Direct benefit of vaccinating boys along with girls against oncogenic human papillomavirus: bayesian evidence synthesis

Males' Access to Human Papillomavirus Vaccination in Resource-Limited Settings

The human papillomavirus is known to cause cervical and anogenital cancer and benign anogenital and cutaneous warts. Both males and females can contract the virus during sexual intercourse and skin-to-skin contact. Communities in low- and middle-income countries, including Africa, are particularly suffering from human papillomavirus-related diseases, mainly cervical cancer. Vaccination is the most economical and efficient prevention strategy to control human papillomavirus-related diseases. Undoubtedly, to control all types of human papillomavirus-related morbidity and mortality, the entire at-risk, sexually active population needs to be vaccinated regardless of their sex. However, the vaccination program, particularly in Africa, the world's most resource-limited region, is habitually limited to the female population, considering only the burden of cervical cancer. We think that it is impossible to fully mitigate the human papillomavirus infection by vaccinating only the female population, while males can carry and pass the virus. In addition, marginalizing males from this program seems to violate gender inequality and their sexual and reproductive health rights. Hence, we voice the need for global and local governments to consider and customize human papillomavirus vaccination programs for the male population. Also, it is better to consider the male population in different research studies regarding human papillomavirus-related malignant and benign conditions.

A comprehensive narrative review of challenges and facilitators in the implementation of various HPV vaccination program worldwide

INTRODUCTION

Cervical cancer has been considered as one of the most common cancers in women (15-44 years) globally, but the advent of the human papilloma virus (HPV) vaccine has raised the anticipation that eradication of cervical carcinoma might be achieved in the near future as several prophylactic cervical carcinoma vaccines have already been currently licensed in various countries. Countries should devise strategies, practices and policies to attain and sustain higher levels of HPV immunization coverage as still 68% countries have introduced HPV vaccine in their national immunization programs even after 17 years following the licensure of the first prophylactic HPV vaccine.

METHODOLOGY

A comprehensive literature analysis was conducted using various databases and search engines, to include the most relevant research articles and data available and critically discussed the operational gaps that need to be answered to achieve adequate coverage of HPV vaccination.

RESULTS

The present review highlights the existing HPV vaccination strategies, unmet needs and challenges needed to be addressed for proper implementation framework as well as the collaborations required to achieve decent vaccination coverage. Well-coordinated vaccination strategy with focus on adolescent girls and if possible, boys can lead to dramatic impact on disease reduction around the world.

Human papilloma virus vaccines: A comprehensive narrative review

Cervical cancer is one of the most common cancers in women aged 15-44 years in the world, with more than three-quarters of cases diagnosed at a locally advanced clinical stage with minor prospects of survival. Although only a small percentage of women with Human Papilloma Virus (HPV) develop cervical cancer and most of the HPV infections are cleared subsequently at primary stage itself, but seroconversion not always guarantees that the individual is immune to HPV. The advent of the cervical carcinoma vaccine has raised the expectations that eradication of cervical carcinoma might be possible in the near future as it exhibited remarkably high efficacy against the vaccine-specific types in naive women with no serious vaccine-related adverse events. Few prophylactic HPV vaccines are currently licensed in over 100 countries. It has also been suggested that vaccinating both men and women is more beneficial than vaccinating only females. Vaccination is a cost-effective strategy to reduce the incidence of cervical cancer and mortality compared to no vaccination based on the cost of cancer treatment. Well-coordinated vaccination strategy with focus on adolescent girls and if possible, boys can lead to dramatic impact on disease reduction around the world.

The effectiveness of HPV vaccination on the incidence of oropharyngeal cancers in men: a review

BACKGROUND

Human Papilloma Virus (HPV) contributes to the development of oropharyngeal cancer (OPC) and is currently the leading cause of OPC in the Western world. There have been limited studies examining the effect of HPV-vaccination on OPC incidence in men. This review aims to interrogate relationship linking HPV-vaccination and OPC in men, to potentially recommend pangender HPV-vaccination, to reduce the incidence of HPV associated OPC.

MAIN BODY

A review was carried out using Ovid Medline, Scopus and Embase databases, on 22nd October 2021 investigating the effect of HPV-vaccination on OPC prevalence in men and including studies with vaccination data pertaining to men in the past 5 years, while excluding those studies without appropriate oral HPV-positivity data and non-systematic reviews. Studies were evaluated as per the PRISMA guidelines and ranked using risk of bias tools including RoB-2, ROBINS-1 and the NIH quality assessment tools. 7 studies were included ranging from original research to systematic review articles. All studies were published in English from 2017 to 2021. Overall, these suggested that HPV-vaccination reduced levels of oral HPV positivity in men. This was thought to be indicative of a reduced risk of development of HPV-associated OPC. A limitation of this study was the inability to conduct meta-analysis due to the heterogeneity of included studies. We noted a significant impact on the reduction of HPV positivity post HPV-vaccination and a potential contribution to reducing the future incidence of OPC.

CONCLUSION

This review makes a strong case for pangender HPV-vaccination in combatting OPC in men.

Optimal vaccine allocation for the control of sexually transmitted infections

The burden of sexually transmitted infections (STIs) poses a challenge due to its large negative impact on sexual and reproductive health worldwide. Besides simple prevention measures and available treatment efforts, prophylactic vaccination is a powerful tool for controlling some viral STIs and their associated diseases. Here, we investigate how prophylactic vaccines are best distributed to prevent and control STIs. We consider sex-specific differences in susceptibility to infection, as well as disease severity outcomes. Different vaccination strategies are compared assuming distinct budget constraints that mimic a scarce vaccine stockpile. Vaccination strategies are obtained as solutions to an optimal control problem subject to a two-sex Kermack-McKendrick-type model, where the control variables are the daily vaccination rates for females and males. One important aspect of our approach relies on conceptualizing a limited but specific vaccine stockpile via an isoperimetric constraint. We solve the optimal control problem via Pontryagin's Maximum Principle and obtain a numerical approximation for the solution using a modified version of the forward-backward sweep method that handles the isoperimetric budget constraint in our formulation. The results suggest that for a limited vaccine supply ([Formula: see text]-[Formula: see text] vaccination coverage), one-sex vaccination, prioritizing females, appears to be more beneficial than the inclusion of both sexes into the vaccination program. Whereas, if the vaccine supply is relatively large (enough to reach at least [Formula: see text] coverage), vaccinating both sexes, with a slightly higher rate for females, is optimal and provides an effective and faster approach to reducing the prevalence of the infection.

