An Overview of Quadrivalent Human Papillomavirus Vaccine Safety: 2006 to 2015

Stakeholders' experiences with school-based immunization programs during the COVID-19 pandemic in the Canadian Maritimes: A qualitative study

Background

School-based immunization programs (SBIP) support access to routine vaccines for adolescents. Across Canada, the COVID-19 pandemic and subsequent public health measures affected SBIP and vaccine uptake. The objectives of this study were to explore 1.) stakeholders' experiences with SBIP and changes to programs during COVID-19 in Nova Scotia, Prince Edward Island and New Brunswick, and 2.) how the pandemic affected parents' and adolescents' vaccine views.

Study design

Semi-structured interviews with decision makers, healthcare providers, teachers, parents and adolescents between February-August 2023.

Methods

The COM-B model and Theoretical Domains Framework informed interview guides. Deductive and inductive analyses saw participant quotes mapped to relevant model components and domains by two coders. Belief statements were generated within each stakeholder group then compared to identify themes and subthemes.

Results

Participants (n = 39) identified five themes: 1) enablers to SBIP delivery, 2) barriers to SBIP delivery, 3) desired changes to SBIP delivery, 4) student anxiety, and 5) vaccination views and changes since the COVID-19 pandemic. Public health measures facilitated more space for clinics, as did taking smaller cohorts of students. School staff-healthcare provider relationships could help or hinder programs, particularly with high turnover in both professions during the pandemic. Adolescents played a passive role in vaccine decision making, with mothers often being the sole decision maker. We did not identify any changes in hesitancy towards routine vaccines since the pandemic.

Conclusions

We identified a range of barriers and enablers to SBIP, many of which were exacerbated by the pandemic. Efforts are needed to ensure SBIP and catch-up programming remains accessible for all adolescents to catch-up on missed vaccines before graduation. Parents and adolescents' vaccination views suggest changes in vaccine coverage since the pandemic may be due to accessibility of services rather than vaccine hesitancy. Future research is needed to engage adolescents in their vaccine decisions.

Adverse events from HPV vaccination in Taiwan

The safety of human papillomavirus (HPV) vaccines has been evaluated continuously in pre-licensure clinical trials, post-marketing surveillance systems, and observational studies. Most studies have found no significant association between serious adverse events and HPV vaccination. However, these studies have focused on Western populations; similar studies focusing on Asian populations are insufficient. Our retrospective cohort study used the HPV-vaccination records of junior high-school adolescent girls aged 12-15 years between 2013 and 2018 in Taiwan's National Immunization Information System and linked them to a registry for beneficiaries in Taiwan's National Health Insurance Database (NHID) to establish the vaccinated group. We selected 19 serious diseases as serious adverse events. We compared the incidence rates of these serious adverse events between the vaccinated group and girls in the same age group population, and we calculated the standardized incidence ratio (SIR) to evaluate the risk of serious adverse events after HPV vaccination. Because of the onset of different types of diseases, we set three periods after the subjects received HPV vaccination: within 3 months, within 1 year, and during the study period (2013-2018). The results showed the incidence rates and the SIRs of 19 selected adverse events. Among the 19 selected serious adverse events, the disease with the highest incidence rate during the study period was fibromyalgia (73.23 cases per million population), and the disease with the lowest incidence rate during the study period was Crohn's disease (0.15 cases per million population). The results showed no statistically significant increases in the risk of 19 selected serious adverse events and indicated no association between HPV vaccination and serious adverse events. Given the benefits and safety of HPV vaccination, our research can reduce concerns about vaccine side effects, inform health policies and improve public and clinician's acceptance of HPV vaccine policy.

County-level correlates of completed HPV vaccination in Indiana

The Healthy People 2030 goal is for 80% of all adolescents to complete their HPV vaccination series. Per the 2021, National Immunization Survey-Teen (NIS-Teen), 61.7% of adolescents have completed the series, and Indiana lags below the national average (55.2%). The present study estimated the 2-dose HPV vaccine series completion rates across Indiana counties among individuals aged 9-14 years who received their first dose of vaccine and determined what factors were associated with series completion at the county level. The association of county-level sociodemographic and health measures with series completion was also examined. Data were extracted from the Indiana Immunization Information System (IIS), administered by the Indiana Department of Health. All vaccine providers are required to report all immunizations to the system for any patient under age 19 years. All Indiana children ages 9-14 years at the time of first dose who had initiated HPV vaccination in 2017 or 2018 were included. Two-dose series completion was evaluated through October of 2020, allowing a minimum gap of 22 months from first dose administration. All statistical analyses were conducted at the county-level. The Indiana HPV vaccination series completion rate among individuals that received the first dose was on average 73% across counties, ranging from 55.7% to 90.4%. Higher series completion was positively associated with primary care providers per capita, participation in mammography screening among Medicare enrollees, median household income, life expectancy, percentage of residents with some college, percentage of adults up-to-date with colonoscopy screening, and percentage of adults with flu vaccine. There was wide variability in series completion across Indiana counties. HPV series completion was associated with county-level sociodemographic and health measures, particularly variables reflecting difficulties with access to care and lack of financial resources.

Safety of 9-valent human papillomavirus vaccine administered to males and females in routine use

BACKGROUND

The nine-valent human papillomavirus vaccine (HPV9, Gardasil®9) was licensed in the USA in December 2014. This study was a multiyear post-licensure study to assess HPV9 safety following routine administration.

METHODS

This retrospective cohort study compared the risk of emergency department visits and hospitalizations during the interval soon after vaccination with risk during a later interval. Kaiser Permanente Northern California (KPNC) members aged ≥ 9 years who received ≥ 1 HPV9 dose between 10/1/2015-9/30/2017 were included. Outcomes were grouped into predefined diagnostic categories. We compared the odds of events in postvaccination risk intervals (days 0-14, days 1-60) with odds of events during control intervals (days 61-75, days 61-120) using conditional logistic regression. We characterized prespecified events on the day of vaccination (allergic reaction and syncope) and all deaths in the study period.

RESULTS

The study included 215,965 individuals receiving ≥ 1 dose of HPV9, of whom 140,628 had no prior HPV vaccination. We observed similar numbers of males and females and racial/ethnic diversity consistent with the underlying population. At first dose median age was 12-13 years and 77% received ≥ 1 concomitant vaccine. Eighteen event categories were significantly elevated, including skin disorders (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.00, 3.53) and ill-defined conditions (OR 1.36, 95% CI 1.13, 1.64; category includes abdominal pain, allergic reactions, syncope, etc.). On review, most findings were previously known, preceded vaccination, or had other causes. Allergic reactions and syncope at vaccination were infrequent but many were potentially related. No deaths (n = 37) were considered related to HPV9 and were consistent with the background rate.

CONCLUSIONS

We did not identify new safety concerns related to HPV9. The results are consistent with the HPV9 safety profile as established from previous studies/surveillance.

REGISTRATION

European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS13151, protocol V503-028).

Can Adjuvant HPV Vaccination Be Helpful in the Prevention of Persistent/Recurrent Cervical Dysplasia after Surgical Treatment?—A Literature Review

Simple Summary

Primary prophylactic, early detection and the treatment of precancerous lesions are the main goals of cervical cancer screening. Despite effective surgical treatment methods, using loop electrosurgical excision procedures and conization, the overall risk of the recurrence of HSIL lesions remains at approximately 6.6%. There is increasing evidence of the potential role of HPV vaccines in the adjuvant setting and their impact on the reduction of disease recurrence. This review aims to analyze the up-to-date research concerning the use and efficacy of secondary human papilloma virus (HPV) vaccination as an adjuvant method to surgical treatment in patients diagnosed with cervical HSILs.

Abstract

Cervical cancer formation is preceded by precursor lesions, including low-grade squamous intraepithelial lesions (LSILs) and high-grade squamous intraepithelial lesions (HSILs), which are usually diagnosed in women of reproductive age. Despite the recent advanced diagnostic and treatment methods, including colposcopy, the loop electrosurgical excision procedure (LEEP), and surgical conization, the recurrence or residual disease affects as many as 6.6% of patients. The lesions are often associated with human papilloma virus (HPV) infection. As HPV persistence is the leading and only modifiable factor affecting the risk of progression of CIN lesions into high-grade cervical dysplasia and cancer, it has been proposed to conduct adjuvant vaccination in patients treated for high-grade cervical dysplasia. To date, no vaccine has been approved for therapeutic use in patients diagnosed with HSILs; however, attempts have been made to determine the use of HPV prophylactic vaccination to reduce recurrent HSILs and prevent cervical cancer. The aim of this review was to analyze the up-to-date literature concerning the possible use of secondary human papilloma virus (HPV) vaccination as an adjuvant method to surgical treatment in patients diagnosed with cervical HSILs. Adjuvant HPV vaccination after surgical treatment may reduce the risk of recurrent cervical dysplasia.

