive one or no vaccine dose. Frequency of HPV16/18 infection was low (e.g. <1% for 12-month-persistent infection) in all vaccinated participants up to seven years post vaccination and did not significantly differ by number of doses (p > 0.05 in all cases). Frequency of infection was significantly lower in one-dose recipients compared to unvaccinated controls (p < 0.01 for all infection endpoints in each study). HPV16/18 seropositivity rates were high in all HPV vaccine recipients (100% in three of four studies reporting this endpoint), though antibody levels were lower with one compared to two or three doses.

CONCLUSIONS

This review supports the premise that one HPV vaccine dose may be as effective in preventing HPV infection as multi-dose schedules in healthy young women. However, it also highlights the paucity of available evidence from purpose-designed, prospectively-randomised trials. Results from ongoing clinical trials assessing the efficacy and immunogenicity of single-dose HPV vaccination compared to currently-recommended schedules are awaited.

Detection of Felis catus papillomavirus type-2 DNA and viral gene expression suggest active infection in feline oral squamous cell carcinoma

Papillomavirus (PV) infection is associated with development of epithelial cancer in different species, including domestic cat (Felis catus). Felis catus PV type-2 (FcaPV-2) is considered the causative agent of a proportion of feline cutaneous squamous cell carcinoma (SCC), through the transforming properties of its E6 and E7 oncogenes. However, the possible role of FcaPVs in the aetiology of feline oral SCC (FOSCC) is still unclear. The aim of this study was to assess the presence and gene expression of FcaPV-2 in FOSCC samples. We detected FcaPV-2 DNA in 10/32 (31%) of the analysed FOSCC by the use of PCR methods. Importantly, viral mRNA was detected by RT-PCR in 7/10 (70%) of DNA positive samples. In particular, FcaPV-2 L1, E2 and E6E7 genes were found to be expressed in 5/10 (50%), 3/10 (33%) and 5/10 (50%) samples, respectively. Viral DNA was also detected in non neoplastic oral ulcerative lesions (ULs) (4/11, 36%); qPCR suggested a difference in viral load between ULs and FOSCCs, particularly in those expressing E6E7, although it was not statistically significant. These data suggest, but do not definively prove, a possible role of FcaPV-2 in the development of a proportion of FOSCC. Moreover, L1 and E2 gene expression results indicate that FcaPV-2 infection associated with these tumours may possibly be productive.

Summary of the evidence on the safety, efficacy, and effectiveness of human papillomavirus vaccines: Umbrella review of systematic reviews

BACKGROUND

This objective of this umbrella review was to summarize the evidence on safety, efficacy, and effectiveness of human papillomavirus (HPV) vaccines in the general population.

METHODS

The authors conducted a literature search and selected systematic reviews if they were published from January 2006 through November 2018, included randomized controlled trials or observational studies, related to the general population, and evaluated HPV vaccine-related clinical outcomes. The authors independently and in duplicate screened literature, extracted data, and appraised reviews using AMSTAR 2, a critical appraisal tool for systematic reviews.

RESULTS

The authors selected 30 systematic reviews that included male and female participants aged 9 through 76 years from multiple countries. Reviews evaluated postvaccine seroconversion, HPV infection rates, precancerous or benign lesions, and adverse events; none of the researchers reported on oral or oropharyngeal lesions. Results from the reviews showed that, compared with those who received a placebo or non-HPV-type vaccine, HPV-vaccinated participants had statistically significantly higher rates of seroconversion and local adverse events, statistically significantly lower rates of HPV infection and condylomata lesions, and decreased rates of HPV-related precancerous lesions, which did not always attain statistical significance.

CONCLUSIONS

Systematic reviews have found evidence that the available HPV vaccines are safe, effective, and efficacious against vaccine-type HPV infection and HPV-associated cellular changes, including precancerous and benign lesions.

PRACTICAL IMPLICATIONS

Dentists may use this resource to better understand the literature on the potential harms and benefits of HPV vaccination.