HPV Vaccination Adherence in Working-Age Men: A Systematic Review and Meta-Analysis

BACKGROUND

Human papillomavirus (HPV) infection is the most common sexually transmitted viral infection in the world. HPV vaccination adherence rates in men are generally lower than in women. The aim of this systematic review and meta-analysis was to assess adherence to HPV vaccination in young working-age males (18-30 years old).

METHODS

A systematic review was performed using three databases: PubMed, Scopus, and Web of Science, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

After duplicate removal, the initial search resulted in 478 eligible papers. With the exclusion of 425 papers after screening the abstracts, full texts of 53 articles were reviewed. Subsequently, 45 were excluded. Among the eight studies included, four (50%) examined the vaccination adherence in young adults through data registered in nationwide insurance or private companies' databases, three (37.5%) in young adults in different settings through data collected from surveys and questionnaires, and one (12.5%) an HPV vaccination campaign in a family medicine residency practice.

CONCLUSION

Adherence to HPV vaccination in men of working age (18-30 years) does not appear to be adequate (pooled prevalence 11%). In order to achieve a higher level of compliance, it is important to place an emphasis on vaccination campaigns in schools as well as in the workplace, after consultation with and approval from local, regional, and federal public health agencies.

HPV and Cervical Cancer: A Review of Epidemiology and Screening Uptake in the UK

Cervical cancer is the fourth most common malignancy in females worldwide, and a leading cause of death in the United Kingdom (UK). The human papillomavirus (HPV) is the strongest risk factor for developing cervical intraepithelial neoplasia and cancer. Across the UK, the national HPV immunisation programme, introduced in 2008, has been successful in protecting against HPV-related infections. Furthermore, the National Health Service (NHS) implemented the cytology-based cervical cancer screening service to all females aged 25 to 64, which has observed a decline in cervical cancer incidence. In the UK, there has been an overall decline in age-appropriate coverage since April 2010. In 2019, the COVID-19 pandemic disrupted NHS cancer screening and immunisation programmes, leading to a 6.8% decreased uptake of cervical cancer screening from the previous year. Engagement with screening has also been associated with social deprivation. In England, incidence rates of cervical cancer were reported to be 65% higher in the most deprived areas compared to the least, with lifestyle factors such as cigarette consumption contributing to 21% of cervical cancer cases. In this article, we provide an update on the epidemiology of cervical cancer, and HPV pathogenesis and transmission, along with the current prevention programmes within the NHS.

Human papillomavirus in men

OBJECTIVE

To describe the clinical behavior of human papillomavirus in men.

MATERIALS AND METHODS

Current international literature was reviewed to describe the clinical behavior of human papillomavirus in men.

RESULTS

Internationally, the overall prevalence of HPV DNA is 50.8%, HPV considered high risk are 14 types. Prevalence of HPV DNA in invasive penile cancer ranges from 33.1% to 47%. HPV-16 has been the most frequent (68.3%), followed by HPV-6 (8.1%) and HPV-18 (6.9%). Positive HPV is described as an independent prognostic factor for cancer-specific survival.

CONCLUSION

It is not clear why HPV infection has a predilection in specific areas of the genital tract. However, it is important to note that there are factors that increase the risk of HPV infection.

Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies

INTRODUCTION

Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence.

METHODS

We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV.

RESULTS

We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%).

CONCLUSION

Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities.

The Annual costs of treating genital warts in the Public Healthcare Sector in Peru

OBJECTIVES

To estimate the cost of six different techniques used to treat Genital Warts and the annual average cost of treating a typical GW patient in Peru. To estimate the annual economic burden diagnosing and treating GW in the Peruvian public healthcare system.

METHODS

We developed a prevalence-based, cost-of-illness study from the provider's perspective, the healthcare facilities under the purview of Peruvian Ministry of Health. We used an activity-based costing approach. We conducted primary data collection in three regions in Peru and supplemented it with governmental data. Uncertainty of the costing estimates was assessed via Monte Carlo simulations. We estimated the average cost and associated confidence intervals for six treatment options - three topical and three surgical - and the overall cost per patient.

RESULTS

The average treatment cost per patient was 59.9USD (95 %CI 45.5, 77.6). Given a population of 18.4 million adults between 18 and 60 years of age and a GW prevalence of 2.28 %, the annual cost of treating GW was 25.1 million USD (uncertainty interval 16.9, 36.6).

CONCLUSIONS

This study provides the first quantification of the economic burden of treating genital warts in Peru and one of the few in Latin America. The costing data did not include other healthcare providers or out-of-pocket expenditures, and hence we present a conservative estimate of the COI of GW in Peru. Our findings bring attention to the financial burden of treating GW, a vaccine-preventable disease.

Factors affecting human papillomavirus (HPV) vaccination in men: A systematic literature review (Preprint)

Background

Despite the high risks associated with human papillomavirus (HPV), the HPV vaccination rate of men is far lower than women. Most previous review studies have focused on female vaccination and related affecting factors. However, previous studies have reported that the factors affecting HPV vaccination differ by gender.

Objective

The aim of this review was to identify the factors affecting HPV vaccine initiation in men through a systematic review approach.

Methods

A literature review was conducted across 3 central electronic databases for relevant articles. A total of 30 articles published between 2013 and 2019 met the inclusion criteria and were reviewed in this study.

