Declining genital Warts in young women in england associated with HPV 16/18 vaccination: an ecological study

How has post-implementation surveillance of high-coverage vaccination with HPV16/18-AS04 vaccine in England added to evidence about its cross-protective effects?

BACKGROUND

Bivalent human papillomavirus HPV16/18-AS04 vaccine (Cervarix, GSK) offers direct protection against HPV16/18. Results from randomised controlled trials showed cross protective effects and suggested that declines in some closely related HPV types could be expected in a population with high vaccination coverage.

AIM

To evaluate the evidence for cross-protection afforded by HPV16/18-AS04 from post-implementation surveillance in England, and how this complements clinical trial data and post-implementation observations in other countries.

METHODS

Evidence of cross-protection in young women offered vaccination with HPV16/18-AS04 was gathered from HPV surveillance in England. Data from clinical trials and other post-implementation studies were reviewed.

RESULTS

Surveillance using anonymised residual specimens in England found declines of 52.3%, 67.4% and 33.3% against grouped HPV-31/33/45 in 16-18, 19-21, and 22-24 year olds, respectively. Additionally, type-specific analysis found that the prevalence of HPV31 declined to below 1% across all age groups. Cross-protection has been monitored and maintained for over 10 years since the introduction of the vaccination programme. Cross-protection against HPV6/11 was not found in English surveillance outcomes.

CONCLUSION

Surveillance of type-specific infections in vaccine-eligible populations in England has generated clear evidence of cross-protective effects from HPV16/18-AS04 vaccination against high-risk HPV 31/33/45 infections, consistent with other post-implementation observations and confirming and in some ways exceeding expectations from clinical trials.

Long-term outcomes of penile squamous cell carcinoma in men age ≤50 years old compared with men >50 years old from a single tertiary referral centre: a propensity score matched analysis

Penile cancer (PeCa) is rare, and the oncological outcomes in younger men are unclear. We aimed to analyse and compare oncological outcomes of men age ≤50 years (y) and >50 years with PeCa. A retrospective analysis of men ≤50 y with penile squamous cell carcinoma managed at a tertiary centre was performed. A propensity score matched cohort of men >50 y was identified for comparison. Matching was according to tumour, nodal stage and the types of primary surgery. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metastasis-free survivals (MFS) were estimated using Kaplan-Meier plots and compared using log-rank tests. Between 2005-2020, 100 men ≤50 y (median (IQR) age, 46 y (40-49)) were identified and matched with 100 men >50 y (median (IQR) age, 65 y (59-73)). 10, 24, 32, 34 men age ≤50 y were diagnosed in 2005-2007, 2008-2012, 2013-2016 and 2017-2020 respectively. Median (IQR) follow-up was 53.5 (18-96) months. OS at 2 years: ≤50 y, 86%>50 y, 80.6%; 5 years: ≤50 y, 78.1%, >50 y, 63.1%; 10 years: ≤50 y, 72.3%, >50 y, 45.6% (p = 0.01). DSS at 2 years: ≤50 y, 87.2%>50 y, 87.8%; 5 years: ≤50 y, 80.9%>50 y, 78.2%; 10 years: ≤50 y, 78%, >50 y, 70.9% (p = 0.74). RFS was 93.1% in the ≤50 y group (vs. >50 y, 96.5%) at 2 year, and 90% (vs. >50 y, 88.5%) at 5 years, p = 0.81. Within the ≤50 y group, 2 years and 5 years MFS was 93% (vs. >50 y, 96.5%), and 89.5% (vs. >50 y, 92.7%) respectively, (p = 0.40). There were no statistical significance in DFS, RFS and MFS in men age ≤50 y and >50 y. PeCa in younger patients is fatal, public awareness and patient education are crucial for early detection and management.

Human papillomavirus vaccines effectiveness to prevent genital warts: A population-based study using health system integrated databases, 2009-2017

OBJECTIVES

To assess the effectiveness of the HPV vaccines in preventing genital warts (GW) in women aged 14-23 years and to estimate the incidence of GW in the whole population aged from 14 to 65.

DESIGN

Population-based retrospective cohort study using real-world data from the Valencia health system Integrated Databases (VID).

STUDY POPULATION

All subjects aged 14-65 years residing in the Valencia Region during 2009-2017 (n = 4,492,724), including a cohort of 563,240 females aged 14-23 years followed-up for the vaccine effectiveness (VE) estimations.

MAIN OUTCOME MEASURES

Incident cases of GW defined as the first activation of GW-related codes (ICD-9-CM 078.11 or ICD-10-CM A63.0) in hospital, primary and specialized care during the study period. Adjusted VE was estimated as (1-Relative Risk (RR)) × 100 by a negative binomial Bayesian model.

RESULTS

There were 23,049 cases of GW in the overall population and 2,565 in the females' cohort 14-23 years old. The incidence rate (IR) (in 100,000 persons-year) was 69.1 (95% CI 68.21-69.99) in the population overall, being higher in men (72.73; 95% CI 71.45-74.04). The IR of GW was 104.08 (95% CI 100.79-108.94) in the cohort of young women. The RR of GW increased with age from 14 to 21 years, reaching a plateau from 21 to 23. The VE of a complete schedule was 74% (95% CrI 68-79) for quadrivalent HPV vaccine (HPV4v). No effectiveness was seen with a full vaccination course with the bivalent HPV vaccine (HPV2v) in girls up to 21 years old. GW IR tends to be higher in unvaccinated cohorts covered by HPV4v vaccine than in unvaccinated cohorts not covered by HPV4v vaccine.

CONCLUSIONS

A complete HPV4v vaccination schedule was 74% effective in reducing GW in our population. Our results also suggest an indirect protection to unvaccinated and HPV2v vaccinated girls.

Partial Protective Effect of Bivalent Human Papillomavirus 16/18 Vaccination Against Anogenital Warts in a Large Cohort of Dutch Primary Care Patients

Background

There is ongoing debate about the possible protective effect of the bivalent human papillomavirus (2vHPV) vaccine, targeting oncogenic types HPV-16/18, against anogenital warts (AGWs), commonly attributed to HPV-6/11. We performed a retrospective registry-based open cohort study to assess the effect of 2vHPV vaccination on AGWs.

Methods

We linked general practice (ie, primary care) data from women born between 1993 and 2002, who had been eligible for HPV vaccination in the Netherlands, to the Dutch national immunization registry on an individual level. Women were followed until their first AGW diagnosis or end of follow-up. Adjusted incidence rate ratios (aIRRs) were estimated using Poisson regression with vaccination status as a time-dependent exposure.

Results

We linked data of 96 468 women with a total of 328 019 years observation time and 613 AGW diagnoses (incidence: 1.87/1000 person-years). At the end of follow-up, 61% were 2vHPV vaccinated (≥ 1 dose) of whom 91% were fully vaccinated. The AGW incidence was lower among those with ≥ 1 dose vs 0 doses (aIRR, 0.75 [95% confidence interval {CI}, .64–.88]). The effect of vaccination was stronger after full vaccination (aIRR, 0.72 [95% CI, .61–.86]) and for women who were offered vaccination at 12–13 years of age (aIRR, 0.69 [95% CI, .51–.93]) vs those at 13–16 years of age (aIRR, 0.77 [95% CI, .64–.93]).

Conclusions

This is the largest population-based study so far to examine the effect of 2vHPV vaccination on AGWs, with reliable individual information on AGW diagnoses and vaccination status. The results indicate that 2vHPV vaccination partially protects against AGWs, especially when administered in early adolescence.

Post-vaccination HPV seroprevalence among female sexual health clinic attenders in England

BACKGROUND

The National HPV Immunisation Programme was introduced in England in September 2008 using the HPV16/18 bivalent vaccine. We conducted serological surveillance to explore vaccination coverage levels. We also conducted a case-control study to investigate a hypothesised cross-protective effect of the HPV16/18 vaccine against genital warts.