Immunization Against Staphylococcus aureus Infections

Background: Infections caused by Staphylococcus aureus continue to plague surgical patients, whether as surgical site infections or other nosocomial infections that complicate surgical care. The only meaningful methods available to decrease the risk of developing such infections are topical skin antisepsis (pre-operative skin preparation) and peri-operative antibiotic prophylaxis, neither of which offer a panacea. Alternatives to the latter are sought so as to minimize antibiotic selection pressure as a factor in the increasing problem of antimicrobial drug resistance. This review considers the possibility that immunization against S. aureus may offer a viable alternative for prophylaxis. Methods: Review and synthesis of pertinent English-language medical literature. Results: Vaccination against viral pathogens has been in successful clinical use for more than two centuries and was instrumental in the eradication of smallpox and the near-elimination of diseases such as poliomyelitis. Vaccinations against a limited number of bacterial pathogens (e.g., Bordetella pertussis, Clostridium tetanii, Corynebacterium diphtheriae, Haemophilus influenzae type b, Neisseria meningiditis, Streptococcus pneumoniae) have also been introduced with success, whereas others against bacteria are in development (C. difficile, Pseudomonas aeruginosa, S. aureus). Vaccination against S. aureus infection is in current veterinary use (e.g., to prevent mastitis among dairy cattle) but has not been successful to date in human beings despite multiple attempts, although development continues. Conclusions: Because of its complex microbiology, including multiple virulence factors and the ability to evade host immune surveillance, S. aureus presents numerous antigenic targets for vaccine development. Failure of two prior single-antigen vaccines in clinical trials has led to the consensus that future vaccine candidates must be directed against multiple antigens. Two distinct four-antigen vaccines are in clinical trials, but efficacy is yet to be determined.

The burden of 14 hr-HPV genotypes in women attending routine cervical cancer screening in 20 states of Mexico: a cross-sectional study

In Mexico, HPV vaccines available immunize against genotypes 16/18 and 16/18/6/11; however, there is limited surveillance about carcinogenic subtypes in different states of the country that allow evaluating the effectiveness of vaccination and cervical cancer screening programs. Here, we report the regional and age-specific prevalence of 14 hr-HPV genotypes as well as their prevalence in abnormal cytology (from ASCUS to cervical cancer) among Mexican women which were undergoing from cervical cancer screening in the Salud Digna clinics in 20 states of the country. This study includes women with social security from the majority of public health institutions (IMSS, ISSSTE, SEMAR, and PEMEX), and women without social security. For cervical cancer screening, we used the SurePath liquid-based cytology and the BD Onclarity HPV Assay. From December 1, 2016, to August 2, 2018, the hr-HPV prevalence among 60,135 women was 24.78%, the most prevalent types were HPV 16 (4.13%), HPV 31 (4.12%) and HPV 51 (3.39%), while HPV 18 (1.70%) was less prevalent among infected women. Interestingly, the genotypes not covered by current vaccines in Mexico were commonly found in precancerous lesions, evidencing their carcinogenic potential, so it is necessary to increase their surveillance and inclusion in cervical cancer screening triage.

Voxel Forecast for Precision Oncology: Predicting Spatially Variant and Multiscale Cancer Therapy Response on Longitudinal Quantitative Molecular Imaging

PURPOSE

Prediction of spatially variant response to cancer therapies can inform risk-adaptive management within precision oncology. We developed the "Voxel Forecast" multiscale regression framework for predicting spatially variant tumor response to chemoradiotherapy on fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging.