Results

In total, 50 factors affecting HPV vaccination in men were identified, including 13 sociodemographic factors and social structure factors, 12 belief-related variables, 4 family factors, 4 community factors, 14 variables related to needs, and 3 environmental factors.

Conclusions

To increase HPV vaccination rates in men, strategies targeting young males and their families should consider frequent visits to or contact with health care providers so that health care professionals can provide recommendations for HPV vaccination.

Landscape assessment for gender neutral human papillomavirus vaccination recommendations including head and neck cancer burden data

INTRODUCTION

Head and neck cancers (HNC) accounted for over 450,000 deaths and 900,000 cases in 2018 worldwide. Of those, 38,000 cases were attributable to human papillomavirus (HPV). HNC is two to four times more prevalent in men than in women. The incidence of oropharyngeal cancers (OPC) and oral cavity cancers caused by HPV has increased in recent decades. Given the substantial burden of HPV-related HNC in males, this study aimed to assess whether and how national agencies included HPV-related HNC when evaluating HPV genderneutral vaccination (GNV) programs.

METHODS

A systematic literature review was conducted in MEDLINE® and EMBASE®, and on the websites of selected national agencies.

RESULTS

Searches identified a potential 205 records; seventeen were eligible for the review. Seventy percent of assessments were published by European countries and most were recent (2014-2019). Eleven (65%) reports considered OPC when discussing HNC, and a few included other anatomic sites. All reports that considered incidence data were in consensus that incidence of OPC was higher in men and showed that the mortality rates for HPV-related HNC were also higher in men. When looking at the economic impact, the incremental cost-effectiveness ratios in the assessments varied widely, as the inputs into the analyses were heterogeneous. However, several reports concluded GNV programs were likely to be cost-effective versus not vaccinating males.

CONCLUSION

The burden of HPV-related HNC in the general male population has been recognized by several Heatlth Technology Assessment (HTA) agencies and National Immunization Technical Advisory Groups (NITAGs) when evaluating HPV GNV programs. The assessments identified on GNV programs strongly indicate a cost-effective clinical benefit. Nevertheless, the epidemiological burden of HNC may have been underestimated in some countries due to limited data. Further research is crucial to obtain more robust data that will help address the information gap in epidemiological and economic burden of HPV-associated HNC in men.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of penile cancer

Squamous cell carcinoma of the penis (SCCP) is uncommon in some countries (including the U.S.), but is an important malignancy elsewhere. As a rare disease, progress has been slow compared to more common tumor types discussed in this anniversary issue and most often limited to single-center or retrospective datasets.  In this section we describe developments leading to the current standard approach with current research questions.

Vaccines for immunoprevention of cancer

The immunoprevention of cancer and cancer recurrence is an important area of concern for the scientific community and society as a whole. Researchers have been working for decades to develop vaccines with the potential to alleviate these health care and economic burdens. So far, vaccines have made more progress in preventing cancer than in eliminating already established cancer. In particular, vaccines targeting oncogenic viruses, such as the human papillomavirus and the hepatitis B virus, are exceptional examples of successful prevention of virus-associated cancers, such as cervical cancer and hepatocellular carcinoma. Cancer-preventive vaccines targeting nonviral antigens, such as tumor-associated antigens and neoantigens, are also being extensively tested. Here, we review the currently approved preventive cancer vaccines; discuss the challenges in this field by covering ongoing preclinical and clinical human trials in various cancers; and address various issues related to maximizing cancer vaccine benefit.

Developments and challenges in dermatology: an update from the Interactive Derma Academy (IDeA) 2019

The 2019 Interactive Derma Academy (IDeA) meeting was held in Lisbon, Portugal, 10-12 May, bringing together leading dermatology experts from across Europe, the Middle East and Asia. Over three days, the latest developments and challenges in relation to the pathophysiology, diagnosis, evaluation and management of dermatological conditions were presented, with a particular focus on acne, atopic dermatitis (AD) and actinic keratosis (AK). Interesting clinical case studies relating to these key topics were discussed with attendees to establish current evidence-based best practices. Presentations reviewed current treatments, potential therapeutic approaches and key considerations in the management of acne, AK and AD, and discussed the importance of the microbiome in these conditions, as well as the provision of patient education/support. It was highlighted that active treatment is not always required for AK, depending on patient preferences and clinical circumstances. In addition to presentations, two interactive workshops on the diagnosis and treatment of sexually transmitted infections/diseases (STIs/STDs) presenting to the dermatology clinic, and current and future dermocosmetics were conducted. The potential for misdiagnosis of STIs/STDs was discussed, with dermoscopy and/or reflectance confocal microscopy suggested as useful diagnostic techniques. In addition, botulinum toxin was introduced as a potential dermocosmetic, and the possibility of microbiome alteration in the treatment of dermatological conditions emphasized. Furthermore, several challenges in dermatology, including the use of lasers, the complexity of atopic dermatitis, wound care, use of biosimilars and application of non-invasive techniques in skin cancer diagnosis were reviewed. In this supplement, we provide an overview of the presentations and discussions from the fourth successful IDeA meeting, summarizing the key insights shared by dermatologists from across the globe.

The cost-effectiveness profile of sex-neutral HPV immunisation in European tender-based settings: a model-based assessment

BACKGROUND

In many European countries, human papillomavirus (HPV) vaccine uptake among girls has remained below target levels, supporting the scope for vaccination of boys. We aimed to investigate if sex-neutral HPV vaccination can be considered cost-effective compared with girls-only vaccination at uptake levels equal to those among girls and under tender-based vaccination costs achieved throughout Europe.

METHODS

We investigated the cost-effectiveness of sex-neutral HPV vaccination in European tender-based settings. We applied a Bayesian synthesis framework for health economic evaluation to 11 countries (Austria, Belgium, Croatia, Estonia, Italy, Latvia, the Netherlands, Poland, Slovenia, Spain, and Sweden), accommodating country-specific information on key epidemiological and economic parameters, and on current HPV vaccination programmes. We used projections from three independently developed HPV transmission models to tailor region-specific herd effects. The main outcome measures in the comparison of sex-neutral with girls-only vaccination were cancer cases prevented and incremental cost-effectiveness ratios (ICERs), defined as the cost in international dollars (I$) per life-year gained.