METHODS

Residual serum specimens from 16 to 20 year-old women attending six specialist sexual health services (SSHS) between 2011 and 2015 in England were tested for antibodies against HPV16 and HPV18 using a virus-like particle (VLP)-based multiplex serology assay. Patients were classified as having vaccine-induced seropositivity if they were seropositive for both HPV types and either had high antibody levels for at least one HPV type, or moderately high levels for both HPV types. Differences in vaccine-induced seropositivity by patient characteristics were investigated using logistic regression. Vaccine-induced seropositivity was then compared for patients with genital warts (cases) and matched patients without (controls).

RESULTS

Of 3,973 serum specimens collected, 3,870 (97.4%) had a valid result. The proportion of women with vaccine-induced seropositivity decreased with age (from 78.1% in 16-year-olds to 52.6% in 20-year-olds). Vaccine-induced seropositivity was lower among women born outside the UK, from more deprived areas and with a history of chlamydia diagnosis. A difference in uptake by ethnic group was also seen but this was largely confounded by differences in deprivation and country of birth. Among 537 cases and 1,515 controls, there was little evidence of a protective effect of the bivalent HPV vaccine against genital warts (adjusted odds ratio 0.93; 95% CI: 0.74-1.18).

DISCUSSION

Vaccine-induced seropositivity in this high-risk population was in line with vaccination coverage in the general population although was lower in some at-risk sub-groups. This study does not provide evidence to support a cross-protective effect of the HPV16/18 vaccine against genital warts.

Systematic literature review of cross-protective effect of HPV vaccines based on data from randomized clinical trials and real-world evidence

BACKGROUND

The extent of cross-protection provided by currently licensed bivalent and quadrivalent HPV vaccines versus direct protection against HPV 31-, 33-, 45-, 52-, and 58-related disease is debated. A systematic literature review was conducted to establish the duration and magnitude of cross-protection in interventional and observational studies.

METHODS

PubMed and Embase databases were searched to identify randomized controlled trials (RCT) and observational studies published between 2008 and 2019 reporting on efficacy and effectiveness of HPV vaccines in women against non-vaccine types 31, 33, 45, 52, 58, and 6 and 11 (non-bivalent types). Key outcomes of interest were vaccine efficacy against 6- and 12-month persistent infection or genital lesions, and type-specific genital HPV prevalence or incidence. RCT data were analyzed for the according-to-protocol (bivalent vaccine) or negative-for-14-HPV-types (quadrivalent vaccine) efficacy cohorts.

RESULTS

Data from 23 RCTs and 33 observational studies evaluating cross-protection were extracted. RCTs assessed cross-protection in post-hoc analyses of small size subgroups. Among fully vaccinated, baseline HPV-naïve women, the bivalent vaccine showed statistically significant cross-protective efficacy, although with wide confidence intervals, against 6-month and 12-month persistent cervical infections and CIN2+ only consistently for HPV 31 and 45, with the highest effect observed for HPV 31 (range 64.6% [95% CI: 27.6 to 83.9] to 79.1% [97.7% CI: 27.6 to 95.9] for 6-month persistent infection; maximal follow-up 4.7 years). No cross-protection was shown in extended follow-up. The quadrivalent vaccine efficacy reached statistical significance for HPV 31 (46.2% [15.3-66.4]; follow-up: 3.6 years). Similarly, observational studies found consistently significant effectiveness only against HPV 31 and 45 with both vaccines.

CONCLUSIONS

RCTs and observational studies show that cross-protection is inconsistent across non-vaccine HPV types and is largely driven by HPV 31 and 45. Furthermore, existing data suggest that it wanes over time; its long-term durability has not been established.

Elimination of cervical cancer in low- and middle-income countries: Inequality of access and fragile healthcare systems

In 2018, WHO called for global action to eliminate cervical cancer. The complexity of the processes involved in terms of prevention is often underestimated. Low- and middle-income countries do not have a robust healthcare framework to ensure high-quality programs. The present article discusses how fragile healthcare systems are barriers to eliminating cervical cancer, and also reports the experience of a Brazilian prevention program. The article considers how cervical cancer can be interpreted as an indicator of inequality: how women's attitudes and access to care determine an early or late diagnosis, and how strategies combining vaccine and DNA-HPV tests are crucial. New vaccine schemes, the critical analysis of local data, strengthening communication, managing sentinel events, and integrating vaccination and screening data for the health information system are some of the key activities to sustainable improvement in both access and quality of care.

Strong reduction in prevalence of HPV16/18 and closely related HPV types in sexually active adolescent women following the introduction of HPV vaccination in Argentina

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HPV16/18 decreased by >93% in vaccinated sexually active Argentine girls.

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Detected reduction of HPV31 and 45 would add to the success of immunization.

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No genotype replacement was observed.

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First HPV vaccination monitoring data reported from a Latin American country.

Impact of a single-age cohort human papillomavirus vaccination strategy in Catalonia, Spain: Population-based analysis of anogenital warts in men and women

Extensive multiple-age cohort human papillomavirus (HPV) vaccination has proved to be highly effective. We aimed to determine the 8-year population impact of a female single-age cohort HPV vaccination programme on the incidence of anogenital warts (AGW). In 2008, Catalonia initiated a school-based quadrivalent HPV vaccination programme targeting 11-year-old girls, achieving coverage over 80%. Data on diagnoses of AGW and genital herpes were obtained from a population-based database of electronic health records covering 74% of the population. The annual incidence rates from 2009 to 2016 were calculated, stratified by age and sex using Joinpoint regression to estimate trends and annual percentage changes (APC). Among women aged 16-19 years, the AGW incidence decreased by 61% from 2012 to 2016 (APC -19.4%; 95% CI: -30.0 to -7.3). In contrast, the incidence of genital herpes in same-aged women increased throughout the study period (APC 11.1%; 95% CI: 7.2-15.2). Among men aged 20-22 years, the increasing incidence of AGW shifted to a downward trend in 2013 (APC 2009-2013: 17.0%; 95% CI: 8.2-26.5; and APC 2013-2016: -4.5%; 95% CI: -14.6 to 6.9). A similar pattern was observed among men aged 23-25 years (APC 2009-2014: 16.0%; 95% CI: 12.0-20.2; and APC 2014-2016: -6.0%; 95% CI: -18.4 to 8.3). In contrast to AGW, among men aged 20-25 years, the incidence of genital herpes increased over this period. Our study strongly suggests that a single-cohort HPV vaccination strategy with high vaccine uptake not only provides direct benefit in the vaccinated cohorts but also extends protection through a herd effect to unvaccinated men.

Vaccination With Moderate Coverage Eradicates Oncogenic Human Papillomaviruses If a Gender-Neutral Strategy Is Applied

BACKGROUND

Human papillomavirus (HPV) vaccination of girls with very high (>90%) coverage has the potential to eradicate oncogenic HPVs, but such high coverage is hard to achieve. However, the herd effect (HE) depends both on the HPV type and the vaccination strategy.

METHODS

We randomized 33 Finnish communities into gender-neutral HPV16/18 vaccination, girls-only HPV16/18 vaccination, and hepatitis B virus vaccination arms. In 2007-2010, 11 662 of 20 513 of 40 852 of 39 420 resident boys/girls from 1992 to 1995 birth cohorts consented. In 2010-2014, cervicovaginal samples from vaccinated and unvaccinated girls at age 18.5 years were typed for HPV6/11/16/18/31/33/35/39/45/51/52/56/58/59/66/68. Vaccine efficacy for vaccinated girls, HE for unvaccinated girls, and the protective effectiveness (PE) for all girls were estimated. We extended the community-randomized trial results about vaccination strategy with mathematical modeling to assess HPV eradication.