Safety of 4-valent human papillomavirus vaccine in males: a large observational post-marketing study

The 4-valent human papillomavirus (HPV) vaccine (4vHPV vaccine), Gardasil®, is indicated for the prevention of several HPV-related diseases. The objective was to assess the safety of 4vHPV vaccine administered to males as part of routine care. The study used a US health insurance claims database, and included males, age 9 to 26 years, who initiated 4vHPV between October 2009 and December 2016. General safety outcomes were identified using ICD diagnosis codes associated with emergency room visits and hospitalizations in the claims database in risk periods (Days 1–60 and Days 1–14 following vaccine administration) and self-comparison periods (Days 91–150 and 91–104 for the Days 1–60 and Days 1–14 analysis, respectively). Incidence rates (IRs) and relative rates (RRs) with 95% confidence intervals (CIs) were calculated comparing the risk and self-comparison periods. In this study, 114,035 males initiated 4vHPV vaccine and received 202,737 doses. Using the 60-day time window, 5 outcomes had significantly elevated RRs after accounting for multiple comparisons: ear conditions (RR 1.28, 95% CI 1.03–1.59); otitis media and related conditions (RR 1.65, 95% CI 1.09–2.54); cellulitis and abscess of arm (RR 2.17, 95% CI 1.06–4.72); intracranial injury (RR 1.23, 95% CI 1.01–1.50); and concussion (RR 1.29, 95% CI 1.05–1.59). A higher rate of allergic reactions was noted on the day of 4vHPV vaccine receipt compared to other vaccines (21.07 events per 10,000 doses, 95% CI 18.89–23.44 versus 11.44 per 10,000 doses, 95% CI 9.84–13.22). A higher incidence rate of VTE was observed following vaccination but this association was not significant (RR 2.17, 95% CI 0.35–22.74). The 4vHPV vaccine was associated with same-day allergic reactions as well as ear infections, intracranial injury, cellulitis, and concussion within 2 months after vaccination. While allergic reaction and cellulitis are consistent with the known safety profile of 4vHPV vaccine, the association of the other outcomes were determined by an independent Safety Review Committee to be most likely a result of activities common in adolescent males that coincide with the timing of vaccination and not directly related to vaccination itself.

Implications and Contributions: The study results support the general safety of routine immunization with 4vHPV vaccine among males to prevent HPV-related diseases and cancers.

Current Take on Systemic Sclerosis Patients' Vaccination Recommendations

Systemic sclerosis (SSc) is a rare autoimmune inflammatory rheumatic disease. The prevalence of SSc ranges from 7 to 700 cases per million worldwide. Due to multiple organ involvement and constant inflammatory state, this group of patients presents an increased risk of infectious diseases. This paper aimed to gather the up-to-date evidence on vaccination strategies for patients with SSc and to be a useful tool for the prevention and management of infectious diseases. The authors conducted a scoping review in which each paragraph presents data on a specific vaccine’s safety, immunogenicity, and efficacy. The work deals with the following topics: SARS-CoV-2, seasonal influenza, S. pneumoniae, HAV, HBV, HZV, N. meningitidis, H. influenzae, HPV, and diphtheria-tetanus-pertussis.

Tracking the progress in COVID-19 and vaccine safety research - a comprehensive bibliometric analysis of publications indexed in Scopus database

INTRODUCTION

COVID-19 pandemic public health emergency is one of the worse disease outbreaks in the history of infectious disease. The consequence has resulted in over 4 million deaths globally. Therefore, a more in-depth understanding of the dynamics of the disease, vaccine development, and safety has become crucial for the disease eradication.

OBJECTIVE

The study adopted bibliometric analysis to identify the global contribution in COVID-19 and Vaccine Safety and analyzed the current status, development, and research hotspots to reference for future research directions.

METHODS

Studies published between January 1, 2019 and July 11, 2021 were retrieved from the Scopus database. Data analysis and visualization were conducted using VOSviewer ver 1.6.6, Bibliometrix app. (Using R).

RESULTS

A total of 1827 publications with 12.14 average citations per document were identified. These publications were published in 796 journals by 10,243 authors (with 5.61 authors per document) from 80 countries/regions. About 33.75% of the researches were from the developed countries. The USA, China, and India were top contributors for scientific research on COVID-19 and vaccine safety. The "Vaccine" is the most productive journal with 58 articles. Li Y, NA NA, and Liu X were the top three prolific authors. Furthermore, "Human," "Coronavirus disease 2019," and "Drug safety," were the most common frontier topics.

CONCLUSIONS

Our analysis highlights the characteristics of the most influential articles on COVID-19 related to vaccine safety. The findings provided valuable insight into the scientific research progress in this domain and suggest scaling-up research and information dissemination on COVID-19 and vaccine safety.

In the Name of Prevention: Maternal Perspectives on School-Based HPV Vaccination in Rural Southern Chile

Purpose

Since the introduction of the HPV vaccine in Chile in 2014, there have been few studies exploring community perspectives on the vaccine, specifically of parents of adolescents. This study sought to identify maternal factors and family dynamics that affect HPV vaccination behavior.

Participants and Methods

Participants were recruited at an OB/GYN clinic in Linares, Chile. Participation was voluntary, and eligibility required 1) having an adolescent daughter between 9 and19 years-old and 2) demonstrating a willingness to discuss HPV-related topics. Thirty semi-structured interviews were conducted to generate qualitative data analyzed using Grounded Theory methodology.

Results

Three thematic constructs emerged from the interviews. Mothers’ motivations to vaccinate centered on disease prevention and trust in the medical system but were influenced by notions of sexual liberalism and promiscuity. Second, participants desired, but often had trouble finding, adequate information about vaccine safety and turned to the internet. Third, joint decision making in the family about vaccination led to open family discussions about sex and sexuality.

Conclusion

Chile’s school-based opt-out HPV vaccination program engenders a unique landscape of maternal decision-making, risk-benefit analysis, information-seeking, and at-home discussion. More studies are needed around the variable role of fathers in the decision-making process.

Association of Inadvertent 9-Valent Human Papillomavirus Vaccine in Pregnancy With Spontaneous Abortion and Adverse Birth Outcomes

IMPORTANCE

The 9-valent human papillomavirus (9vHPV) vaccine is recommended for individuals through age 26 years and may be administered to women up to age 45 years. Data on 9vHPV vaccine exposures during pregnancy are limited.

OBJECTIVE

To evaluate the associations between 9vHPV vaccine exposures during pregnancy or peripregnancy and selected pregnancy and birth outcomes (spontaneous abortion [SAB], preterm birth, small-for-gestational age [SGA] birth, and major structural birth defect).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from 7 participating health systems in the Vaccine Safety Datalink. The cohort comprised pregnancies among girls and women aged 12 to 28 years that ended between October 26, 2015, and November 15, 2018. Singleton pregnancies that ended in a live birth, stillbirth, or SAB were included.

EXPOSURES

Vaccine exposure windows were distal (9vHPV or 4vHPV vaccine administered from 22 to 16 weeks before last menstrual period [LMP]), peripregnancy (9vHPV vaccine administered from 42 days before LMP until LMP), and during pregnancy (9vHPV vaccine administered from LMP to 19 completed weeks' gestation). Primary comparisons were (1) girls and women with 9vHPV vaccine exposures during pregnancy vs those with 4vHPV or 9vHPV distal vaccine exposures, (2) girls and women with vaccine exposures peripregnancy vs those with 4vHPV or 9vHPV distal vaccine exposures, and (3) girls and women with 9vHPV vaccine exposures during pregnancy or peripregnancy vs those with 4vHPV or 9vHPV distal vaccine exposure.

MAIN OUTCOMES AND MEASURES

Spontaneous abortions were confirmed based on medical record review and adjudication. Preterm and SGA births were identified from electronic health record and birth data. Major structural birth defects were based on diagnostic codes using a validated algorithm. Inverse probability weighting was used to balance the covariates. Time-dependent covariate Cox proportional hazards regression models and Poisson regression were used to estimate the associations between 9vHPV vaccine exposures and pregnancy and birth outcomes.