FINDINGS

The total number of cancer cases to be prevented by vaccinating girls at currently realised vaccine uptake varied from 318 (95% CI 197-405) per cohort of 200 000 preadolescents (100 000 girls plus 100 000 boys) in Croatia (under 20% uptake of the 9-valent vaccine) to 1904 (1741-2101) in Estonia (under 70% uptake of the 9-valent vaccine). Vaccinating boys at equal coverage increased these respective numbers by 168 (95% CI 121-213) in Croatia and 467 (391-587) in Estonia. Sex-neutral vaccination was likely to be cost-effective, with ICERs of sex-neutral compared with girls-only vaccination varying from I$4300 per life-year gained in Latvia (95% credibility interval 3450-5160; 40% uptake) to I$25 720 per life-year gained in Spain (21 380-30 330; 80% uptake). At uniform 80% uptake, a favourable cost-effectiveness profile was retained for most of the countries investigated (Austria, Belgium, Italy, Latvia, the Netherlands, Slovenia, Spain, and Sweden).

INTERPRETATION

Sex-neutral HPV vaccination is economically attractive in European tender-based settings. However, tendering mechanisms need to ensure that vaccination of boys will remain cost-effective at high vaccine uptake rates.

FUNDING

European Commission 7th Framework Programme and WHO.

Human Papillomavirus Vaccines: An Updated Review

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

Comparison of different human papillomavirus (HPV) vaccine types and dose schedules for prevention of HPV-related disease in females and males

BACKGROUND

Uptake of human papillomavirus (HPV) vaccine remains low in many countries, although the bivalent and quadrivalent HPV vaccines given as a three-dose schedule are effective in the prevention of precancerous lesions of the cervix in women. Simpler immunisation schedules, such as those with fewer doses, might reduce barriers to vaccination, as may programmes that include males.

OBJECTIVES

To evaluate the efficacy, immunogenicity, and harms of different dose schedules and different types of HPV vaccines in females and males.

SEARCH METHODS

We conducted electronic searches on 27 September 2018 in Ovid MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library), and Ovid Embase. We also searched the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov (both 27 September 2018), vaccine manufacturer websites, and checked reference lists from an index of HPV studies and other relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with no language restriction. We considered studies if they enrolled HIV-negative males or females aged 9 to 26 years, or HIV-positive males or females of any age.

DATA COLLECTION AND ANALYSIS

We used methods recommended by Cochrane. We use the term 'control' to refer to comparator products containing an adjuvant or active vaccine and 'placebo' to refer to products that contain no adjuvant or active vaccine. Most primary outcomes in this review were clinical outcomes. However, for comparisons comparing dose schedules, the included RCTs were designed to measure antibody responses (i.e. immunogenicity) as the primary outcome, rather than clinical outcomes, since it is unethical to collect cervical samples from girls under 16 years of age. We analysed immunogenicity outcomes (i.e. geometric mean titres) with ratios of means, clinical outcomes (e.g. cancer and intraepithelial neoplasia) with risk ratios or rate ratios and, for serious adverse events and deaths, we calculated odds ratios. We rated the certainty of evidence with GRADE.

MAIN RESULTS

We included 20 RCTs with 31,940 participants. The length of follow-up in the included studies ranged from seven months to five years. Two doses versus three doses of HPV vaccine in 9- to 15-year-old females Antibody responses after two-dose and three-dose HPV vaccine schedules were similar after up to five years of follow-up (4 RCTs, moderate- to high-certainty evidence). No RCTs collected clinical outcome data. Evidence about serious adverse events in studies comparing dose schedules was of very low-certainty owing to imprecision and indirectness (three doses 35/1159; two doses 36/1158; 4 RCTs). One death was reported in the three-dose group (1/898) and none in the two-dose group (0/899) (low-certainty evidence). Interval between doses of HPV vaccine in 9- to 14-year-old females and males Antibody responses were stronger with a longer interval (6 or 12 months) between the first two doses of HPV vaccine than a shorter interval (2 or 6 months) at up to three years of follow-up (4 RCTs, moderate- to high-certainty evidence). No RCTs collected data about clinical outcomes. Evidence about serious adverse events in studies comparing intervals was of very low-certainty, owing to imprecision and indirectness. No deaths were reported in any of the studies (0/1898, 3 RCTs, low-certainty evidence). HPV vaccination of 10- to 26-year-old males In one RCT there was moderate-certainty evidence that quadrivalent HPV vaccine, compared with control, reduced the incidence of external genital lesions (control 36 per 3081 person-years; quadrivalent 6 per 3173 person-years; rate ratio 0.16, 95% CI 0.07 to 0.38; 6254 person-years) and anogenital warts (control 28 per 2814 person-years; quadrivalent 3 per 2831 person-years; rate ratio 0.11, 95% CI 0.03 to 0.38; 5645 person-years). The quadrivalent vaccine resulted in more injection-site adverse events, such as pain or redness, than control (537 versus 601 per 1000; risk ratio (RR) 1.12, 95% CI 1.06 to 1.18, 3895 participants, high-certainty evidence). There was very low-certainty evidence from two RCTs about serious adverse events with quadrivalent vaccine (control 12/2588; quadrivalent 8/2574), and about deaths (control 11/2591; quadrivalent 3/2582), owing to imprecision and indirectness. Nonavalent versus quadrivalent vaccine in 9- to 26-year-old females and males Three RCTs were included; one in females aged 9- to 15-years (n = 600), one in females aged 16- to 26-years (n = 14,215), and one in males aged 16- to 26-years (n = 500). The RCT in 16- to 26-year-old females reported clinical outcomes. There was little to no difference in the incidence of the combined outcome of high-grade cervical epithelial neoplasia, adenocarcinoma in situ, or cervical cancer between the HPV vaccines (quadrivalent 325/6882, nonavalent 326/6871; OR 1.00, 95% CI 0.85 to 1.16; 13,753 participants; high-certainty evidence). The other two RCTs did not collect data about clinical outcomes. There were slightly more local adverse events with the nonavalent vaccine (905 per 1000) than the quadrivalent vaccine (846 per 1000) (RR 1.07, 95% CI 1.05 to 1.08; 3 RCTs, 15,863 participants; high-certainty evidence). Comparative evidence about serious adverse events in the three RCTs (nonavalent 243/8234, quadrivalent 192/7629; OR 0.60, 95% CI 0.14 to 2.61) was of low certainty, owing to imprecision and indirectness. HPV vaccination for people living with HIV Seven RCTs reported on HPV vaccines in people with HIV, with two small trials that collected data about clinical outcomes. Antibody responses were higher following vaccination with either bivalent or quadrivalent HPV vaccine than with control, and these responses could be demonstrated to have been maintained for up to 24 months in children living with HIV (low-certainty evidence). The evidence about clinical outcomes and harms for HPV vaccines in people with HIV is very uncertain (low- to very low-certainty evidence), owing to imprecision and indirectness.