RESULTS

The HE and PE estimates in the 1995 birth cohort for HPV18/31/33 were significant in the gender-neutral arm and 150% and 40% stronger than in the girls-only arm. Concordantly, HPV18/31/33 eradication was already predicted in adolescents/young adults in 20 years with 75% coverage of gender-neutral vaccination. With the 75% coverage, eventual HPV16 eradication was also predicted, but only with the gender-neutral strategy.

CONCLUSIONS

Gender-neutral vaccination is superior for eradication of oncogenic HPVs.

Long-term follow-up of human papillomavirus type replacement among young pregnant Finnish females before and after a community-randomised HPV vaccination trial with moderate coverage

Large scale human papillomavirus (HPV) vaccination against the most oncogenic high-risk human papillomavirus (HPV) types 16/18 is rapidly reducing their incidence. However, attempts at assessing if this leads to an increase of nonvaccine targeted HPV types have been hampered by several limitations, such as the inability to differentiate secular trends. We performed a population-based serological survey of unvaccinated young women over 12 years. The women were under 23-years-old, residents from 33 communities which participated in a community-randomised trial (CRT) with approximately 50% vaccination coverage. Serum samples were retrieved pre-CRT and post-CRT implementation. Seropositivity to 17 HPV types was assessed. HPV seroprevalence ratios (PR) comparing the postvaccination to prevaccination era were estimated by trial arm. This was also assessed among the sexual risk-taking core group, where type replacement may occur more rapidly. In total, 8022 serum samples from the population-based Finnish Maternity Cohort were retrieved. HPV types 16/18 showed decreased seroprevalence among the unvaccinated in communities only after gender-neutral vaccination (PR_16/18A = 0.8, 95% CI 0.7-0.9). HPV6/11 and HPV73 were decreased after gender-neutral vaccination (PR_6/11A = 0.8, 95% CI 0.7-0.9, PR_73A = 0.7, 95% CI 0.6-0.9, respectively) and girls-only vaccination (PR_6/11B = 0.8, 95% CI 0.7-0.9, PR_73B = 0.9, 95% CI 0.8-1.0). HPV68 alone was increased but only after girls-only vaccination (PR_68B = 1.3, 95% CI 1.0-1.7, PR_core68B = 2.8, 95% CI 1.2-6.3). A large-scale, long-term follow-up found no type replacement in the communities with the strongest reduction of vaccine HPV types. Limited evidence for an increase in HPV68 was restricted to girls-only vaccinated communities and may have been due to secular trends (ClinicalTrials.gov number: NCT00534638).

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.

Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis

BACKGROUND

More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination.

METHODS

In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks.

FINDINGS

We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5-8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11-0·25) among girls aged 13-19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23-0·49) among women aged 20-24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33-0·66) among girls aged 13-19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24-0·46) among girls aged 15-19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36-0.60) among women aged 20-24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53-0·89) among women aged 25-29 years. Among boys aged 15-19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37-0·75) and among men aged 20-24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47-0·98). After 5-9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42-0·58) among screened girls aged 15-19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57-0·84) among women aged 20-24 years.

INTERPRETATION

This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects.

FUNDING

WHO, Canadian Institutes of Health Research, Fonds de recherche du Québec - Santé.

Epidemiology of genital warts in the British population: implications for HPV vaccination programmes

OBJECTIVES

To estimate the prevalence of, and describe risk factors for, genital warts (GWs) in the British population, following the introduction of the bivalent (human papillomavirus (HPV)-16/18) vaccination programme in girls, and prior to the switch to quadrivalent (HPV-6/11/16/18) vaccine (offering direct protection against GWs) and compare this with GW diagnoses in the prevaccination era.

METHODS

Natsal-3, a probability sample survey in Britain, conducted in 2010-2012, interviewed 9902 men and women aged 16-44. Natsal-2, conducted in 1999-2001, surveyed 11 161 men and women aged 16-44. Both surveys collected data on sexual behaviour and sexually transmitted infection diagnoses using computer-assisted interview methods.

RESULTS

In Natsal-3, 3.8% and 4.6% of sexually experienced men and women reported ever having a diagnosis of GWs, with 1.3% of men and 1.7% of woman reporting a GWs diagnosis in the past 5 years. GWs were strongly associated with increasing partner numbers and condomless sex. Diagnoses were more frequent in men who have sex with men (MSM) (11.6% ever, 3.3% past 5 years) and in women reporting sex with women (10.8% ever, 3.6% past 5 years). In the age group who were eligible for vaccination at the time of Natsal-3 (16-20 years), a similar proportion of same-aged women reported a history of GWs in Natsal-2 (1.9%, 1.1-3.4) and Natsal-3 (2.6%, 1.5-4.4).

CONCLUSIONS

These data provide essential parameters for mathematical models that inform cost-effectiveness analyses of HPV vaccination programmes. There was no evidence of population protection against GWs conferred by the bivalent vaccine. Even with vaccination of adolescent boys, vaccination should be offered to MSM attending sexual health clinics.

HPV vaccination in HIV infection

Persons with HIV are at increased risk of HPV infection, HPV disease, and HPV-related cancers compared to HIV negative persons. In persons with HIV, immune responses to vaccination are often sub-optimal, and while these improve with ART, they often remain lower and decline more rapidly than in HIV-negative individuals. Although the evidence base to support the immunogenicity of HPV vaccines in HIV + ve persons is reasonable, the evidence base to support the efficacy of HPV vaccines in HIV + ve individuals is inconsistent. There is one study in HIV + ve men who have sex with men (MSM) which showed no effect, and two other studies, one in HIV + ve women and one in HIV + ve adolescents that showed reduced effectiveness. All these effectiveness studies used Gardasil 4 (G4). Two studies in HIV + ve persons have shown superior immunogenicity of Cervarix (which uses a TLR4 agonist adjuvant) compared to G4. Studies of Hepatitis B vaccines in HIV + ve persons have shown that either (i) increased number of doses (ii) increased vaccine dose, or (iii) TLR agonist adjuvanted vaccines, all produce increased immunogenicity compared to standard vaccine regimes. Therefore, questions remain as to optimal HPV vaccine regimes in HIV and further clinical trials with different HPV vaccine regimes are needed.

Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK

BACKGROUND

Human papillomavirus (HPV) is the most widespread sexually transmitted infection worldwide. It causes several health consequences, in particular accounting for the majority of cervical cancer cases in women. In the United Kingdom, a vaccination campaign targeting 12-year-old girls started in 2008; this campaign has been successful, with high uptake and reduced HPV prevalence observed in vaccinated cohorts. Recently, attention has focused on vaccinating both sexes, due to HPV-related diseases in males (particularly for high-risk men who have sex with men) and an equity argument over equalising levels of protection.

METHODS

We constructed an epidemiological model for HPV transmission in the UK, accounting for nine of the most common HPV strains. We complemented this with an economic model to determine the likely health outcomes (healthcare costs and quality-adjusted life years) for individuals from the epidemiological model. We then tested vaccination with the three HPV vaccines currently available, vaccinating either girls alone or both sexes. For each strategy we calculated the threshold price per vaccine dose, i.e. the maximum amount paid for the added health benefits of vaccination to be worth the cost of each vaccine dose. We calculated results at 3.5% discounting, and also 1.5%, to consider the long-term health effects of HPV infection.

RESULTS

At 3.5% discounting, continuing to vaccinate girls remains highly cost-effective compared to halting vaccination, with threshold dose prices of £56-£108. Vaccination of girls and boys is less cost-effective (£25-£53). Compared to vaccinating girls only, adding boys to the programme is not cost-effective, with negative threshold prices (-£6 to -£3) due to the costs of administration. All threshold prices increase when using 1.5% discounting, and adding boys becomes cost-effective (£36-£47). These results are contingent on the UK's high vaccine uptake; for lower uptake rates, adding boys (at the same uptake rate) becomes more cost effective.