RESULTS

The final cohort included 1493 pregnancies among girls and women with a mean (SD) maternal age of 23.9 (2.9) years. Of these pregnancies, 445 (29.8%) had exposures to the 9vHPV vaccine during pregnancy, 496 (33.2%) had exposures to the 9vHPV vaccine peripregnancy, and 552 (37.0%) had 4vHPV or 9vHPV distal vaccine exposures. The 9vHPV vaccine administered during pregnancy was not associated with increased risk for SAB (hazard ratio, 1.12; 95% CI, 0.66-1.93) compared with distal vaccine exposures. Findings were similar for 9vHPV vaccine exposures peripregnancy (relative risk [RR], 0.72; 95% CI, 0.42-1.24). Among live births (n = 1409), 9vHPV vaccine exposures during pregnancy were not associated with increased risks for preterm birth (RR, 0.73; 95% CI, 0.44-1.20) or SGA birth (RR, 1.31; 95% CI, 0.78-2.20). Results were similar regarding the association between 9vHPV vaccine exposures peripregnancy and preterm birth (RR, 0.72; 95% CI, 0.45-1.17) and SGA birth (RR, 1.10; 95% CI, 0.65-1.88). Birth defects were rare in all exposure groups, occurring in about 1% of live births with available infant data.

CONCLUSIONS AND RELEVANCE

This study found that 9vHPV vaccine exposures during or around the time of pregnancy were uncommon and not associated with SABs or selected adverse birth outcomes. These findings can inform counseling for inadvertent 9vHPV vaccine exposures.

Long-term immunogenicity, effectiveness, and safety of nine-valent human papillomavirus vaccine in girls and boys 9 to 15 years of age: Interim analysis after 8 years of follow-up

BACKGROUND

The nine-valent human papillomavirus (9vHPV) vaccine protects against infection and disease related to HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The pivotal 36-month Phase III immunogenicity study of 9vHPV vaccine in 9- to 15-year-old girls and boys was extended to assess long-term immunogenicity and effectiveness through approximately 10 years after vaccination. We describe results of an interim analysis based on approximately 8 years of follow-up after vaccination.

METHODS

Participants aged 9-15 years who received three doses of 9vHPV vaccine (at day 1, month 2, and month 6) in the base study and consented to follow-up were enrolled in the long-term follow-up study extension (N = 1272 [females, n = 971; males, n = 301]). Serum was collected at months 66 and 90 to assess antibody responses. For effectiveness analysis, genital swabs were collected (to assess HPV DNA by polymerase chain reaction [PCR]) and external genital examination was conducted (to detect external genital lesions) every 6 months starting when the participant reached 16 years of age. Cervical cytology tests were conducted annually when female participants reached 21 years of age; participants with cytological abnormalities were triaged to colposcopy based on a protocol-specified algorithm. External genital and cervical biopsies of abnormal lesions were performed, and histological diagnoses were adjudicated by a pathology panel. Specimens were tested by PCR to detect HPV DNA.

RESULTS

Geometric mean titers for each 9vHPV vaccine HPV type peaked around month 7 and gradually decreased through month 90. Seropositivity rates remained >90% through month 90 for each of the 9vHPV vaccine types by HPV immunoglobulin Luminex Immunoassay. No cases of HPV6/11/16/18/31/33/45/52/58-related high-grade intraepithelial neoplasia or genital warts were observed in the per-protocol population (n = 1107) based on a maximum follow-up of 8.2 years (median 7.6 years) post-Dose 3. Incidence rates of HPV6/11/16/18/31/33/45/52/58-related 6-month persistent infection in females and males were 49.2 and 37.3 per 10,000 person-years, respectively, which were within ranges expected in vaccinated cohorts. There were no vaccine-related SAEs or deaths during the period covered by this interim analysis.

CONCLUSIONS

The 9vHPV vaccine provided sustained immunogenicity and durable effectiveness through approximately 7 and 8 years, respectively, following vaccination of girls and boys aged 9-15 years.

Immunogenicity and safety of the quadrivalent human papillomavirus vaccine in Chinese females aged 9 to 26 years: A phase 3, open-label, immunobridging study

BACKGROUND

The quadrivalent human papillomavirus (qHPV; HPV6/11/16/18) vaccine was approved for use in Chinese women aged 20-45 years in 2017. This Phase 3, open-label study (NCT03493542) aimed to assess immunogenicity and safety of the qHPV vaccine in Chinese girls aged 9-19 years versus Chinese young women aged 20-26 years; we report results from Day 1 through Month 7. The study will continue through Month 60 to assess antibody persistence in Chinese girls aged 9-19 years.

METHODS

Participants aged 9-26 years received three doses of the qHPV vaccine (Day 1, Month 2, Month 6). Geometric mean titers (GMTs) and seroconversion percentages for anti-HPV6/11/16/18 antibodies were determined by competitive Luminex immunoassay (cLIA) in serum samples obtained on Day 1 and at Month 7. Injection-site adverse events (AEs) and systemic AEs within 30 days post-vaccination, and serious AEs (SAEs) occurring at any time during the study, were recorded.

RESULTS

In total, 766 participants (383 aged 9-19 years; 383 aged 20-26 years) were enrolled and received ≥1 vaccine dose. All participants in the per-protocol immunogenicity population of both age groups seroconverted to each of the vaccine HPV types at Month 7. Anti-HPV6/11/16/18 antibody GMTs at Month 7 in participants aged 9-19 years were non-inferior to those in participants aged 20-26 years. Injection-site AEs and systemic AEs were reported by 36.6% and 49.3% of 9-19-year-olds, and 40.7% and 54.8% of 20-26-year-olds, respectively. There were no vaccine-related SAEs. No participants discontinued the vaccine due to an AE and no deaths were reported.

CONCLUSION

Antibody responses induced by the 3-dose qHPV vaccination regimen in Chinese girls aged 9-19 years were non-inferior to those in Chinese young women aged 20-26 years. The vaccine was generally well tolerated in the study population. ClinicalTrials.gov Identifier: NCT03493542.

Safety and immunogenicity of the quadrivalent human papillomavirus vaccine in patients with juvenile dermatomyositis: a real-world multicentre study

BACKGROUND

Concerns about the safety and efficacy of vaccines in patients with autoimmune diseases (AID) have led to contradictions and low vaccination coverage in this population, who are at a higher risk of infections, including by human papillomavirus (HPV). Although HPV vaccines have been recommended for immunocompromised patients, there is still a lack of data to support its use for AID patients, such as juvenile dermatomyositis (JDM) patients. The aim of this study was to assess the safety and immunogenicity of the quadrivalent HPV (qHPV) vaccine in a cohort of JDM patients.

METHODS

JDM patients aged from 9 to 20 years and healthy controls (HC) were enrolled to receive a 3-dose schedule of qHPV vaccine from March/2014 to March/2016. Study visits were performed before the first dose, 1 month after the second and third doses, and 6 months after the third dose. Participants completed a diary of possible adverse events for 14 days following each dose of vaccination (AEFV). Disease activity and current therapy were analyzed at each visit for JDM patients. In addition, serum samples from all participants were collected to test antibody concentrations against HPV16 and 18 at each visit. Participant recruitment was conducted in ten Brazilian centres. From 47 eligible JDM patients and 41 HC, 42 and 35, respectively, completed the 3-dose schedule of the vaccine, given that five JDM patients and two HC had received doses prior to their inclusion in the study.

RESULTS

The AEFVs presented by the participants were mild and in general did not differ between JDM and HC groups. No severe AEFVs were related to the vaccination. Disease activity was stable, or even improved during the follow-up. One month after the third dose of the vaccine the JDM group presented seropositivity of 100% for HPV16 and 97% for HPV18, similarly to the HC group, who presented 100% for both serotypes (p = 1.000). Six months after the third dose the seropositivity for the patient group was 94% for both HPV types.

CONCLUSIONS

The HPV vaccination in this cohort of JDM patients was safe and immunogenic. Since the seropositivity against HPV16 and 18 was very high after the 3-dose schedule, this regimen should be recommended for JDM patients.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry, number: RBR-9ypbtf . Registered 20 March 2018 - Retrospectively registered.