AUTHORS' CONCLUSIONS

The immunogenicity of two-dose and three-dose HPV vaccine schedules, measured using antibody responses in young females, is comparable. The quadrivalent vaccine probably reduces external genital lesions and anogenital warts in males compared with control. The nonavalent and quadrivalent vaccines offer similar protection against a combined outcome of cervical, vaginal, and vulval precancer lesions or cancer. In people living with HIV, both the bivalent and quadrivalent HPV vaccines result in high antibody responses. For all comparisons of alternative HPV vaccine schedules, the certainty of the body of evidence about serious adverse events reported during the study periods was low or very low, either because the number of events was low, or the evidence was indirect, or both. Post-marketing surveillance is needed to continue monitoring harms that might be associated with HPV vaccines in the population, and this evidence will be incorporated in future updates of this review. Long-term observational studies are needed to determine the effectiveness of reduced-dose schedules against HPV-related cancer endpoints, and whether adopting these schedules improves vaccine coverage rates.

A comprehensive review of otorhinolaryngological global health concerns

Background

ENT disease prevalence, risk factors and treatment vary between developed and developing countries. Health provision, particularly disease prevention strategies and surgery, in developing countries is poor, manifesting as a high frequency of common and preventable diseases. Healthcare systems in developing countries are unsustainable, and the technological advances that provide ENT surgery with novel diagnostic and treatment opportunities are inaccessible.

Conclusion

A multifaceted approach is essential to improve the care of patients with ENT diseases in developing countries. Public health efforts must focus on educating the local community, reducing high-risk behaviours and decreasing the frequency of preventable diseases. Governments must be pressured to prioritise the funding of long-term, sustainable efforts with effective disease prevention strategies. Providing local healthcare professionals with high-quality ENT training so that self-sustaining and low-cost care can be delivered, mainly in a primary care setting, is key.

Prevalence and incidence of anal human papillomavirus infection in Mexican men: Need for universal prevention policies

OBJECTIVE

Describe the natural history of anal HPV among men.

MATERIALS AND METHODS

Prospective study among men 18-70 years (n=665), from Cuernavaca, Mexico who completed questionnaires and provided specimens (HPV genotyped) at enrollment and 1+ follow-up visit. HPV prevalence and incidence were estimated. Prevalence ratios were calculated with Poisson regression using robust variance estimation. Person-time for incident HPV infection was estimated using number of events modeled as Poisson variable for total person-months.

RESULTS

Anal infection prevalence: any HPV type=15%, high-risk=8.4%, HPV16=1.4%, tetravalent vaccine types (4vHPV)=4.4%, nonavalent vaccine types (9vHPV)=6.3%. Factors associated with prevalence: 50+ lifetime female sex partners (adjusted prevalence ratio, a PR=3.25, 95% CI:1.12- 9.47), 10+ lifetime male sex partners (aPR=3.06, 95%CI:1.4- 6.68), and 1+ recent male anal sex partners (aPR=2.28, 95%CI:1.15-4.5). Anal incidence rate: high-risk HPV=7.8/1000 person-months (95%CI:6.0-10.1), HPV16=1.8/1000 personmonths (95%CI:1.1-2.9),4vHPV=3.4/1000 person-months (95%CI:2.3-4.9) and 9vHPV=5.5/1000 person-months (95%CI:4.1-7.5).

CONCLUSIONS

Implementation of universal HPV vaccination programs, including men, is a public health priority.

Potential effectiveness of prophylactic HPV immunization for men who have sex with men in the Netherlands: A multi-model approach

BACKGROUND

Men who have sex with men (MSM) are at high risk for anal cancer, primarily related to human papillomavirus genotype 16 (HPV16) infections. At 8.5 per 100,000 per year, the incidence rate of anal cancer among MSM is similar to that of cervical cancer among adult women in the Netherlands. However, MSM are not included in most HPV vaccination programs. We explored the potential effectiveness of prophylactic immunization in reducing anogenital HPV16 transmission among MSM in the Netherlands.