CONCLUSIONS

Vaccinating girls is extremely cost-effective compared with no vaccination, vaccinating both sexes is less so. Adding boys to an already successful girls-only programme has a low cost-effectiveness, as males have high protection through herd immunity. If future health effects are weighted more heavily, threshold prices increase and vaccination becomes cost-effective.

Effect of the bivalent HPV vaccine on viral load of vaccine and non-vaccine HPV types in incident clearing and persistent infections in young Dutch females

Background

HPV vaccination with the bivalent vaccine is efficacious against HPV16 and 18 infections and cross-protection against non-vaccine HPV types has been demonstrated. Here, we assessed (cross-) protective effects of the bivalent HPV16/18 vaccine on incident and persistent infections and viral load (VL) of fifteen HPV types in an observational cohort study monitoring HPV vaccine effects.

Methods

Vaginal samples were obtained annually. Type-specific VL assays were developed for HPV6,11,31 33,35,39,45,51,52,56,58,59 and 66 and used in addition to existing HPV16 and 18 assays. Rate differences of incident clearing and persistent infections were correlated with differences in VL and vaccination status.

Results

HPV16/18 vaccination resulted in significantly lower incidence of HPV16/18 infections and significantly lower VL in breakthrough HPV16 (p<0.01) and 18 infections (p<0.01). The effects of vaccination on non-vaccine type VL were ambiguous. Incidence and/or persistence rates of HPV31, 33, 35 and 45 were reduced in the vaccinated group. However, no significant type specific VL effects were found against HPV31, 33, 45, 52 in the vaccinated group. For HPV 6, 59 and 66 no significant reductions in numbers of incident and persistent infections were found, however borderline) VL reductions following vaccination were observed for HPV6 (p = 0.01), 59 (p = 0.10) and 66 (p = 0.03), suggesting a minor effect of the vaccine on the VL level of these HPV types. Overall, vaccination resulted in infections with slightly lower VL, irrespective of HPV type.

Conclusions

In conclusion, vaccination with the bivalent HPV16/18 vaccine results in significantly reduced numbers of HPV16 and 18 incidence rates and reduced VL in breakthrough infections. Significant reductions in incident and/or persistent HPV31, 33, 35 and 45 infections were found, but no significant effect was observed on the VL for infections with these types. For the other non-vaccine HPV types no reduction in incident and/or persistent infections were found, but overall the VL tended to be somewhat lower in vaccinated women.

Declines in anogenital warts diagnoses since the change in 2012 to use the quadrivalent HPV vaccine in England: data to end 2017

OBJECTIVES

In 2008, a national human papillomavirus (HPV) vaccination programme for females was introduced in England using the bivalent vaccine (HPV16 and 18 only). In 2012, the programme changed to offer the quadrivalent vaccine that includes protection against the two HPV types that cause the majority of anogenital warts (AGW; HPV6 and 11). We present data reporting AGW diagnoses in sexual health clinics (SHCs) in England to the end of 2017, including diagnoses among birth cohorts offered the quadrivalent vaccine.

METHODS

Using data from all SHCs across England, we performed ecological analyses to consider rates of AGW diagnoses by age, gender and sexual orientation. We tested for trends over time of diagnoses of AGW in young females, heterosexual males, and men who have sex with men (MSM) between the ages of 15 and 24 years during both bivalent (2009 to 2013) and quadrivalent (2014 to 2017) vaccine time periods using Poisson regression.

RESULTS

Between 2014 and 2017, there was strong evidence for a decreasing trend in the rate of AGW diagnoses at SHC among females aged 15-17 years from 257.5 to 45.7 per 100 000 population (82.3% decline) and same aged heterosexual males from 59.1 to 19.1 per 100 000 population (67.7% decline). The reductions in the incidence of AGW diagnoses in MSM aged 15-17 years were less clear (decreased by 13.6% between 2014 and 2017, from 129.9 to 112.2 per 100 000 population).

CONCLUSIONS

The moderate, unexpected declines in AGW seen since the introduction of a high-coverage HPV vaccination programme using the bivalent vaccine are being followed, as expected, by much larger declines among females offered the quadrivalent vaccine and same-aged heterosexual males. Surveillance plans are in place to continue to monitor AGW diagnoses to evaluate the impact of both female and targeted MSM HPV vaccination on early disease outcomes.

Eradication of human papillomavirus and elimination of HPV-related diseases - scientific basis for global public health policies

INTRODUCTION

Infections with oncogenic human papillomaviruses (HPV) globally cause about 9% of cancers in females and 1% of cancers in males. HPV disease burden can be effectively controlled by prophylactic HPV-vaccination provided it has high impact.

AREAS COVERED

A unique series of biobank-based and health registry-based studies that exploit randomized intervention cohorts has provided data on population-level safety of HPV vaccination, duration of vaccine-induced protection and impact of gender-neutral HPV vaccination, providing a scientific basis for policies to eradicate oncogenic HPV types and associated diseases worldwide.

EXPERT COMMENTARY

The ultimate goal of HPV vaccination is the eradication of high-risk (hr) HPVs. Seventy-five percent coverage gender-neutral vaccination of early adolescents will rapidly eradicate also HPV16 from the general population.

Prevalence and incidence of genital warts and cervical Human Papillomavirus infections in Nigerian women

BACKGROUND

Genital warts are important causes of morbidity and their prevalence and incidence can be used to evaluate the impact of HPV vaccination in a population.

METHODS

We enrolled 1020 women in a prospective cohort study in Nigeria and followed them for a mean (SD) of 9 (4) months. Nurses conducted pelvic examinations and collected ectocervical samples for HPV testing. We used exact logistic regression models to identify risk factors for genital warts.

RESULTS

The mean age of study participants was 38 years, 56% (535/962) were HIV-negative and 44% (427/962) were HIV-positive. Prevalence of genital warts at enrolment was 1% (4/535) among HIV-negative women, and 5% (23/427) among HIV-positive women. Of 614 women (307 HIV negative and 307 HIV positive women) for whom we could compute genital wart incidence, it was 515 (95% CI:13-2872) per 100,000 person-years in HIV-negative and 1370 (95% CI:283-4033) per 100,000 person-years in HIV-positive women. HIV was associated with higher risk of prevalent genital warts (OR:7.14, 95% CI:2.41-28.7, p < 0.001) while higher number of sex partners in the past year was associated with increased risk of incident genital warts (OR:2.86, 95% CI:1.04-6.47. p = 0.04). HPV11 was the only HPV associated with prevalent genital warts in this population (OR:8.21, 95% CI:2.47-27.3, p = 0.001).

CONCLUSION

Genital warts are common in Nigeria and our results provide important parameters for monitoring the impact of future HPV vaccination programs in the country. HIV infection and number of sexual partners in past year were important risk factors for prevalent and incident genital warts respectively.

Viral metagenomics updated the prevalence of human papillomavirus types in anogenital warts

To investigate the composition of human papillomavirus (HPV) types in anogenital warts (AGWs), viral nucleic acid in 110 AGWs, pooled into 11 specimen pools, were subjected to viral metagenomic analysis. After finding HPV7 in AGWs, conventional PCR screening was performed for HPV7 in other 190 individual AGW specimens. Viral metagenomic results indicated that 29 different types of HPV were recovered, with HPV11 and HPV6 showing the highest proportion of sequence reads. HPV7 was detected in 7 of 11 pools, 5 of which contained abundant HPV7 sequence reads. 24 complete genomes of HPV were acquired in viral metagenomic analysis, including 5 HPV7 genomes, based on which phylogenetic analysis and pairwise sequence comparison were conducted. PCR screening for HPV7 in other 190 individual AGW specimens revealed 25 positive cases (13.16%), of which the amplified fragments were sequenced and confirmed to be HPV7 sequences. Although HPV7 was generally found in hand warts and recently also in warts in toe webs, our data suggested that the role of HPV7 in AGW should be considered in the future clinical test and vaccine development for AGWs.