Final analysis of a 14-year long-term follow-up study of the effectiveness and immunogenicity of the quadrivalent human papillomavirus vaccine in women from four nordic countries

BACKGROUND

The quadrivalent human papillomavirus (qHPV) vaccine prevented vaccine HPV type-related infection and disease in young women in the 4-year FUTURE II efficacy study (NCT00092534). We report long-term effectiveness and immunogenicity at the end of 14 years of follow-up after enrollment in FUTURE II.

METHODS

Young women (16-23 years of age) from Denmark, Iceland, Norway, and Sweden who received three qHPV vaccine doses during the randomized, double-blind, placebo-controlled FUTURE II base study were followed for effectiveness for an additional ≥10 years through national registries. Tissue samples including but not limited to those collected during organized cervical cancer screening programs were obtained from regional biobanks to be adjudicated for histopathology diagnosis and tested for HPV DNA. The observed incidence of HPV16/18-related high-grade cervical dysplasia (primary outcome) was compared with recent historical background incidence rates in an unvaccinated population. Serum was collected at years 9 and 14 to assess antibody responses.

FINDINGS

No cases of HPV16/18-related high-grade cervical dysplasia were observed in the per-protocol effectiveness population (N = 2121; 24,099·0 person-years of follow-up) during the entire study. Vaccine effectiveness of 100% (95% CI 94·7-100) was demonstrated for ≥12 years, with a trend toward continued protection through 14 years post-vaccination. Seropositivity rates at study conclusion were >90% (HPV6/11/16) and 52% (HPV18) using competitive Luminex immunoassay, and >90% (all four HPV types) using the more sensitive IgG Luminex immunoassay.

INTERPRETATION

Vaccination of young women with qHPV vaccine offers durable protection against HPV16/18-related high-grade cervical dysplasia for ≥12 years, with a trend toward continued protection through 14 years post-vaccination, and induces sustained HPV6/11/16/18 antibody responses for up to 14 years post-vaccination. There was no evidence of waning immunity, suggesting no need for a booster dose during that period.

FUNDING

Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Strategic health communication on social media: Insights from a Danish social media campaign to address HPV vaccination hesitancy

OBJECTIVE

To evaluate whether the social media strategy developed for the campaign Stop HPV - stop cervical cancer was successful at engaging target groups in communication regarding HPV vaccination.

INTRODUCTION

In 2009, the Human Papillomavirus (HPV) vaccine became part of the Danish childhood vaccination program to protect Danish girls from cervical cancer. In 2015, after a period of massive media coverage questioning the safety of the HPV vaccination, a rapid decline in HPV vaccination coverage was observed. An information campaign was therefore launched in May 2017 to address HPV vaccination hesitancy. THE SOCIAL MEDIA STRATEGY: 'Heart-brain communication' combined facts and emotions through varied content. Community management guidelines were worked out to ensure that there was positive dialogue. Key Point Indicators (KPI) for Engagement Rate (ER) and Click Through Rate (CTR) were chosen to uphold engagement and traffic from Facebook to the website. The KPIs were used to measure effectiveness.

RESULTS

In January 2019, the social media campaign had reached 8,020,000 people with an average of 127 comments per post. The average ER from May 2017 to halfway through 2018 was 6.07% and the CTR was 2.09%. The content subgroup personal stories was the most effective in creating positive dialogue. One year after the launch of the campaign, the number of positive comments had increased from less than 50% to approximately 75%.

CONCLUSION

A comprehensive social media strategy using 'heart-brain communication' proved useful in a campaign for HPV vaccination. The success of the social media strategy was due to meticulous planning prior to launching the campaign, the use of content subgroups, the allocation of adequate resources for community management, the empirical analysis of content, and the use of evaluation results as guidance for the production of new content.

An educational intervention to improve attitudes regarding HPV vaccination and comfort with counseling among US medical students

Many medical students are not comfortable recommending the human papillomavirus (HPV) vaccine because they do not feel prepared to discuss it with their patients. A prior study demonstrated that this is particularly a problem among unvaccinated students. Our purpose was to determine if medical student attitudes and comfort with counseling could be improved by attending a single lecture delivered by an expert on the topic. To assess the effects of the educational program, we conducted pre- and posttests on medical students before and after a single lecture on HPV vaccination. Changes in items related to attitude and comfort were examined. Student characteristics associated with changes in scores were also examined and compared. A total of 256 medical students participated in the pre- and posttests. Before the lecture, students demonstrated low knowledge of HPV vaccination and did not feel comfortable counseling parents of younger patients. However, students <30 years of age demonstrated significant improvements after the lecture in comfort. Asian and Hispanic students showed the greatest improvement in comfort with counseling, as did students who reported they had not received the HPV vaccine. Attending a single lecture given by an expert can improve medical students' attitudes and comfort with HPV vaccine counseling, especially if the students were not vaccinated themselves. This study suggests that including material on HPV vaccination in the standard medical student curriculum could help increase physician recommendation for the HPV vaccine.

Safety of the 9-Valent Human Papillomavirus Vaccine

BACKGROUND

The 9-valent human papillomavirus vaccine (9vHPV) was approved for females and males aged 9 to 26 years in 2014. We analyzed postlicensure surveillance reports to the Vaccine Adverse Event Reporting System (VAERS).

METHODS

We searched VAERS data for US reports of adverse events (AEs) after 9vHPV from December 2014 through December 2017. We calculated reporting rates and conducted empirical Bayesian data mining to identify disproportional reporting. Physicians reviewed reports for selected prespecified conditions.

RESULTS

VAERS received 7244 reports after 9vHPV: 31.2% among females, 21.6% among males, and for 47.2%, sex was not reported. Overall, 97.4% of reports were nonserious. Dizziness, syncope, headache, and injection site reactions were most commonly reported; the most commonly reported AEs were similar between females and males. Two reports of death after 9vHPV were verified; no information in autopsy reports or death certificates suggested a causal relationship with vaccination. Approximately 28 million 9vHPV doses were distributed during the study period; crude AE reporting rates were 259 reports per million 9vHPV doses distributed for all reports and 7 per million doses distributed for serious reports. Syncope (a known AE associated with human papillomavirus vaccination) and several types of vaccine administration errors (eg, administered at wrong age) exceeded the statistical threshold for empirical Bayesian data mining findings.

CONCLUSIONS

No new or unexpected safety concerns or reporting patterns of 9vHPV with clinically important AEs were detected. The safety profile of 9vHPV is consistent with data from prelicensure trials and from postmarketing safety data of its predecessor, the quadrivalent human papillomavirus vaccine.

Near Real-Time Surveillance to Assess the Safety of the 9-Valent Human Papillomavirus Vaccine

BACKGROUND AND OBJECTIVES

Human papillomavirus is the most common sexually transmitted infection in the United States and causes certain anogenital and oropharyngeal cancers. The 9-valent human papillomavirus vaccine (9vHPV) provides protection against additional types not included in the quadrivalent vaccine. We conducted near real-time vaccine safety surveillance for 24 months after the vaccine became available in the Vaccine Safety Datalink.

METHODS

Immunizations and adverse events were extracted weekly from October 2015 to October 2017 from standardized data files for persons 9 to 26 years old at 6 Vaccine Safety Datalink sites. Prespecified adverse events included anaphylaxis, allergic reaction, appendicitis, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, injection site reaction, pancreatitis, seizure, stroke, syncope, and venous thromboembolism. The observed and expected numbers of events after 9vHPV were compared weekly by using sequential methods. Both historical and concurrent comparison groups were used to identify statistical signals for adverse events. Unexpected signals were investigated by medical record review and/or additional analyses.

RESULTS

During 105 weeks of surveillance, 838 991 doses of 9vHPV were administered. We identified unexpected statistical signals for 4 adverse events: appendicitis among boys 9 to 17 years old after dose 3; pancreatitis among men 18 to 26 years old; and allergic reactions among girls 9 to 17 years old and women 18 to 26 years old after dose 2. On further evaluation, which included medical record review, temporal scan analysis, and additional epidemiological analyses, we did not confirm signals for any adverse events.

CONCLUSIONS

After 2 years of near real-time surveillance of 9vHPV and several prespecified adverse events, no new safety concerns were identified.