EXPERIMENTAL DESIGN

Twenty-five patients with locally advanced non-small cell lung cancer, enrolled on the FLARE-RT phase II trial (NCT02773238), underwent FDG PET/CT imaging prior to (PETpre) and during week 3 (PETmid) of concurrent chemoradiotherapy. Voxel Forecast was designed to predict tumor voxel standardized uptake value (SUV) on PETmid from baseline patient-level and voxel-level covariates using a custom generalized least squares (GLS) algorithm. Matérn covariance matrices were fit to patient- specific empirical variograms of distance-dependent intervoxel correlation. Regression coefficients from variogram-based weights and corresponding standard errors were estimated using the jackknife technique. The framework was validated using statistical simulations of known spatially variant tumor response. Mean absolute prediction errors (MAEs) of Voxel Forecast models were calculated under leave-one-patient-out cross-validation.

RESULTS

Patient-level forecasts resulted in tumor voxel SUV MAE on PETmid of 1.5 g/mL while combined patient- and voxel-level forecasts achieved lower MAE of 1.0 g/mL (P < 0.0001). PETpre voxel SUV was the most important predictor of PETmid voxel SUV. Patients with a greater percentage of under-responding tumor voxels were classified as PETmid nonresponders (P = 0.030) with worse overall survival prognosis (P < 0.001).

CONCLUSIONS

Voxel Forecast multiscale regression provides a statistical framework to predict voxel-wise response patterns during therapy. Voxel Forecast can be extended to predict spatially variant response on multimodal quantitative imaging and may eventually guide optimized spatial-temporal dose distributions for precision cancer therapy.

Sociodemographic and clinical correlates of human papillomavirus vaccine attitudes and receipt among Wisconsin adolescents

Few studies have assessed adolescent human papillomavirus (HPV) vaccine attitudes and whether they are associated with vaccination uptake. This study characterized HPV vaccine attitudes among male and female adolescents, identified factors associated with attitude changes, and examined associations between attitudes and vaccination receipt. Surveys were administered to adolescents aged 15-16 years who had not completed the HPV vaccine series. A modified version of the Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS) was employed to assess barriers, harms, ineffectiveness, and uncertainties scores. Surveys were available from 108 participants; 63% were male and 33% had initiated the HPV vaccine series at baseline. CHIAS scores significantly decreased (i.e., became more favorable) between baseline and follow-up for barriers (p = 0.01) and uncertainties (p < 0.01). At least one sociodemographic/clinical factor was associated with changes in each score. Attitude changes were not associated with receipt of HPV vaccine, although adolescents with higher baseline harms scores were significantly less likely to receive an HPV vaccine dose (OR = 0.67). Adolescents' HPV vaccine attitudes slightly improved over a one-year period during which an intervention was implemented. More research is needed to learn how parent and adolescent HPV vaccine attitudes form, and how best to address concerns about vaccine harms.

Pathways to a cancer-free future: A protocol for modelled evaluations to maximize the future impact of interventions on cervical cancer in Australia

OBJECTIVE

Australia's HPV vaccination and HPV-based cervical screening programs are changing the landscape in cervical cancer prevention. We aim to identify areas which can make the biggest further impact on cervical cancer burden. This protocol describes the first stage of a program of work called Pathways-Cervix that aims to generate evidence from modelled evaluations of interventions across the cervical cancer spectrum.

METHODS

Based on evidence from literature reviews and guidance from a multi-disciplinary Scientific Advisory Committee (SAC), the most relevant evaluations for prevention, diagnosis and treatment were identified.

RESULTS

Priority evaluations agreed by the SAC included: increasing/decreasing and retaining vaccination uptake at the current level; vaccinating older women; increasing screening participation; methods for triaging HPV-positive women; improving the diagnosis of cervical intraepithelial neoplasia (CIN) and cancer; treating cervical abnormalities and cancer; and vaccinating women treated for CIN2/3 to prevent recurrence. Evaluations will be performed using a simulation model, Policy1-Cervix previously used to perform policy evaluations in Australia. Exploratory modelling of interventions using idealised scenarios will initially be conducted in single birth cohorts. If these have a significant impact on findings then evaluations with more realistic assumptions will be conducted. Promising strategies will be investigated further by multi-cohort simulations predicting health outcomes, resource use and cost outcomes.