Gender-neutral vaccination provides improved control of human papillomavirus types 18/31/33/35 through herd immunity: Results of a community randomized trial (III)

With optimal strategy, human papillomavirus (HPV) vaccines have the potential to control HPV. We have assessed vaccine efficacy (VE), herd effect (HE) of HPV vaccination and overall protective effectiveness (PE) against high-risk HPV infections by HPV type and vaccination strategy in a community-randomized trial using the bivalent HPV16/18 vaccine. We randomized 33 communities to gender-neutral HPV vaccination (Arm A), HPV vaccination of girls and hepatitis B-virus (HBV) vaccination of boys (Arm B) and gender-neutral HBV vaccination (Arm C). Entire 1992-1995 male (40,852) and female (39,420) birth cohorts were invited, and 11,662 males and 20,513 females vaccinated with 20-30% and 45% coverage in 2007-2010. During 2010-2014, 11,396 cervicovaginal samples were collected from 13,545 18.5-year-old attendees. HPV typing was performed by a high-throughput PCR. VE was calculated for HPV vaccinated women and HE for non-HPV-vaccinated women, using the HBV vaccinated, for HE all non-HPV vaccinated, Arm C women as controls. PE was calculated as coverage rate-weighted mean of VE + HE. HPV16/18/45 and 31/33/35 VEs varied between 86-94% and 30-66%, respectively. Only the gender-neutral vaccination provided significant HEs against HPV18 (61%) and HPV31 (72%) in the 1995 birth cohort-increased HEs against HPV33 (39%) and HPV35 (42%) were also observed. Due to the increased HEs, PEs for HPV16/18/45 and HPV31/33/35 were comparable in the gender-neutral arm 1995 birth cohort. High vaccine efficacy against HPV16/18/45 and, gender-neutral vaccination-enforced, herd effect against HPV18/31/33/35 by the bivalent vaccine rapidly provides comparable overall protective effectiveness against six oncogenic HPV types: 16/18/31/33/35/45.

Lessons learned from domestic and international human papillomavirus vaccination programs: a review

Since the development of the human papillomavirus vaccine, many countries have created implementation programs to bolster vaccination rates and protect their populations. Despite demonstrated efficacy with decreased human papillomavirus-related disease abroad, the vaccine's potential to prevent morbidity and mortality in the United States is not being met. The purpose of this review is to discuss strategies of both international and domestic vaccination programs, their impact on human papillomavirus-related diseases, the unique obstacles faced by the United States, and future directions for success.

Proposal for cervical cancer screening in the era of HPV vaccination

Eradication of cervical cancer involves the expansion of human papillomavirus (HPV) vaccine coverage and the development of efficient screening guidelines that take vaccination into account. In Korea, the HPV National Immunization Program was launched in 2016 and is expected to shift the prevalence of HPV genotypes in the country, among other effects. The experiences of another countries that implement national immunization programs should be applied to Korea. If HPV vaccines spread nationwide with broader coverage, after a few decades, cervical intraepithelial lesions or invasive cancer should become a rare disease, leading to a predictable decrease in the positive predictive value of cervical screening cytology. HPV testing is the primary screening tool for cervical cancer and has replaced traditional cytology-based guidelines. The current screening strategy in Korea does not differentiate women who have received complete vaccination from those who are unvaccinated. However, in the post-vaccination era, newly revised policies will be needed. We also discuss on how to increase the vaccination rate in adolescence.

100 years of STIs in the UK: a review of national surveillance data

Objectives

The 1916 Royal Commission on Venereal Diseases was established in response to epidemics of syphilis and gonorrhoea in the UK. In the 100 years since the Venereal Diseases Act (1917), the UK has experienced substantial scientific, economic and demographic changes. We describe historical and recent trends in STIs in the UK.

Methods

We analysed surveillance data derived from STI clinics’ statistical returns from 1917 to 2016.

Results

Since 1918, gonorrhoea and syphilis diagnoses have fluctuated, reflecting social, economic and technological trends. Following spikes after World Wars I and II, rates declined before re-emerging during the 1960s. At that time, syphilis was more common in men, suggestive of transmission within the men who have sex with men (MSM) population. Behaviour change following the emergence of HIV/AIDS in the 1980s is thought to have facilitated a precipitous decline in diagnoses of both STIs in the mid-1980s. Since the early 2000s, gonorrhoea and syphilis have re-emerged as major public health concerns due to increased transmission among MSM and the spread of antimicrobial-resistant gonorrhoea. Chlamydia and genital warts are now the most commonly diagnosed STIs in the UK and have been the focus of public health interventions, including the national human papillomavirus vaccination programme, which has led to substantial declines in genital warts in young people, and the National Chlamydia Screening Programme in England. Since the 1980s, MSM, black ethnic minorities and young people have experienced the highest STI rates.

Conclusion

Although diagnoses have fluctuated over the last century, STIs continue to be an important public health concern, often affecting more marginalised groups in society. Prevention must remain a public health priority and, as we enter a new era of sexual healthcare provision including online services, priority must be placed on maintaining prompt access for those at greatest risk of STIs.

Population-Level Effects of Human Papillomavirus Vaccination Programs on Infections with Nonvaccine Genotypes

We analyzed human papillomavirus (HPV) prevalences during prevaccination and postvaccination periods to consider possible changes in nonvaccine HPV genotypes after introduction of vaccines that confer protection against 2 high-risk types, HPV16 and HPV18. Our meta-analysis included 9 studies with data for 13,886 girls and women ≤19 years of age and 23,340 women 20-24 years of age. We found evidence of cross-protection for HPV31 among the younger age group after vaccine introduction but little evidence for reductions of HPV33 and HPV45. For the group this same age group, we also found slight increases in 2 nonvaccine high-risk HPV types (HPV39 and HPV52) and in 2 possible high-risk types (HPV53 and HPV73). However, results between age groups and vaccines used were inconsistent, and the increases had possible alternative explanations; consequently, these data provided no clear evidence for type replacement. Continued monitoring of these HPV genotypes is important.

Cost-effectiveness of two-dose human papillomavirus vaccination in Singapore

INTRODUCTION

Cervical cancer is the tenth most common cancer and the eighth most frequent cause of death among women in Singapore. As human papillomavirus (HPV) infection is the necessary cause of cervical cancer, the risk of cervical cancer can be substantially reduced through vaccination. This study was conducted to evaluate the cost-effectiveness of two-dose HPV vaccination as part of a national vaccination programme for 12-year-old girls in Singapore, from the perspective of the healthcare payer.

METHODS

A lifetime Markov cohort model was used to evaluate the cost-effectiveness of introducing the AS04-adjuvanted HPV-16/18 vaccine (AS04-HPV-16/18v) to the current cervical screening programme in Singapore. Furthermore, the cost-effectiveness of the AS04-HPV-16/18v was compared with the HPV-6/11/16/18 vaccine (4vHPV). Model inputs were derived from local data, where possible, and validated by clinical experts in Singapore.

RESULTS

Introduction of the AS04-HPV-16/18v in Singapore was shown to prevent 137 cervical cancer cases and 48 cervical cancer deaths when compared with screening alone. This resulted in an incremental cost-effectiveness ratio of SGD 12,645 per quality-adjusted life year (QALY) gained, which is cost-effective according to the World Health Organization threshold for Singapore. When discounted at 3%, AS04-HPV-16/18v was dominant over 4vHPV, with cost savings of SGD 80,559 and 28 additional QALYs gained. In the one-way sensitivity analysis, AS04-HPV-16/18v remained cost-effective compared with screening alone and dominant compared with 4vHPV.

CONCLUSION

AS04-HPV-16/18v is the most cost-effective choice for reducing the burden of cervical cancer through universal mass vaccination for 12-year-old girls in Singapore.