[HPV vaccination: not only female adolescents and not only prophylactic. Review and position paper of the Italian HPV Study Group (IHSG)]

HPV vaccination has been introduced in clinical practice in recent years and represents the most effective strategy of primary prevention of cervical carcinoma and of female genital preneoplastic conditions. One of the major issues of the subject is represented by vaccination coverage of the target population. Since its introduction, HPV vaccine efficacy has been progressively demonstrated also towards extragenital HPV-correlated conditions and in males too. Moreover, even subjects of older age groups or subjects who already had HPV infections have been demonstrated to received benefits from vaccination, due to improvements of their immunological response. Recently, vaccine efficacy has also been investigated in terms of adjuvant administration after treatments of preneoplastic or benign conditions of the female lower genital tract caused by HPVs; preliminary results indicate an interesting and promising field of application. On this basis, in this article an analysis of the state of the art has been performed, with specific regard to the Italian scenario and with the focus of future perspectives of implementation of the HPV vaccination policy. From the available evidences, the Italian HPV Study Group recommends the extension of systematic HPV vaccination to males too, to adult subjects and also after conservative treatment of genital HPV correlated conditions.

Social representations of mandatory vaccination in patients and general practitioners in Moselle, France

Vaccine controversies affect the image of vaccination. At the end of 2014, there was a shortage of tetra- and pentavalent vaccines, although immunization obligation was being discussed. Our objective in this context was to study the social representations of mandatory vaccination in general practitioners and patients. Thirty general practitioners and 30 patients were recruited for this study based on hierarchal evocation. Each provided seven associations, which were revealed spontaneously in response to the evocation of the inductive concept: "mandatory vaccination". An order of importance and a connotation were attributed to them. These associations were classified into subthemes and themes. For each, the frequency of occurrence, the median rank of importance, and the polarity index were calculated and then compared. The image of vaccination was positive (polarity index from doctors and patients: +0.22 and +0.24, respectively). The doctors mentioned first the organization of the vaccine follow-up (21.9%). For patients, the benefits of vaccination predominated (22.38%), although these benefits were considered more important by the doctors. Doctors raised vaccine controversies more frequently than patients and were more concerned with the practical aspects of vaccination (injection, pain). The current controversies have not eroded the representations of mandatory vaccination. However, doctors are critical towards the media and vaccination policy. Patients, on the other hand, are afraid of side effects and do not have complete confidence in vaccination. Immunization obligation does not appear to be challenged by either of the two populations. To sustain immunization, our main asset remains communication and information to patients.

Facilitators and barriers of human papillomavirus vaccine uptake in young females 18-26 years old in Singapore: A qualitative study

BACKGROUND

Around 70% of cervical cancers are caused by Types 16 and 18 of human papillomavirus (HPV). Vaccines against HPV have been shown to be safe and effective in preventing HPV and cervical cancer.

OBJECTIVE

To explore the facilitators and barriers of HPV vaccination in young females aged 18-26 years in Singapore, and to describe their recommended strategies to improve the uptake of HPV vaccination.

DESIGN

Qualitative, descriptive design guided by the socio-ecological model.

PARTICIPANTS

Young women studying in National University of Singapore (NUS), aged 18-26 (N = 40). Purposive sampling was used to recruit participants from various socio-economic levels and faculties, both vaccinated against HPV and unvaccinated.

METHODS

In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with the participants. IDIs and FGDs were transcribed and coded using NVIVO software. Thematic data analysis was performed using an inductive approach.

RESULTS

Barriers to HPV vaccination included lack of awareness, lack of perceived risk for cervical cancer, cost, lack of parental support, inconvenience of getting the vaccination, stigma associated with connection with sexual activity, and concern regarding safety. Facilitators include parental encouragement, protection of one's health, lack of logistical barriers, and perceived safety and efficacy of the vaccine. Participants recommended increasing awareness of HPV vaccination and cervical cancer, reducing cost of vaccination and making the vaccine compulsory to increase vaccine uptake.

CONCLUSION

Barriers and facilitators exist at different levels to influence vaccine uptake. Public education on cervical cancer and the vaccine should be stepped up to increase public awareness. A school-based national vaccination programme was proposed by the target group to increase the rate of uptake of HPV vaccination in Singapore.

Efficacy, Immunogenicity, and Safety of a 9-Valent Human Papillomavirus Vaccine: Subgroup Analysis of Participants From Asian Countries

Background

A 9-valent human papillomavirus-6/11/16/18/31/33/45/52/58 (9vHPV) vaccine extends coverage to 5 next most common oncogenic types (31/33/45/52/58) in cervical cancer versus quadrivalent HPV (qHPV) vaccine. We describe efficacy, immunogenicity, and safety in Asian participants (India, Hong Kong, South Korea, Japan, Taiwan, and Thailand) from 2 international studies: a randomized, double-blinded, qHPV vaccine-controlled efficacy study (young women aged 16–26 years; NCT00543543; Study 001); and an immunogenicity study (girls and boys aged 9–15 years; NCT00943722; Study 002).

Methods

Participants (N = 2519) were vaccinated at day 1 and months 2 and 6. Gynecological samples (Study 001 only) and serum were collected for HPV DNA and antibody assessments, respectively. Injection-site and systemic adverse events (AEs) were monitored. Data were analyzed by country and vaccination group.

Results

9vHPV vaccine prevented HPV-31/33/45/52/58–related persistent infection with 90.4%–100% efficacy across included countries. At month 7, ≥97.9% of participants seroconverted for each HPV type. Injection-site AEs occurred in 77.7%–83.1% and 81.9%–87.5% of qHPV and 9vHPV vaccine recipients in Study 001, respectively, and 62.4%–85.7% of girls/boys in Study 002; most were mild to moderate.

Conclusions

The 9vHPV vaccine is efficacious, immunogenic, and well tolerated in Asian participants. Data support 9vHPV vaccination programs in Asia.

Clinical Trials Registration

NCT00543543; NCT00943722.

Human papillomavirus vaccination: The ESGO-EFC position paper of the European society of Gynaecologic Oncology and the European Federation for colposcopy

Vaccines against human papillomavirus (HPV) are available in Europe since 2006. They have been highly effective in preventing infection and disease caused by the vaccine types. Clinical efficacy data are available for cervical, vulvovaginal and anal precancer and invasive cervical cancer. Disease reduction is best with early vaccination and a coverage of more than 70%. Gender-neutral vaccination provides direct protection for all men and improves the coverage. A good coverage is followed by herd protection of the unvaccinated men and women. School-based programs appear to be most effective; under the age of 15 years, two doses with an interval of 6-12 months are sufficient. From the age of 15 years, the standard regimen with three doses is recommended. A broad catch-up program for young adult women and men improves the effectiveness. The vaccines are also effective in sexually active women and men with previous but cleared infections. Vaccination in addition to local treatment of HPV-related disease appears to reduce recurrent or subsequent HPV-related disease. Combination of HPV vaccination and screening with HPV testing is the most effective approach to prevention of cervical cancer. The screening intervals may increase in the vaccinated cohorts. The upper age limit for vaccination remains to be evaluated, is country specific and depends on cost-effectiveness. The European Society of Gynaecologic Oncology and the European Federation for Colposcopy strongly support gender-neutral vaccination programs for children and young adolescents, with a catch-up program for young adults.

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.

Vaccination of haemopoietic stem cell transplant recipients: guidelines of the 2017 European Conference on Infections in Leukaemia (ECIL 7)

Infection is a main concern after haemopoietic stem cell transplantation (HSCT) and a major cause of transplant-related mortality. Some of these infections are preventable by vaccination. Most HSCT recipients lose their immunity to various pathogens as soon as the first months after transplant, irrespective of the pre-transplant donor or recipient vaccinations. Vaccination with inactivated vaccines is safe after transplantation and is an effective way to reinstate protection from various pathogens (eg, influenza virus and Streptococcus pneumoniae), especially for pathogens whose risk of infection is increased by the transplant procedure. The response to vaccines in patients with transplants is usually lower than that in healthy individuals of the same age during the first months or years after transplant, but it improves over time to become close to normal 2-3 years after the procedure. However, because immunogenic vaccines have been found to induce a response in a substantial proportion of the patients as early as 3 months after transplant, we recommend to start crucial vaccinations with inactivated vaccines from 3 months after transplant, irrespectively of whether the patient has or has not developed graft-versus-host disease (GvHD) or received immunosuppressants. Patients with GvHD have higher risk of infection and are likely to benefit from vaccination. Another challenge is to provide HSCT recipients the same level of vaccine protection as healthy individuals of the same age in a given country. The use of live attenuated vaccines should be limited to specific situations because of the risk of vaccine-induced disease.