CONCLUSIONS

Pathways-Cervix will assess the relative benefits of strategies and treatment options in a systematic and health economic framework, producing a list of 'best buys' for future decision-making in cervical cancer control.

Hospital contacts and diagnoses five years prior to HPV vaccination among females referred for suspected adverse vaccine effects: A Danish nationwide case-control study

BACKGROUND

High health care utilization before Human Papilloma Virus (HPV) vaccination might be associated with increased risk of suspected adverse effects (AE's) after vaccination. We investigated the association between hospital contacts and diagnoses before HPV vaccination and risk of later referral to a specialized hospital setting (HPV center) for suspected AE's.

METHODS

The study was a Danish register-based matched case-control study. Cases were females referred to an HPV center. Five controls per case were randomly selected in the source population of HPV vaccinated females. Information on hospital contacts and diagnoses was obtained from the Danish National Patient Registry. Conditional logistic regression analyses were used to investigate the association between having one or more diagnoses in each specific International Classification of Diseases 10th version (ICD-10) chapter five years before the HPV vaccination and subsequent referral to an HPV center.

RESULTS

We identified 1496 cases and 7480 controls. In total, 80% of the cases versus 65% of the controls had at least one hospital contact prior to HPV vaccination (Prevalence Proportion Ratio - PPR: 1.24 (95% Confidence Interval - CI: 1.21-1.27)), with 24% vs 12% (PPR: 1.97 (95% CI: 1.76-2.19)) having six or more contacts. Cases were more likely to have had a diagnosis in 15 out of 19 ICD-10 chapters before the vaccination, with ORs larger than 1.8 for infectious diseases, psychiatric diseases, diseases of the nervous, circulatory, digestive and musculoskeletal system, unspecific symptoms and unspecific contacts.

CONCLUSION

Pre-vaccination morbidity and health care utilization seem to play a role in the path leading to suspected AE's after HPV vaccination. Since many of the diagnoses that were particularly increased before vaccination in referred females are overlapping with the most frequent symptoms reported, we cannot exclude that for some of the females, the suspected AE's might have been existing already before the vaccination.

A Natural Isoquinoline Alkaloid With Antitumor Activity: Studies of the Biological Activities of Berberine

Coptis, a traditional medicinal plant, has been used widely in the field of traditional Chinese medicine for many years. More recently, the chemical composition and bioactivity of Coptis have been studied worldwide. Berberine is a main component of Rhizoma Coptidis. Modern medicine has confirmed that berberine has pharmacological activities, such as anti-inflammatory, analgesic, antimicrobial, hypolipidemic, and blood pressure-lowering effects. Importantly, the active ingredient of berberine has clear inhibitory effects on various cancers, including colorectal cancer, lung cancer, ovarian cancer, prostate cancer, liver cancer, and cervical cancer. Cancer, ranked as one of the world’s five major incurable diseases by WHO, is a serious threat to the quality of human life. Here, we try to outline how berberine exerts antitumor effects through the regulation of different molecular pathways. In addition, the berberine-mediated regulation of epigenetic mechanisms that may be associated with the prevention of malignant tumors is described. Thus, this review provides a theoretical basis for the biological functions of berberine and its further use in the clinical treatment of cancer.

National Trends in Parental Human Papillomavirus Vaccination Intentions and Reasons for Hesitancy, 2010-2015

Background

Human papillomavirus (HPV) vaccination uptake remains lower than other recommended adolescent vaccines in the United States. Parental attitudes are important predictors of vaccine uptake, yet little is known about how they have changed over time.

Methods

Participants included US residents aged 13-17 years with documented vaccination status who had received <3 doses of HPV vaccine whose parents responded to the National Immunization Survey-Teen, 2010-2015.