Evaluation of vaccination herd immunity effects for anogenital warts in a low coverage setting with human papillomavirus vaccine-an interrupted time series analysis from 2005 to 2010 using health insurance data

Background

Shortly after the human papillomavirus (HPV) vaccine recommendation and hence the reimbursement of vaccination costs for the respective age groups in Germany in 2007, changes in the incidence of anogenital warts (AGWs) were observed, but it was not clear at what level the incidence would stabilize and to what extent herd immunity would be present. Given the relatively low HPV vaccination coverage in Germany, we aimed to assess potential vaccination herd immunity effects in the German setting.

Methods

A retrospective open cohort study with data from more than nine million statutory health insurance members from 2005 to 2010 was conducted. AGW cases were identified using ICD-10-codes. The incidence of AGWs was estimated by age, sex, and calendar quarter. Age and sex specific incidence rate ratios were estimated comparing the years 2009–2010 (post-vaccination period) with 2005–2007 (pre-vaccination period).

Results

Incidence rate ratio of AGWs for the post-vaccination period compared to the pre-vaccination period showed a u-shaped decrease among the 14- to 24-year-old females and males which corresponds well with the reported HPV vaccination uptake in 2008. A maximum reduction of up to 60% was observed for the 16- to 20-year-old females and slightly less pronounced (up to 50%) for the 16- and 18-year-old males. Age groups outside of the range 14–24 years demonstrated no decrease. The decrease of incidence occurred in both sexes early after the vaccine recommendation and stabilized at lower levels in 2009–2010.

Conclusions

A relative reduction of up to 50% among males of approximately similar age groups as that of females receiving the HPV vaccination suggests herd protection resulting from assortative mixing by age. The early decrease among males can be reduced over time due to partner change.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2663-7) contains supplementary material, which is available to authorized users.

Human papillomavirus vaccination: the population impact

We currently have the knowledge and experience to prevent much of human papillomavirus (HPV)-related disease burden globally. In many countries where prophylactic HPV vaccination programs have been adopted as highly effective public health programs with good vaccine coverage, we are already seeing, in real-world settings, reduction of vaccine-related HPV-type infections, genital warts and cervical pre-cancers with potential reductions in vulvar, vaginal and anal pre-cancers. Moreover, we are seeing a change in cervical screening paradigms, as HPV-based screening programs now have strong evidence to support their use as more sensitive ways to detect underlying cervical abnormalities, as compared with conventional cervical cytology. This article describes the impact of prophylactic vaccination on these outcomes and in settings where these vaccines have been implemented in national immunisation programs. Given the successes seen to date and the availability of essential tools, there has been a global push to ensure that every woman has access to effective cervical screening and every girl has the opportunity for primary prevention through vaccination. A gender-neutral approach by offering vaccination to young boys has also been adopted by some countries and is worthy of consideration given that HPV-related cancers also affect males. Furthermore, vaccination of young boys has the advantage of reducing the risk of HPV transmission to sexual partners, lowering the infectious pool of HPV in the general population and ultimately HPV-related diseases for both genders. Therefore, it is appropriate that all countries consider and promote national guidelines and programs to prevent HPV-related diseases.

Effectiveness of HPV vaccines against genital warts in women from Valencia, Spain

OBJECTIVES

To assess the effectiveness of the HPV vaccines in preventing genital warts in young women.

DESIGN

Population-based study using health databases.

SETTING

Valencian Community (Spain).

PARTICIPANTS

All girls and women aged 14-19years who were registered in the Valencian Community between January 2009 and December 2014 (n=279,787).

MAIN OUTCOME MEASURES

Incident cases of genital warts were defined as the first activation of diagnosis code ICD-9-CM 078.11 (Condyloma acuminatum) in primary care and outpatient clinics during the study period.

RESULTS

There were 612 cases of genital warts. The overall incidence rate was 75.8/100,000 person-years (95% CrI 69.7-81.8). There was a decrease in genital warts when female candidates to be vaccinated with quadrivalent HPV vaccine reached the age of 18 (in 2012), compared to previous years. Incidence of genital warts in unvaccinated women and those who received the bivalent vaccine was higher than in girls and women who received the quadrivalent HPV vaccine. The effectiveness of a three-dose regimen of the quadrivalent HPV vaccine was 77% (95 CrI: 66-85%), whereas that of a single dose was 61% (95 CrI: 20-87%). No effectiveness was seen with a full vaccination course with the bivalent HPV vaccine.

CONCLUSIONS

Three doses of the quadrivalent HPV vaccine were effective against genital warts in our population. Moreover, with low vaccine coverage the incidence of genital warts decreased only in the vaccinated.

No evidence for cross-protection of the HPV-16/18 vaccine against HPV-6/11 positivity in female STI clinic visitors

OBJECTIVES

Data from a vaccine trial and from post-vaccine surveillance in the United Kingdom have suggested that the bivalent HPV-16/18 vaccine offers cross-protection against HPV-6/11 and protection against anogenital warts (AGW). We studied the effect of the bivalent vaccine on genital HPV-6/11 positivity and AGW in the Netherlands.

METHODS

We included all vaccine-eligible women from the PASSYON study, a biennial cross-sectional study among 16- to 24-year-old sexually transmitted infection (STI) clinic attendants. Vaginal self-swabs were analyzed for type specific HPV and AGW were diagnosed at the STI-clinic. Prevalence of HPV-6 and/or HPV-11 and AGW were compared between self-reported vaccinated and unvaccinated women by log-binomial regression analysis, adjusted for demographics and risk behavior.

RESULTS

Of the 1198 women included, 56% reported to be vaccinated at least once. Relative to unvaccinated women, the adjusted prevalence ratio (PR) for HPV-6/11 was 1.03 (95% confidence interval [CI] 0.74-1.43) for women vaccinated at least once. The crude PR for AGW was 0.67 (95% CI 0.22-2.07) for women vaccinated at least once. Adjustment did not change these results.

CONCLUSIONS

We observed no cross-protective effect of the bivalent vaccine on genital HPV-6/11 positivity and a non-significant partially protective effect on AGW.

Psychosocial determinants of parental human papillomavirus (HPV) vaccine decision-making for sons: Methodological challenges and initial results of a pan-Canadian longitudinal study

Background

HPV vaccination decision-making is a complex process that is influenced by multiple psychosocial determinants. Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand where Canadian parents were situated in the HPV vaccine decision-making process for their son, how they changed over time and which psychosocial determinants were relevant for this process.

Methods

We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline (T1, February 2014) and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.

Results

At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.

Conclusions

HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users.

Decline in genital warts diagnoses among young women and young men since the introduction of the bivalent HPV (16/18) vaccination programme in England: an ecological analysis

BACKGROUND

For several decades, diagnoses of genital warts at genitourinary medicine (GUM) clinics in England had been increasing. In 2008, a national human papillomavirus (HPV) vaccination programme was introduced using the bivalent vaccine (types 16 and 18 only). A decrease in genital warts was not anticipated. However, rates of genital warts in GUM clinics have declined significantly since the introduction of the vaccine.

METHODS

Using data from GUM clinics across England, we analysed rates of genital warts by age, gender, sexual orientation and estimated vaccine coverage.

RESULTS

The reduction in rates of genital warts diagnoses at GUM clinics between 2009 and 2014 was 30.6% among young women aged 15-19 years and 25.4% among same age heterosexual young men. Overall there was an association showing higher warts reduction with increasing vaccination coverage with the largest declines in warts diagnoses observed in young women aged 15 years (50.9%) with the highest vaccination coverage. No such declines were observed in men who have sex with men (MSM) of the same age.

CONCLUSION

The results of these ecological analyses are strongly in keeping with the bivalent HPV vaccine providing modest protection against genital warts.