Safety of a quadrivalent human papillomavirus vaccine in a Phase 3, randomized, double-blind, placebo-controlled clinical trial among Chinese women during 90 months of follow-up

BACKGROUND

A quadrivalent human papillomavirus (qHPV) vaccine (HPV6/11/16/18) has demonstrated efficacy and acceptable safety in international studies. However, these studies did not include participants from mainland China, which has a substantial burden of HPV-related disease. This is the first safety report with a follow-up period of up to 90 months from a randomized, double-blind, placebo-controlled trial of qHPV vaccine in Chinese women 20-45 years of age.

METHODS

Participants were randomized 1:1 to receive three doses of qHPV vaccine or placebo (Day1, Month 2, and Month 6). Efficacy outcomes are reported elsewhere. Injection-site and systemic adverse events (AEs) were collected using vaccination report cards (VRCs) for 15 days following each vaccination. Serious AEs (SAEs), pregnancy outcomes, new medical conditions, and fetal/infant SAEs were collected during the entire study.

RESULTS

Of 3006 participants randomized, AEs were reported by 926 (61.8%) qHPV vaccine recipients and 856 (57.1%) placebo recipients over the entire study. Four participants (two in each group) discontinued the study vaccination due to AEs that were considered vaccination-related. Within 15 days following any vaccination, injection-site AEs prompted for on the VRC were more frequent among qHPV vaccine recipients (37.6% vs 27.8%), and systemic AEs prompted for on the VRC were similar in frequency between qHPV vaccine and placebo groups (46.8% vs 45.1%). Thirty-eight and 43 participants reported SAEs in qHPV vaccine and placebo groups, respectively. No SAE was considered qHPV vaccine-related. Pregnancy outcomes, fetal/infant SAEs, and new medical conditions were generally similar in frequency between the qHPV vaccine and placebo groups, and within normal ranges.

CONCLUSION

The qHPV vaccine was well tolerated and demonstrated a favorable safety profile in Chinese women 20-45 years of age, consistent with findings from global trials and safety surveillance studies.

TRIAL REGISTRATION

clinicaltrials.gov; NCT00834106.

Safety of Human Papillomavirus Vaccines: An Updated Review

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

Recommendations and barriers to vaccination in systemic lupus erythematosus

Patients with Systemic Lupus Erythematosus (SLE) pose a unique dilemma pertaining to immunization against common pathogens. SLE patients are usually not immunized with vaccines based on the fear of either precipitating infection in this immunosuppressed patient population (with live vaccines) or aggravating autoimmunity and hence lupus flares (with any vaccines). However, elevated vulnerability to infection makes patients with SLE precisely the population that needs protection from vaccine-preventable diseases. A summary of guidelines from the Centers for Disease Control and Prevention, professional societies, review articles and expert opinions regarding use of individual vaccines applicable to adults with SLE is presented in this review.

Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors

BACKGROUND

Persistent infection with high-risk human papillomaviruses (hrHPV) types is causally linked with the development of cervical precancer and cancer. HPV types 16 and 18 cause approximately 70% of cervical cancers worldwide.

OBJECTIVES

To evaluate the harms and protection of prophylactic human papillomaviruses (HPV) vaccines against cervical precancer and HPV16/18 infection in adolescent girls and women.

SEARCH METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and Embase (June 2017) for reports on effects from trials. We searched trial registries and company results' registers to identify unpublished data for mortality and serious adverse events.

SELECTION CRITERIA

Randomised controlled trials comparing efficacy and safety in females offered HPV vaccines with placebo (vaccine adjuvants or another control vaccine).

DATA COLLECTION AND ANALYSIS

We used Cochrane methodology and GRADE to rate the certainty of evidence for protection against cervical precancer (cervical intraepithelial neoplasia grade 2 and above [CIN2+], CIN grade 3 and above [CIN3+], and adenocarcinoma-in-situ [AIS]), and for harms. We distinguished between the effects of vaccines by participants' baseline HPV DNA status. The outcomes were precancer associated with vaccine HPV types and precancer irrespective of HPV type. Results are presented as risks in control and vaccination groups and risk ratios (RR) with 95% confidence intervals in brackets.

MAIN RESULTS

We included 26 trials (73,428 participants). Ten trials, with follow-up of 1.3 to 8 years, addressed protection against CIN/AIS. Vaccine safety was evaluated over a period of 6 months to 7 years in 23 studies. Studies were not large enough or of sufficient duration to evaluate cervical cancer outcomes. All but one of the trials was funded by the vaccine manufacturers. We judged most included trials to be at low risk of bias. Studies involved monovalent (N = 1), bivalent (N = 18), and quadrivalent vaccines (N = 7). Most women were under 26 years of age. Three trials recruited women aged 25 and over. We summarize the effects of vaccines in participants who had at least one immunisation.Efficacy endpoints by initial HPV DNA statushrHPV negativeHPV vaccines reduce CIN2+, CIN3+, AIS associated with HPV16/18 compared with placebo in adolescent girls and women aged 15 to 26. There is high-certainty evidence that vaccines lower CIN2+ from 164 to 2/10,000 (RR 0.01 (0 to 0.05)) and CIN3+ from 70 to 0/10,000 (RR 0.01 (0.00 to 0.10). There is moderate-certainty evidence that vaccines reduce the risk of AIS from 9 to 0/10,000 (RR 0.10 (0.01 to 0.82).HPV vaccines reduce the risk of any CIN2+ from 287 to 106/10,000 (RR 0.37 (0.25 to 0.55), high certainty) and probably reduce any AIS lesions from 10 to 0/10,000 (RR 0.1 (0.01 to 0.76), moderate certainty). The size of reduction in CIN3+ with vaccines differed between bivalent and quadrivalent vaccines (bivalent: RR 0.08 (0.03 to 0.23), high certainty; quadrivalent: RR 0.54 (0.36 to 0.82), moderate certainty). Data in older women were not available for this comparison.HPV16/18 negativeIn those aged 15 to 26 years, vaccines reduce CIN2+ associated with HPV16/18 from 113 to 6 /10,000 (RR 0.05 (0.03 to 0.10). In women 24 years or older the absolute and relative reduction in the risk of these lesions is smaller (from 45 to 14/10,000, (RR 0.30 (0.11 to 0.81), moderate certainty). HPV vaccines reduce the risk of CIN3+ and AIS associated with HPV16/18 in younger women (RR 0.05 (0.02 to 0.14), high certainty and RR 0.09 (0.01 to 0.72), moderate certainty, respectively). No trials in older women have measured these outcomes.Vaccines reduce any CIN2+ from 231 to 95/10,000, (RR 0.41 (0.32 to 0.52)) in younger women. No data are reported for more severe lesions.Regardless of HPV DNA statusIn younger women HPV vaccines reduce the risk of CIN2+ associated with HPV16/18 from 341 to 157/10,000 (RR 0.46 (0.37 to 0.57), high certainty). Similar reductions in risk were observed for CIN3+ associated with HPV16/18 (high certainty). The number of women with AIS associated with HPV16/18 is reduced from 14 to 5/10,000 with HPV vaccines (high certainty).HPV vaccines reduce any CIN2+ from 559 to 391/10,000 (RR 0.70 (0.58 to 0.85, high certainty) and any AIS from 17 to 5/10,000 (RR 0.32 (0.15 to 0.67), high certainty). The reduction in any CIN3+ differed by vaccine type (bivalent vaccine: RR 0.55 (0.43 to 0.71) and quadrivalent vaccine: RR 0.81 (0.69 to 0.96)).In women vaccinated at 24 to 45 years of age, there is moderate-certainty evidence that the risks of CIN2+ associated with HPV16/18 and any CIN2+ are similar between vaccinated and unvaccinated women (RR 0.74 (0.52 to 1.05) and RR 1.04 (0.83 to 1.30) respectively). No data are reported in this age group for CIN3+ or AIS.Adverse effectsThe risk of serious adverse events is similar between control and HPV vaccines in women of all ages (669 versus 656/10,000, RR 0.98 (0.92 to 1.05), high certainty). Mortality was 11/10,000 in control groups compared with 14/10,000 (9 to 22) with HPV vaccine (RR 1.29 [0.85 to 1.98]; low certainty). The number of deaths was low overall but there is a higher number of deaths in older women. No pattern in the cause or timing of death has been established.Pregnancy outcomesAmong those who became pregnant during the studies, we did not find an increased risk of miscarriage (1618 versus 1424/10,000, RR 0.88 (0.68 to 1.14), high certainty) or termination (931 versus 838/10,000 RR 0.90 (0.80 to 1.02), high certainty). The effects on congenital abnormalities and stillbirths are uncertain (RR 1.22 (0.88 to 1.69), moderate certainty and (RR 1.12 (0.68 to 1.83), moderate certainty, respectively).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that HPV vaccines protect against cervical precancer in adolescent girls and young women aged 15 to 26. The effect is higher for lesions associated with HPV16/18 than for lesions irrespective of HPV type. The effect is greater in those who are negative for hrHPV or HPV16/18 DNA at enrolment than those unselected for HPV DNA status. There is moderate-certainty evidence that HPV vaccines reduce CIN2+ in older women who are HPV16/18 negative, but not when they are unselected by HPV DNA status.We did not find an increased risk of serious adverse effects. Although the number of deaths is low overall, there were more deaths among women older than 25 years who received the vaccine. The deaths reported in the studies have been judged not to be related to the vaccine. Increased risk of adverse pregnancy outcomes after HPV vaccination cannot be excluded, although the risk of miscarriage and termination are similar between trial arms. Long-term of follow-up is needed to monitor the impact on cervical cancer, occurrence of rare harms and pregnancy outcomes.