METHODS AND FINDINGS

We developed a range of mathematical models for penile-anal HPV16 transmission, varying in sexual contact structure and natural history of infection, to provide robust and plausible predictions about the effectiveness of targeted vaccination. Models were informed by an observational cohort study among MSM in Amsterdam, 2010-2013. Parameters on sexual behavior and HPV16 infections were obtained by fitting the models to data from 461 HIV-negative study participants, considered representative of the local MSM population. We assumed 85% efficacy of vaccination against future HPV16 infections as reported for HIV-negative MSM, and age-specific uptake rates similar to those for hepatitis B vaccination among MSM in the Netherlands. Targeted vaccination was contrasted with vaccination of 12-year-old boys at 40% uptake in base-case scenarios, and we also considered the effectiveness of a combined strategy. Offering vaccine to MSM without age restrictions resulted in a model-averaged 27.3% reduction (90% prediction interval [PI] 11.9%-37.5%) in prevalence of anal HPV16 infections, assuming similar uptake among MSM as achieved for hepatitis B vaccination. The predicted reduction improved to 46.1% (90% PI 21.8%-62.4%) if uptake rates among MSM were doubled. The reductions in HPV16 infection prevalence were mostly achieved within 30 years of a targeted immunization campaign, during which they exceeded those induced by vaccinating 40% of preadolescent boys, if started simultaneously. The reduction in anal HPV16 prevalence amounted to 74.8% (90% PI 59.8%-93.0%) under a combined vaccination strategy. HPV16 prevalence reductions mostly exceeded vaccine coverage projections among MSM, illustrating the efficiency of prophylactic immunization even when the HPV vaccine is given after sexual debut. Mode of protection was identified as the key limitation to potential effectiveness of targeted vaccination, as the projected reductions were strongly reduced if we assumed no protection against future infections in recipients with prevalent infection or infection-derived immunity at the time of immunization. Unverified limitations of our study include the sparsity of data to inform the models, the omission of oral sex in transmission to the penile or anal site, and the restriction that our modeling results apply primarily to HIV-negative MSM.

CONCLUSIONS

Our findings suggest that targeted vaccination may generate considerable reductions in anogenital HPV16 infections among MSM, and has the potential to accelerate anal cancer prevention, especially when combined with sex-neutral vaccination in preadolescence.

Knowledge and Behavior of University Students toward Human Papillomavirus and Vaccination

Objectives:

Human papillomavirus (HPV) causes cervical cancer. This study aimed to determine the knowledge and attitude of university students toward HPV infection and vaccine prevention in Turkey.

Methods:

A total of 1563 female and male university students participated in the study. The study design was descriptive and cross-sectional. The study included students enrolled in the departments of faculties and vocational schools.

Results:

In total, 16.8% of students stated that they had heard of HPV. There was a statistically significant relationship between the mean awareness of HPV and different variables, such as age, gender, marital status, family history of cancer, and conversation about sexual matters (P < 0.01). As the age of the students increased, the chance of hearing about HPV also increased. Of all the students, 1.5% took HPV vaccination. Furthermore, 87.7% of the female students stated that they had heard of cervical cancer.

Conclusions:

The depth of knowledge among Turkish university students toward cervical cancer, HPV infection, and vaccination was inadequate. It is important to provide educational and counseling services by nurses to make university students aware of HPV infection and vaccination.

Who Will Benefit From Expanding HPV Vaccination Programs to Boys?

Indications for human papillomavirus vaccination programs are expanding to boys. However, the rationale behind their inclusion is often not clear. Using a Bayesian synthesis framework and assuming equal vaccine coverage in both sexes, we assessed how the incremental number of cancer cases prevented and life-years gained from boys’ vaccination are distributed between women, heterosexual men, and men who have sex with men (MSM). Below 60% coverage, at least 50% of the gains from boys’ vaccination was attributable to cervical cancer prevention, whereas at 80% coverage, 50% of the gains was attributable to women, 15% to heterosexual men, and 35% to MSM. Above 90% coverage, 85–100% of the gains from boys’ vaccination was attributable to anal and oropharyngeal cancer prevention, mainly in MSM. Sex-neutral vaccination can be advocated on grounds of bolstering herd protection to women and directly protecting men, particularly MSM, with the clinical significance of either argument determined by the coverage.

Assessment of herd effects among women and heterosexual men after girls-only HPV16/18 vaccination in the Netherlands: A repeated cross-sectional study

Data on the impact of human papillomavirus (HPV) vaccination on the population HPV prevalence are largely obtained from women. We assessed the impact of the girls‐only HPV16/18 vaccination program in the Netherlands that started in 2009, on trends in HPV prevalence among women and heterosexual men, using data from the PASSYON study. In this cross‐sectional study, the HPV prevalence among 16‐ to 24‐year‐old visitors to sexually transmitted infection clinics was assessed in 2009, 2011, 2013, and 2015. We compared the genital postvaccination HPV prevalence with the prevaccination prevalence (2009) using Poisson GEE models. In total, we included 4,996 women and 1,901 heterosexual men. The percentage of women who reported to be vaccinated increased from 2.3% in 2009 to 37% in 2015. Among all women, the HPV16/18 prevalence decreased from 23% prevaccination to 15% in 2015 (adjusted prevalence ratio [aPR] 0.62, p_trend < 0.01). Among heterosexual men, the HPV16/18 prevalence decreased from 17% prevaccination to 11% in 2015 (aPR 0.52, p_trend < 0.01). Of the heterosexual men with a steady partner, HPV16/18 prevalence was lower among those whose steady partner had been vaccine‐eligible in the national immunization program (aPR 0.13). Among unvaccinated women, the HPV16/18 prevalence in 2015 was not different from prevaccination. The decreasing HPV16/18 prevalence among heterosexual men and the reduced HPV16/18 prevalence among heterosexual men with a vaccine‐eligible steady partner strongly suggests herd protection from girls‐only vaccination. Absence of notable herd effects among unvaccinated women 6 years postvaccination may be due to the moderate vaccine uptake among girls in the Netherlands.

What's new?

Human papillomavirus (HPV) is a sexually transmitted virus that plays a causal role in the development of anogenital and oropharyngeal cancers in both men and women. The population‐level impact of HPV vaccination programs on the HPV prevalence has however mainly been studied in women. This study shows decreasing trends in the HPV16 and HPV18 prevalence among both women and heterosexual men after the introduction of a girls‐only HPV16/18 vaccination program in the Netherlands. The findings provide compelling evidence for herd protection in men. Because HPV16/18 are the most oncogenic types, HPV‐related cancers are expected to decline in both sexes after girls‐only HPV vaccination.