Impact of HPV vaccination on anogenital warts and respiratory papillomatosis

Human papillomavirus (HPV), the most common sexually transmitted infection in the US and worldwide, can cause cancers, anogenital warts (AGW), and recurrent respiratory papillomatosis (RRP) in men, women, and children. Global incidence of AGW ranges from 160-289 cases per 100,000 person-years and peaks in young men and women in the third decade of life. RRP has an estimated incidence of 3 per 1 million person-years in children. Pre-licensure trial efficacy, modeling and time-trend ecological studies have shown a significant short-term impact of 4vHPV vaccine. In girls aged 15-19 years, a previously published meta-analysis indicated that genital warts decreased significantly by 31%; stratified analysis revealed more substantial reductions in populations with high (≥50 %) vs. low (<50 % ) vaccination coverage (61% vs. 14%). Longer-term monitoring will reveal whether this impact continues under 9vHPV programs, and whether current declines in AGW are mirrored by declines in RRP.

Monitoring the impact of HPV vaccine in males-Considerations and challenges

In this article, we examine the issues involved if national or sub-national programs are considering extending post HPV vaccine introduction monitoring to include males. Vaccination programs are now being extended to include males in some countries, in order to improve population level HPV infection control and to directly prevent HPV-related disease in males such as anogenital warts and anal cancers. Coverage and adverse events surveillance are essential components of post-vaccination monitoring. Monitoring the impact of vaccination on HPV infection and disease in men raises some similar challenges to monitoring in females, such as the long time frame until cancer outcomes, and also different ones given that genital specimens suitable for monitoring HPV prevalence are not routinely collected for other diagnostic or screening purposes in males. Thus, dedicated surveillance strategies must be designed; the framework of these may be country-specific, dependent upon the male population that is offered vaccination, the health care infrastructure and existing models of disease surveillance such as STI networks. The primary objective of any male HPV surveillance program will be to document changes in the prevalence of HPV infection and disease due to vaccine targeted HPV types occurring post vaccination. The full spectrum of outcomes to be considered for inclusion in any surveillance plan includes HPV prevalence monitoring, anogenital warts, potentially pre-cancerous lesions such as anal squamous intraepithelial lesions (SIL), and cancers. Ideally, a combination of short term and long term outcome measures would be included. Surveillance over time in specific targeted populations of men who have sex with men and HIV-infected men (populations at high risk for HPV infection and associated disease) could be an efficient use of resources to demonstrate impact.

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Males surveillance can provide information about both herd protection and direct impact.

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Dedicated specimen collection is needed for HPV prevalence surveillance in males.

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Anogenital wart monitoring is a useful early indicator of HPV vaccine impact.

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Trends in HPV-related male cancers will be the ultimate indicator of success.

The epidemiology of sexually transmitted infections in the UK: impact of behavior, services and interventions

Sexually transmitted infections (STIs) are a major public health concern. The UK has some of the most advanced STI surveillance systems globally. This article uses national surveillance data to describe remarkable changes in STI epidemiology in the UK over the last century and explores the behavioral and demographic shifts that may explain these trends. The past 10 years have seen considerable improvements in STI service provision and the introduction of national public health interventions. However, sexual health inequalities persist and men who have sex with men, young adults and black ethnic minorities remain a priority for interventions. Technological advances in testing and a shift in sexual health service commissioning arrangements will present both opportunities and challenges in future.

HPV prophylactic vaccines: lessons learned from 10 years experience

When HPV vaccines were registered in 2006/2007, it was unclear whether these new and type-specific prophylactic vaccines would be accepted by the community for cancer prevention. With an optimal vaccination age of early adolescence, three vaccine doses required, HPV a sexually transmitted infection, and secondary prevention already available in the form of cervical screening, considerable potential challenges were faced. At the time of licensing, vaccine efficacy in males and duration of immunity were not yet unknown. Almost a decade later, with over 230 million doses of the vaccines distributed worldwide and national HPV vaccination programs in place in many countries, it is timely to reflect on current knowledge about the vaccines and some of the lessons learned during implementation.

How to best measure the effectiveness of male human papillomavirus vaccine programmes?

In many countries now, vaccination of young adolescent girls with prophylactic human papillomavirus (HPV) vaccines has been rolled out as a public health programme. In countries where coverage has been high, this has led to dramatic reductions in cervical high-grade precancerous lesions, as well as genital warts. A reduction in circulating vaccine-related HPV types has also been demonstrated. With the introduction of gender-neutral approaches incorporating universal vaccination of pre-adolescent boys in some countries, implementation of post-vaccine monitoring will be critical to evaluate the incremental impact of male vaccination. In contrast to cervical screening programmes, population-wide screening for HPV infection or related disease in males is not recommended; hence real-time monitoring of HPV vaccine effectiveness in males will require dedicated surveillance strategies. Monitoring the prevalence of circulating genital HPV types using a sentinel surveillance model could offer a good surrogate marker of early vaccine effectiveness in males. However, such an approach requires careful consideration of the most appropriate anatomical sites from which to collect specimens, the best sampling methods and the most sensitive assays to use. Additionally, in assessing an accurate measure of the impact of HPV vaccination in the male population, the effect of herd protection will need to be assessed, as most male programmes will commence in the setting of established female programmes. This poses an interesting epidemiological challenge.

Reduction in cervical intraepithelial neoplasia in young women in British Columbia after introduction of the HPV vaccine: An ecological analysis

We report on the rates of cervical intraepithelial neoplasia (CIN) in young women aged 15-22 years of age in British Columbia before and after the introduction of an HPV vaccine program. Rates of cervical intraepithelial neoplasia (CIN) 2+ for each age stratum (15-22) in the calendar years 2004-2012 for the province of British Columbia were obtained from the BC Cancer Agency's population-based cervical cancer program. Incidence rate ratios (IRR) of CIN2+ were described and compared before and after HPV vaccine program introduction in cohorts born in vaccine eligible years, and in non-vaccine eligible years using piece-wise Poisson regression analysis, and adjusted for age. Between 2004 and 2012, rates of CIN2 and CIN2+ in young women aged 15-22 years in the province of British Columbia have decreased overall. After the introduction of the HPV vaccine program, the age adjusted IRR for CIN2+ for young women aged 15-17 years decreased significantly from 0.91 (95% CI: 0.86-0.98 p < 0.01) to 0.36 (95% CI: 0.18-0.73 p < 0.01). During the same time period, no similar reduction was found in young women 18-22 years. After introduction of HPV vaccine program, IRR for CIN2+ in young women 15-17 was significantly reduced for CIN2+ (0.14; 95% CI: 0.04- 0.47; p < 0.01) and CIN2 (0.1; 95% CI: 0.02-0.54; p < 0.01). This ecological analysis shows a significant reduction in CIN2+ lesions in young women aged 15-17 years in British Columbia after the introduction of the HPV vaccine in young women despite vaccine uptake levels below 70%.

Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis

BACKGROUND

Human papillomavirus (HPV) vaccination programmes were first implemented in several countries worldwide in 2007. We did a systematic review and meta-analysis to assess the population-level consequences and herd effects after female HPV vaccination programmes, to verify whether or not the high efficacy reported in randomised controlled clinical trials are materialising in real-world situations.

METHODS

We searched the Medline and Embase databases (between Jan 1, 2007 and Feb 28, 2014) and conference abstracts for time-trend studies that analysed changes, between the pre-vaccination and post-vaccination periods, in the incidence or prevalence of at least one HPV-related endpoint: HPV infection, anogenital warts, and high-grade cervical lesions. We used random-effects models to derive pooled relative risk (RR) estimates. We stratified all analyses by age and sex. We did subgroup analyses by comparing studies according to vaccine type, vaccination coverage, and years since implementation of the vaccination programme. We assessed heterogeneity across studies using I(2) and χ(2) statistics and we did trends analysis to examine the dose-response association between HPV vaccination coverage and each study effect measure.