Human papillomavirus vaccine and demyelinating diseases-A systematic review and meta-analysis

Approved in 2006, human papillomavirus (HPV) vaccines were initially targeted for girls aged 9-14 years. Although the safety of these vaccines has been monitored through post-licensure surveillance programmes, cases of neurological events have been reported worldwide. The present study aimed to assess the risk of developing demyelination after HPV immunization by meta-analysing risk estimates from pharmacoepidemiologic studies. A systematic review was conducted in Medline, Embase, ISI Web of Science and the Cochrane Library from inception to 10 May 2017, without language restriction. Only observational studies including a control group were retained. Study selection was performed by two independent reviewers with disagreements solved through discussion. This meta-analysis was performed using a generic inverse variance random-effect model. Outcomes of interest included a broad category of central demyelination, multiple sclerosis (MS), optic neuritis (ON), and Guillain-Barré syndrome (GBS), each being considered independently. Heterogeneity was investigated; sensitivity and subgroup analyses were performed when necessary. In parallel, post-licensure safety studies were considered for a qualitative review. This study followed the PRISMA statement and the MOOSE reporting guideline. Of the 2,863 references identified, 11 articles were selected for meta-analysis. No significant association emerged between HPV vaccination and central demyelination, the pooled odds ratio being 0.96 [95% CI 0.77-1.20], with a moderate but non-significant heterogeneity (I² = 29%). Similar results were found for MS and ON. Sensitivity analyses did not alter our conclusions. Findings from qualitative review of 14 safety studies concluded in an absence of a relevant signal. Owing to limited data on GBS, no meta-analysis was performed for this outcome. This study strongly supports the absence of association between HPV vaccines and central demyelination.

Primary care pediatricians' attitudes and practice towards HPV vaccination: A nationwide survey in Italy

This national online cross-sectional survey in Italy assessed primary care pediatricians’ (PCPs) attitudes and practices regarding Human papillomavirus (HPV) vaccination and the contribution of several characteristics. The questionnaire was distributed from September 2016 to June 2017 to a random sample of 640 PCPs by email via an internet-link leading to a web-based survey platform (Lime Survey). Only 18.4% of PCPs always recommend the HPV vaccine to 11–12 year old boys. PCPs with longer practice activity, working in solo practice, always recommended the HPV vaccine to 11–12 year old girls, and believed that the vaccine was effective for boys were more likely to always recommend the HPV vaccine. PCPs working in a Region where the vaccination was actively recommended and provided free of charge to 11–12 year old boys had higher odds of recommending vaccination. More than two thirds of PCPs (77.4%) always recommend the HPV vaccine to 11–12 year old girls. PCPs who believed that the vaccine was effective for girls and safe in both boys and girls, who always talk with patients of 11–18 years or their parents about HPV infection and vaccination, and who obtain vaccine information from scientific journals were more likely to always recommend the vaccine. PCPs should employ evidence-based educational strategies in order to achieve a better coverage and to reduce the morbidities and mortality of diseases associated with HPV.

[One decade of HPV vaccination in Germany]

As a worldwide very common sexually transmitted infection (STI), HPV causes millions of genital warts every year and is responsible for 5% of all cancers in men and women. With strong empirical evidence for both vaccine safety and efficacy, the HPV vaccines proved to protect against these HPV-related conditions over the last decade. But current HPV vaccination coverage is suboptimal in many countries. Even in Germany the absence of a school-based immunization program and the recommendation of a publicly funded girls-only HPV vaccination strategy are the main reasons for a female coverage rate under 40%, which does not achieve herd immunity for the boys. Therefore, the German immunization program urgently needs revision to fight an increasing number of young Germans missing out on the most important development in cancer prevention. Gender-neutral bundling of the HPV vaccine to other routinely recommended vaccines for preteens at one visit will have many advantages at the same time: Lowering the age of HPV vaccination to 9-12 years will improve the cost-effectiveness because a two-dose vaccination schedule is established on this score. Time-consuming and redundant explanations of the attending physician as well as parent's discussion on feeling stigmatized by the STI nature of HPV could be avoided in a combined vaccination setting. By expanding the HPV vaccination to boys, the resulting gender-neutral vaccination program can be cost-effective if all HPV-related diseases which can be prevented by vaccination are considered.

Paediatric Virology and its interaction between basic science and clinical practice (Review)

The 3rd Workshop on Paediatric Virology, which took place on October 7th, 2017 in Athens, Greece, highlighted the role of breast feeding in the prevention of viral infections during the first years of life. Moreover, it focused on the long-term outcomes of respiratory syncytial virus and rhinovirus infections in prematurely born infants and emphasised the necessity for the development of relevant preventative strategies. Other topics that were covered included the vaccination policy in relation to the migration crisis, mother‑to‑child transmission of hepatitis B and C viruses, vaccination against human papilloma viruses in boys and advances on intranasal live‑attenuated vaccination against influenza. Emphasis was also given to the role of probiotics in the management of viral infections in childhood, the potential association between viral infections and the pathogenesis of asthma, fetal and neonatal brain imaging and the paediatric intensive care of children with central nervous system viral infections. Moreover, an interesting overview of the viral causes of perinatal mortality in ancient Greece was given, where recent archaeological findings from the Athenian Agora's bone well were presented. Finally, different continuing medical educational options in Paediatric Virology were analysed and evaluated. The present review provides an update of the key topics discussed during the workshop.

Post-licensure safety monitoring of quadrivalent human papillomavirus vaccine in the Vaccine Adverse Event Reporting System (VAERS), 2009-2015

BACKGROUND

The Food and Drug Administration (FDA) approved quadrivalent human papillomavirus vaccine (4vHPV) for use in females and males aged 9-26 years, since 2006 and 2009 respectively. We characterized reports to the Vaccine Adverse Event Reporting System (VAERS), a US spontaneous reporting system, in females and males who received 4vHPV vaccination.

METHODS

We searched VAERS for US reports of adverse events (AEs) following 4vHPV from January 2009 through December 2015. Signs and symptoms were coded using Medical Dictionary for Regulatory Activities (MedDRA). We calculated reporting rates and conducted empirical Bayesian data mining to identify disproportional reports. Clinicians reviewed available information, including medical records, and reports of selected pre-specified conditions.

FINDINGS

VAERS received 19,760 reports following 4vHPV; 60.2% in females, 17.2% in males, and in 22.6% sex was missing. Overall, 94.2% of reports were non-serious; dizziness, syncope and injection site reactions were commonly reported in both males and females. Headache, fatigue and nausea were commonly reported serious AEs. More than 60 million 4vHPV doses were distributed during the study period. Crude AE reporting rates were 327 reports per million 4vHPV doses distributed for all reports, and 19 per million for serious reports. Among 29 verified reports of death, there was no pattern of clustering of deaths by diagnosis, co-morbidities, age, or interval from vaccination to death.

INTERPRETATION

No new or unexpected safety concerns or reporting patterns of 4vHPV with clinically important AEs were detected. Safety profile of 4vHPV is consistent with data from pre-licensure trials and postmarketing safety data.