Prevention of HPV-Related Oral Cancer by Dentists: Assessing the Opinion of Dutch Dental Students

The aim of this study is to assess dental students' opinions of the dentists' role in primary prevention of human papillomavirus (HPV)-related oral cancer using a cross-sectional web-based survey. A questionnaire, containing questions about knowledge of HPV and oral cancer, confidence in head and neck examination and role of the dentist in preventing HPV-related oral cancer, was sent to all students of the Academic Centre of Dentistry Amsterdam (n = 912). One hundred and twenty-six (n = 126) students completed the questionnaire. Significantly, more master students (75%) than bachelor students (54.3%) were aware that HPV is a causative factor for oral cancer. Master students had more knowledge of HPV than bachelor students, but knowledge about HPV vaccination was irrespective of the study phase. The majority of dental students agreed that it is important to discuss HPV vaccination with patients. Eighty-nine percent of the students think that more education about symptoms of oral cancer will increase screening for oral cancer. Development of a protocol for screening in dental practices was considered even more important. According to dental students, dentists should discuss HPV as a risk factor for oral cancer with patients. Future dentists are willing to be involved in both primary and secondary prevention of HPV-related oral cancer. Therefore, screening for oral cancer and education about HPV vaccination should be integral elements of the dental curriculum.

Ten years of HPV vaccination in the Netherlands: current evidence and future challenges in HPV-related disease prevention

INTRODUCTION

Girls-only vaccination against human papillomavirus (HPV) type 16 and 18 was implemented in the Netherlands in 2009. Despite the evidence of the efficacy against precancerous lesions, cross-protection induced by the vaccine and a greater potential for cancer prevention than cervical cancer only, vaccine coverage in the girls-only program has remained below target levels.

AREAS COVERED

In this paper, we review the literature from the Netherlands on the effectiveness and cost-effectiveness of HPV vaccination since vaccine introduction, give an account of the coverage, safety and effectiveness of HPV vaccination as has been reported in the Dutch surveillance program and discuss challenges of the current HPV vaccination program.

EXPERT COMMENTARY

Girls-only HPV vaccination may confer a substantial health gain in HPV-related disease prevention. However, vaccine coverage declined remarkably recently possibly related to safety concerns, limiting the benefits from girls' vaccination and increasing the potential additional benefit of sex-neutral HPV vaccination. Considering the emergence of novel vaccination and screening options and the change from cytology- to HPV-based screening in 2017, further research is required to inform decisions on the optimization of an integrated vaccination and screening program.

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.

Cost Effectiveness of Human Papillomavirus Vaccination for Men Who have Sex with Men; Reviewing the Available Evidence

BACKGROUND

Men who have sex with men require special attention for human papillomavirus vaccination given elevated infection risks and the development of, in particular, anal cancer.

OBJECTIVE

Our purpose was to review the cost effectiveness of human papillomavirus vaccination for both currently vaccine-eligible and non-eligible individuals, particularly the men-who-have-sex-with-men population, and synthesize the available evidence.

METHODS

We systematically searched for published articles in two main databases (PubMed and EMBASE). Screening and data extraction were performed by two independent reviewers. The risk of bias was assessed using a validated instrument (Bias in Economic Evaluation, ECOBIAS). Methodological aspects, study results, and sensitivity analyses were extracted and synthesized to generate a consistent overview of the cost effectiveness of human papillomavirus vaccination in the men-who-have-sex-with-men population.

RESULTS

From 770 identified articles, four met the inclusion criteria. Across the studies, human papillomavirus vaccination showed incremental cost-effectiveness ratios ranging from dominant to US$96,146 and US$14,000 to US$18,200 for tertiary prevention and primary prevention, respectively. The incremental cost-effectiveness ratio seemed most sensitive to vaccine efficacy, vaccine costs, and the incidence of anal cancer in the selected target populations.

CONCLUSION

This review presents the human papillomavirus vaccine, both as a primary and adjuvant (tertiary) vaccination, as a potentially cost-effective strategy for preventing mainly-but not limited to only-anal cancer in men-who-have-sex-with-men populations.

HPV vaccination in male physicians: A survey of gynecologists and otolaryngology surgeons' attitudes towards vaccination in themselves and their patients

OBJECTIVE

Attitudes and barriers towards HPV vaccination were explored in a population of male surgeons in Gynecology and Otolaryngology in Ontario, Canada.

MATERIALS/METHODS

An internet-based survey was distributed to male residents and physicians affiliated with the departments of Obstetrics and Gynecology, and Otolaryngology at six Ontario universities. The survey consisted of 16 questions (3 demographic, 3 workplace exposure, 6 regarding personal vaccination, and 3 regarding patient vaccination). Subgroup analyses examined differences between residents versus staff physicians and gynecologists versus otolaryngologists.

RESULTS

Most respondents (51/63, 81.0%) had not been vaccinated against HPV, yet would consider vaccination in the future (41/51, 80.4%). Significantly more residents would consider vaccination compared to staff physicians (p = .03). Personal protection from benign HPV disease was the most common motivating factor (25/59, 42.4%) among participants. A notable barrier to vaccination was "age over recommendations" (9/44, 20.4%). Most participants would recommend the HPV vaccine to both male patients (49/62, 79.0%) and male partners of female patients (47/62, 75.8%).

CONCLUSIONS

This study demonstrates male gynecologists and otolaryngologists had largely favorable attitudes towards HPV vaccination though few had received vaccination. These findings may be used to increase HPV vaccine uptake among male health care professionals and their patients.

Population-Level Herd Protection of Males From a Female Human Papillomavirus Vaccination Program: Evidence from Australian Serosurveillance

Background

Australia instituted funded female human papillomavirus (HPV) immunization in 2007, followed by a targeted male vaccination program in 2013. To date, Australia is one of only several countries with a funded male HPV immunization program. In 2012-2013, we conducted a survey of HPV seroprevalence in males to assess whether or not a herd impact of female vaccination could be observed.