FINDINGS

We identified 20 eligible studies, which were all undertaken in nine high-income countries and represent more than 140 million person-years of follow-up. In countries with female vaccination coverage of at least 50%, HPV type 16 and 18 infections decreased significantly between the pre-vaccination and post-vaccination periods by 68% (RR 0·32, 95% CI 0·19-0·52) and anogenital warts decreased significantly by 61% (0·39, 0·22-0·71) in girls 13-19 years of age. Significant reductions were also recorded in HPV types 31, 33, and 45 in this age group of girls (RR 0·72, 95% CI 0·54-0·96), which suggests cross-protection. Additionally, significant reductions in anogenital warts were also reported in boys younger than 20 years of age (0·66 [95% CI 0·47-0·91]) and in women 20-39 years of age (0·68 [95% CI 0·51-0·89]), which suggests herd effects. In countries with female vaccination coverage lower than 50%, significant reductions in HPV types 16 and 18 infection (RR 0·50, 95% CI 0·34-0·74]) and in anogenital warts (0·86 [95% CI 0·79-0·94]) occurred in girls younger than 20 years of age, with no indication of cross-protection or herd effects.

INTERPRETATION

Our results are promising for the long-term population-level effects of HPV vaccination programmes. However, continued monitoring is essential to identify any signals of potential waning efficacy or type-replacement.

FUNDING

The Canadian Institutes of Health Research.

The effect of a booster dose of quadrivalent or bivalent HPV vaccine when administered to girls previously vaccinated with two doses of quadrivalent HPV vaccine

This randomized, blinded study evaluated the immunogenicity and safety of a booster dose of Gardasil (qHPV) or Cervarix (bHPV) when administered to 12-13 year-old girls who were vaccinated at the age of 9-10 with 2 doses of qHPV (0-6 months). 366 out of 416 eligible girls participated in this follow-up study. Antibody titers were measured just before and one month post-booster. A Luminex Total IgG assay was used for antibody assessment and results are presented in Liminex Units (LU). Three years post-primary vaccination, 99-100% of subjects had detectable antibodies to 4HPV genotypes included in the qHPV with GMTs varying from 50 to 322 LU depending on genotype. After a booster dose of qHPV, a ≥4 fold increase of antibody titers to genotypes included in the vaccine was observed in 88-98% of subjects. Post-booster GMTs varied from 1666 to 4536 LU depending on genotype. These GMTs were 1.1 to 1.8-fold higher when compared to those observed one month post-second dose. After a booster of bHPV, a ≥4 fold increase of antibody titers to HPV16 and HPV18 was observed in 93-99% of subjects. The anti-HPV16 and HPV18 GMTs were 5458 and 2665 LU, respectively. These GMTs were 1.2 and 1.8 higher than those observed in the qHPV group (both P < 0.01). In bHPV group a 1.4-1.6-fold increase of antibody GMTs to HPV6 and HPV11was also observed (P < 0.001). The safety profile was acceptable for both vaccines. Both qHPV and bHPV increase antibody titers when given as a booster to girls previously vaccinated with 2 doses of qHPV. The magnitude of the immune response after booster is vaccine-dependent and has the same pattern as that reported after primary vaccination with qHPV or bHPV. When given as a booster, both vaccines have an acceptable safety profile. Longer follow-up studies are warranted to assess the need of booster doses.

Early direct and indirect impact of quadrivalent HPV (4HPV) vaccine on genital warts: a systematic review

INTRODUCTION

Since 2007, many countries have implemented national human papillomavirus (HPV) vaccination programs with the quadrivalent HPV (4HPV) vaccine that has been shown to be efficacious in clinical trials involving 25,000 subjects. Two vaccine serotypes, HPV16 and 18, are responsible for cervical cancer and other HPV-related cancers, but the impact of the 4HPV vaccine on these cancers cannot be seen immediately as there is a considerable lag between infection with HPV and cancer development. The other two serotypes, HPV6 and 11, are responsible for genital warts (GWs), which develop within a few months after infection, making GWs an early clinical endpoint for the assessment of the impact of 4HPV vaccination.

METHODS

We performed a systematic literature search in PubMed to identify all published studies on 4HPV vaccination, including those that assessed the impact of 4HPV vaccination programs on the incidence of GWs at a population level around the world.

RESULTS

A total of 354 records were identified in the PubMed search. After screening and obtaining full papers for 56 publications, 16 publications presenting data on the impact or effectiveness of 4HPV vaccination on GWs were identified. These reported data on the impact or effectiveness of 4HPV in six countries [Australia (n = 6), New Zealand (n = 2), United States (n = 3), Denmark (n = 2), Germany (n = 1), and Sweden (n = 2)]. In Australia, no GWs were diagnosed in women aged <21 years who reported being vaccinated. A 92.6% reduction in GWs incidence was reported for all women in this age group, where the vaccine uptake rate (VUR) was 70% for 3 doses. The highest reductions were reported in countries with high VURs, mostly through school-based vaccination programs, although high VURs were obtained with some non-school-based programs.

CONCLUSION

The results are coherent with the GWs incidence reduction reported in clinical trials and are an early indicator of what can be expected for the long-term clinical impact on vaccine-type HPV-related cancers.

Human papilloma virus vaccination: impact and recommendations across the world

Human papilloma virus (HPV) vaccination has been implemented in several countries for about the past 7 years, mainly in the adolescent female population, with varying coverage results. Although the impact of immunization on cervical and other HPV-related cancers will be evident in the next decades, a marked decrease of prevalent HPV infections, precancerous lesions and genital warts is already dramatic in the vaccinated cohorts, and also in their sexual partners, thus providing clear evidence of the effectiveness of HPV vaccination, including a herd-protection effect. Today, recommendations and implementation of universal HPV vaccination for adolescent girls are a public-health priority in all countries of the world. Countries with limited resources are presently involved in demonstration projects and, in some cases, have launched national programmes with the help of international agencies and alliances. Extension of immunization offer to young women and to adolescent male subjects has become an important additional opportunity for several countries, with a special focus needed on homosexual men with HIV infection who are at particularly increased risk of HPV-related diseases. Public-health authorities are confronted with the need to enlarge HPV-vaccination offer to all target groups, especially pre-adolescent girls, so that they can be saved from dreadful cancers by reaching high immunization coverage.

Improving surveillance of sexually transmitted infections using mandatory electronic clinical reporting: the genitourinary medicine clinic activity dataset, England, 2009 to 2013

A new electronic surveillance system for sexually transmitted infections (STIs) was introduced in England in 2009. The genitourinary medicine clinic activity dataset (GUMCAD) is a mandatory, disaggregated, pseudo-anonymised data return submitted by all STI clinics across England. The dataset includes information on all STI diagnoses made and services provided alongside demographic characteristics for every patient attendance at a clinic. The new system enables the timely analysis and publication of routine STI data, detailed analyses of risk groups and longitudinal analyses of clinic attendees. The system offers flexibility so new codes can be introduced to help monitor outbreaks or unusual STI activity. From January 2009 to December 2013 inclusive, over twenty-five million records from a total of 6,668,648 patients of STI clinics have been submitted. This article describes the successful implementation of this new surveillance system and the types of epidemiological outputs and analyses that GUMCAD enables. The challenges faced are discussed and forthcoming developments in STI surveillance in England are described.

Human papillomavirus vaccination: where are we now?

The development of efficacious prophylactic human papillomavirus vaccines provided an opportunity for the primary prevention of related infections and diseases. Certain oncogenic human papillomaviruses that preferentially infect the genital epithelium cause cervical cancer and a substantial proportion of anal, penile, vaginal, vulvar and oropharyngeal cancers. Following extensive clinical trials demonstrating their efficacy and safety, two vaccines have been in global use for over 6 years. This review summarises the accumulated evidence regarding their high level of efficacy, safety in population usage, reductions in genital warts, infections and cervical disease following their adoption, and facilitators and barriers to achieving high vaccination coverage. The review also discusses practical issues and frequently asked questions regarding duration of effect, vaccination of women treated for cervical disease and alternate vaccination schedules, as well as the need to review cervical screening strategies in the post- vaccination environment.