Results

Of the 76971 participants, 63.0% were male, 58.8% were non-Hispanic white, and 14.4 years was the median age. The percentage of unvaccinated teens decreased from 2010 to 2015, yet, annually, parents of unvaccinated teens of both sexes most often reported that they were "not likely at all" to vaccinate their teen. The percentage decreased significantly from 41.5% to 31.2% (P < .001) for parents of unvaccinated females from 2010 to 2015 but did not change among parents of males from 2012 to 2015. Conversely, parents of undervaccinated teens of both sexes reported higher and increasing vaccination intent over time. In 2015, nearly one-third of parents of unvaccinated teens reported that the vaccine was "not needed/necessary." Concerns about vaccine safety and side effects declined among parents of unvaccinated females but increased among parents of males (7.3% to 14.8%; P < .001).

Conclusions

Although parental vaccination intent and knowledge improved over time, intent remains low and many parents still have significant concerns about HPV vaccination, even after series initiation. Multiple strategies are needed to improve series initiation and completion in the United States.

Optimizing a Human Papillomavirus Type 16 L1-Based Chimaeric Gene for Expression in Plants

Human papillomaviruses (HPVs) are the causative agents of cervical cancer, the fourth most prevalent cancer in women worldwide. The major capsid protein L1 self-assembles into virus-like particles (VLPs), even in the absence of the minor L2 protein: such VLPs have successfully been used as prophylactic vaccines. There remains a need, however, to develop cheaper vaccines that protect against a wider range of HPV types. The use of all or parts of the L2 minor capsid protein can potentially address this issue, as it has sequence regions conserved across several HPV types, which can elicit a wider spectrum of cross-neutralizing antibodies. Production of HPV VLPs in plants is a viable option to reduce costs; the use of a L1/L2 chimera which has previously elicited a cross-protective immune response is an option to broaden cross-protection. The objective of this study was to investigate the effect of codon optimization and of increasing the G+C content of synthetic L1/L2 genes on protein expression in plants. Additionally, we replaced varying portions of the 5' region of the L1 gene with the wild type (wt) viral sequence to determine the effect of several negative regulatory elements on expression. We showed that GC-rich genes resulted in a 10-fold increase of mRNA levels and 3-fold higher accumulation of proteins. However, the highest increase of expression was achieved with a high GC-content human codon-optimized gene, which resulted in a 100-fold increase in mRNA levels and 8- to 9-fold increase in protein levels. Changing the 5' end of the L1 gene back to its wt sequence decreased mRNA and protein expression. Our results suggest that the negative elements in the 5' end of L1 are inadvertently destroyed by changing the codon usage, which enhances protein expression.

Immunization and media coverage in Italy: an eleven-year analysis (2007-17)

Immunization polices in Italy has recently reached important milestones, including the approval of the National Immunization Prevention Plan and of a new law mandatory immunization; this stimulating a lively debate at the scientific, political and societal-level, reflected on the media. We applied a model previously published to quantitatively and qualitatively assess media coverage on vaccines and immunization-related topics on the most read Italian newspaper, "Corriere della Sera", over an 11-year study period (2007-2017). We retrieved relevant key words and articles, reported on included articles' topic, position, approach to immunization and on other selected indicators' summary statistics, temporal trends and correspondence with key epidemiological and policy events. Over the study period the quote "vaccin*" was mentioned on average 325 times per year; with an increase of 150% after the approval of the new law on mandatory immunization in 2017. In the same year, on average, two first-page articles per week were published on the topic. We report a clear association between key events (i.e the H1N1 influenza pandemic, the "Fluad case", the approval of the new law on mandatory immunization) and their media coverage. Overall, 84% of articles had a positive attitude towards immunization, this share decreasing to 79% when only considering articles published after the approval of the law on mandatory vaccination. Media play a crucial role in channelling health-related information and significantly influence health behaviours. We urge public institutions, health authorities and the scientific community not to underestimate the opportunity to monitor media coverage on key healthcare topics and to convey evidence-based health education messages through the media.