Quadrivalent human papillomavirus vaccine and autoimmune adverse events: a case-control assessment of the vaccine adverse event reporting system (VAERS) database

Gardasil is a quadrivalent human papillomavirus (HPV4) vaccine that was approved for use by the US Food and Drug Administration in June 2006. HPV4 vaccine is routinely recommended for administration to women in the USA who are 11-12 years old by the Advisory Committee on Immunization Practices. Previous studies suggest HPV4 vaccine administration was associated with autoimmune diseases. As a consequence, an epidemiological assessment of the vaccine adverse event reporting system database was undertaken for adverse event reports associated with vaccines administered from 2006 to 2014 to 6-39 year-old recipients with a listed US residence and a specified female gender. Cases with the serious autoimmune adverse event (SAAE) outcomes of gastroenteritis (odds ratio (OR) 4.627, 95 % confidence interval (CI) 1.892-12.389), rheumatoid arthritis (OR 5.629, 95 % CI 2.809-12.039), thrombocytopenia (OR 2.178, 95 % CI 1.222-3.885), systemic lupus erythematosus (OR 7.626, 95 % CI 3.385-19.366), vasculitis (OR 3.420, 95 % CI 1.211-10.408), alopecia (OR 8.894, 95 % CI 6.255-12.914), CNS demyelinating conditions (OR 1.585, 95 % CI 1.129-2.213), ovarian damage (OR 14.961, 95 % CI 6.728-39.199), or irritable bowel syndrome (OR 10.021, 95 % CI 3.725-33.749) were significantly more likely than controls to have received HPV4 vaccine (median onset of initial symptoms ranged from 3 to 37 days post-HPV4 vaccination). Cases with the outcome of Guillain-Barre syndrome (OR 0.839, 95 % CI 0.601-1.145) were no more likely than controls to have received HPV4 vaccine. In addition, cases with the known HPV4-related outcome of syncope were significantly more likely than controls to have received HPV4 vaccine (OR 5.342, 95 % CI 4.942-5.777). Cases with the general health outcomes of infection (OR 0.765, 95 % CI 0.428-1.312), conjunctivitis (OR 1.010, 95 % CI 0.480-2.016), diarrhea (OR 0.927, 95 % CI 0.809-1.059), or pneumonia (OR 0.785, 95 % CI 0.481-1.246) were no more likely than controls to have received HPV4 vaccine. Confirmatory epidemiological studies in other databases should be undertaken and long-term clinical consequences of HPV-linked SAAEs should be examined.

Association between Human Papilloma Virus (HPV) vaccination and risk of Multiple Sclerosis: A systematic review

INTRODUCTION

The vaccination against Humanpapilloma Virus (HPV) is an effective strategy to prevent high-risk HPV infection and subsequent cervical carcinogenesis. Although the safety profile has been ascertained, the relation with the development of central nervous system (CNS) autoimmune disorders (AD) appears still controversial. Multiple Sclerosis (MS) is the most common cause of chronic neurological impairment in young people, typically striking females. The main purpose of this review was to assess the association between HPV vaccination and MS.

METHODS

The systematic review of the literature was carried out using 5 search engines: MEDLINE, SCOPUS, ISI WEB OF KNOWLEDGE, GOOGLE SCHOLAR and ClinicalTrial.gov. The web search was updated on January 2017. PRISMA checklist was adopted to address the content of the systematic review. The measures of outcome were reported as relative risk (RR) in cohort studies and odds ratio (OR) in case-control studies.

RESULTS

The systematic review identified 5 observational studies, 9 reviews, and 1 randomized clinical trials (RCT) pooled analysis. The RR of MS onset detected by cohort studies ranged from 1.54 (95%CI, 0.04-8.59) to 1.37 (95%CI, 0.74-3.20). Concerning case-control studies, the OR spanned from 0.3, (95%CI 0.1-0.9) to 1.60 (95%CI = 0.79-3.25) for the group exposed to HPV vaccination. No result was significant.

CONCLUSION

This review showed no significant association between HPV vaccination and MS. The low statistical power of the studies agreed with the low incidence of MS disease among general population. In order to overcome the shortcoming the research may be extended to the entire pattern of CNS ADs.

Vaccine-associated inflammatory diseases of the central nervous system: from signals to causation

PURPOSE OF REVIEW

As the most cost-effective intervention in preventive medicine and as a crucial element of any public health program, vaccination is used extensively with over 90% coverage in many countries. As approximately 5-8% of the population in developed countries suffer from an autoimmune disorder, people with an autoimmune disease are most likely to be exposed to some vaccines before or after the disease onset. In fact, a number of inflammatory disorders of the central nervous system have been associated with the administration of various vaccines. These adverse events, be they spurious associations or genuine reactions to the vaccine, may lead to difficulties in obtaining public trust in mass vaccination programs. There is, thus, an urgent need to understand whether vaccination triggers or enhances autoimmune responses.

RECENT FINDINGS

By reviewing vaccine-associated inflammatory diseases of the central nervous system, this study describes the current knowledge on whether the safety signal was coincidental, as in the case of multiple sclerosis with several vaccines, or truly reflected a causal link, as in narcolepsy with cataplexy following pandemic H1N1 influenza virus vaccination.

SUMMARY

The lessons learnt emphasize a central role of thorough, ideally prospective, epidemiological studies followed, if the signal is deemed plausible or real, by immunological investigations.

9-Valent human papillomavirus vaccine: a review of the clinical development program

INTRODUCTION

The 9-valent human papillomavirus (9vHPV) vaccine covers the same HPV types (6/11/16/18) as the quadrivalent HPV (qHPV) vaccine and 5 additional cancer-causing types (31/33/45/52/58). Epidemiological studies indicate that the 9vHPV vaccine could prevent approximately 90% of cervical cancers, 70-85% of high-grade cervical dysplasia (precancers), 85-95% of HPV-related vulvar, vaginal, and anal cancers, and 90% of genital warts. Areas covered: Study design features and key findings from the 9vHPV vaccine clinical development program are reviewed. In particular, 9vHPV vaccine efficacy was established in a Phase III study in young women age 16-26 years. Efficacy results in young women were extrapolated to pre- and young adolescent girls and boys and young men by immunological bridging (i.e., demonstration of non-inferior immunogenicity in these groups versus young women). Expert commentary: The development of the 9vHPV vaccine is the outcome of 20 years of continuous clinical research. Broad vaccination programs could help substantially decrease the incidence of HPV-related disease.

Motivos para recusa da vacina contra o Papilomavírus Humano entre adolescentes de 11 a 14 anos no município de Maringá-PR

Introdução: O Ministério da Saúde incluiu a vacina contra o Papilomavírus Humano (HPV) no calendário básico de imunizações em 2014 com a meta vacinar pelo menos 80% das adolescentes entre 11 e 13 anos de idade. Objetivos: Frente à baixa adesão à campanha nacional de vacinação contra o HPV no município de Maringá, PR, em 2014, o presente estudo teve como objetivos: 1) identificar o nível de conhecimento das adolescentes acerca do vírus e da vacina; e 2) descrever os motivos pelos quais elas não se vacinaram. Métodos: Trata-se de um estudo observacional transversal, do tipo inquérito domiciliar com delineamento descritivo, conduzido com 58 adolescentes que não tomaram a 1ª e/ou a 2ª dose da vacina dentro do prazo estipulado pela campanha vacinal de 2014. Para coleta de dados, foi aplicado questionário por meio de entrevistas face a face. Resultados: 86% das adolescentes já ouviram falar do vírus, 74% sabe que sua transmissão é sexual, 49% conhece sua relação com o câncer de colo de útero e 88% já ouviu falar da vacina. A maior parte das meninas entrevistadas não se vacinou por recusa por parte dos pais. Conclusão: Os resultados do presente estudo sugerem que o desconhecimento sobre a infecção pelo HPV e sobre a campanha de vacinação entre as entrevistadas e seus responsáveis, bem como o medo de efeitos colaterais da vacina, como apontado pela população do estudo, interferiram negativamente na tomada de decisão.

Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline

PURPOSE

To provide resource-stratified (four tiers), evidence-based recommendations on the primary prevention of cervical cancer globally.

METHODS

The American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group) for one round of formal ratings.

RESULTS

Existing sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%.

RECOMMENDATIONS

In all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus-related cancers and diseases. Basic settings: vaccinating boys is not recommended.

It is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.