Therapeutic DNA Vaccines for Human Papillomavirus and Associated Diseases

Human papillomavirus (HPV) has long been recognized as the causative agent of cervical cancer. High-risk HPV types 16 and 18 alone are responsible for over 70% of all cases of cervical cancers. More recently, HPV has been identified as an etiological factor for several other forms of cancers, including oropharyngeal, anogenital, and skin. Thus, the association of HPV with these malignancies creates an opportunity to control these HPV lesions and HPV-associated malignancies through immunization. Strategies to prevent or to therapeutically treat HPV infections have been developed and are still pushing innovative boundaries. Currently, commercial prophylactic HPV vaccines are widely available, but they are not able to control established infections or lesions. As a result, there is an urgent need for the development of therapeutic HPV vaccines, to treat existing infections, and to prevent the development of HPV-associated cancers. In particular, DNA vaccination has emerged as a promising form of therapeutic HPV vaccine. DNA vaccines have great potential for the treatment of HPV infections and HPV-associated cancers due to their safety, stability, simplicity of manufacturability, and ability to induce antigen-specific immunity. This review focuses on the current state of therapeutic HPV DNA vaccines, including results from recent and ongoing clinical trials, and outlines different strategies that have been employed to improve their potencies. The continued progress and improvements made in therapeutic HPV DNA vaccine development holds great potential for innovative ways to effectively treat HPV infections and HPV-associated diseases.

Viral Oncology: Molecular Biology and Pathogenesis

Oncoviruses are implicated in approximately 12% of all human cancers. A large number of the world's population harbors at least one of these oncoviruses, but only a small proportion of these individuals go on to develop cancer. The interplay between host and viral factors is a complex process that works together to create a microenvironment conducive to oncogenesis. In this review, the molecular biology and oncogenic pathways of established human oncoviruses will be discussed. Currently, there are seven recognized human oncoviruses, which include Epstein-Barr Virus (EBV), Human Papillomavirus (HPV), Hepatitis B and C viruses (HBV and HCV), Human T-cell lymphotropic virus-1 (HTLV-1), Human Herpesvirus-8 (HHV-8), and Merkel Cell Polyomavirus (MCPyV). Available and emerging therapies for these oncoviruses will be mentioned.

Prevalence of anal, oral, penile and urethral Human Papillomavirus in HIV infected and HIV uninfected men who have sex with men

Aims of the study were to evaluate Human Papillomavirus (HPV) and type-specific prevalence in four anatomical sites in HIV infected men who have sex with men (MSM) compared with HIV uninfected MSM. Participants were recruited among the attendees of Infectious Diseases Clinics in Central Italy. A trained medical practitioner collected by interview sociodemographic data and information on medical history, sexual behavior, and drug use. Swabs from anal canal, oral cavity, urethral mucosa, and coronal sulcus were tested for HPV DNA and genotyping. Ninety MSM were enrolled, 45 subjects within each group. Overall, 48.9% MSM were HPV positive and prevalence was higher in HIV infected men (60.0% vs 37.8%, P = 0.035). HPV at multiple anatomic sites occurred in 59.1% MSM, with 34.1% and 22.7% at two and three sites, respectively. Prevalence of anal, coronal sulcus, oral, and urethral HPV was 96.3%, 37%, 21.6%, and 18.5% in HIV infected MSM, and 70.6%, 70.6%, 29.4%, and 23.5% among HIV uninfected. A similar proportion of HIV infected and uninfected MSM (59.2% and 58.8%) carried at least one high-risk genotype. Prevalence of types covered by nonavalent vaccine was 77.8% in HIV infected compared with 82.3% in HIV uninfected MSM. HPV 58 and 16 were mostly detected in HIV positive (43.7% and 31.2%) and negative MSM (50.0% and 40.0%). HPV detection rate underlined the high vulnerability of MSM to acquire multisite infections, characterized by various genotype combinations. Since nonavalent vaccine could have prevented 80% of HPV infections, study findings support the implementation of vaccination programs among MSM.

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.