Methods

We conducted a cross-sectional study of de-identified residual diagnostic test serum samples from males aged 15-39 years from laboratories in 3 Australian states and calculated the proportion seropositive to HPV types 6, 11, 16, and 18. We compared type-specific results by age group against those from a baseline 2005 Australian HPV serosurvey.

Results

There were decreases in proportion seropositive for every HPV type across all age groups, many statistically significant. The largest decrease was observed for HPV-11, with decreases of 8- and 9-fold for ages 20-29 and 30-39 years, respectively. Despite substantial reductions in seroprevalence, at least 9% of males were seropositive for at least 1 of the 4 HPV types.

Conclusions

This is the first serosurvey confirming broad population-level impact in males from female HPV vaccination. Our research may assist policy makers considering implementing HPV vaccination programs.

Impact of gender-neutral or girls-only vaccination against human papillomavirus-Results of a community-randomized clinical trial (I)

Human papillomavirus (HPV) vaccine is efficacious but the real-life effectiveness of gender-neutral and girls-only vaccination strategies is unknown. We report a community-randomized trial on the protective effectiveness [(PE) = vaccine efficacy (VE) + herd effect (HE)] of the two strategies among females in virtually HPV vaccination naïve population. We randomized 33 Finnish communities into Arm A) gender-neutral vaccination with AS04-adjuvanted HPV16/18 vaccine (11 communities), Arm B) HPV vaccination of girls and hepatitis B-virus (HBV) vaccination of boys (11 communities) or Arm C) gender-neutral HBV vaccination (11 communities). All resident 39,420 females and 40,852 males born 1992-95 were invited in 2007-09. Virtually all (99%) 12- to 15-year-old participating males (11,662) and females (20,513) received three doses resulting in uniform 20-30% male and 50% female vaccination coverage by birth cohort. Four years later (2010-14) 11,396 cervicovaginal samples obtained from 18.5 year-old women were tested for HPV DNA, and prevalence of cervical HPV infections by trial arm and birth cohort was the main outcome measure. VEs against HPV16/18 varied between 89.2% and 95.2% across birth cohorts in arms A and B. The VEs against non-vaccine types consistent with cross-protection were highest in those born 1994-95 for HPV45 (VEA 82.8%; VEB 86.1%) and for HPV31 (VEA 77.6%, VEB 84.6%). The HEs in the non HPV-vaccinated were statistically significant in those born 1994-95 for HPV18 (HEA 51.0%; 95% CI 8.3-73.8, HEB 47.2%; 6.5-70.2) and for HPV31/33 in arm A (HEA 53.7%; 22.1-72.5). For HPV16 and 45 no significant herd effects were detected. PE estimates against HPV16/18 were similar by both strategies (PEA 58.1%; 45.1-69.4; PEB 55.7%; 42.9-66.6). PE estimates against HPV31/33 were higher by the gender-neutral vaccination (PEA 60.5%; 43.6-73.4; PEB 44.5%; 24.9-60.6). In conclusion, while gender-neutral strategy enhanced the effectiveness of HPV vaccination for cross-protected HPV types with low to moderate coverage, high coverage in males appears to be key to providing a substantial public health benefit also to unvaccinated females. Trial registration www.clinicaltrials.gov.com NCT000534638.

What Drives Health Professionals to Tweet About #HPVvaccine? Identifying Strategies for Effective Communication

Introduction

We conducted this study to quantify how health professionals use Twitter to communicate about the human papillomavirus (HPV) vaccine.

Methods

We collected 193,379 tweets from August 2014 through July 2015 that contained key words related to HPV vaccine. We classified all tweets on the basis of user, audience, sentiment, content, and vaccine characteristic to examine 3 groups of tweets: 1) those sent by health professionals, 2) those intended for parents, and 3) those sent by health professionals and intended for parents. For each group, we identified the 7-day period in our sample with the most number of tweets (spikes) to report content.

Results

Of the 193,379 tweets, 20,451 tweets were from health professionals; 16,867 tweets were intended for parents; and 1,233 tweets overlapped both groups. The content of each spike varied per group. The largest spike in tweets from health professionals (n = 851) focused on communicating recently published scientific evidence. Most tweets were positive and were about resources and boys. The largest spike in tweets intended for parents (n = 1,043) centered on a national awareness day and were about resources, personal experiences, boys, and girls. The largest spike in tweets from health professionals to parents (n = 89) was in January and centered on an event hosted on Twitter that focused on cervical cancer awareness month.

Conclusion

Understanding drivers of tweet spikes may help shape future communication and outreach. As more parents use social media to obtain health information, health professionals and organizations can leverage awareness events and personalize messages to maximize potential reach and parent engagement.

Strengthening the case for gender-neutral and the nonavalent HPV vaccine

PURPOSE

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020.

METHODS

PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)].

RESULTS

There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a "herd effect" for females by preventing the propagation of the virus.

CONCLUSION

Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

Impact and Cost-effectiveness of Selective Human Papillomavirus Vaccination of Men Who Have Sex With Men

Background.

Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination.

Methods.

We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16–25, 16–30, 16–35, and 16–40 years.

Results.

Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective.

Conclusions.

Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.

Modeling the consequences of regional heterogeneity in human papillomavirus (HPV) vaccination uptake on transmission in Switzerland

BACKGROUND

Completed human papillomavirus (HPV) vaccination by age 16 years among women in Switzerland ranges from 17 to 75% across 26 cantons. The consequences of regional heterogeneity in vaccination coverage on transmission and prevalence of HPV-16 are unclear.

METHODS

We developed a deterministic, population-based model that describes HPV-16 transmission among young adults within and between the 26 cantons of Switzerland. We parameterized the model using sexual behavior data from Switzerland and data from the Swiss National Vaccination Coverage Survey. First, we investigated the general consequences of heterogeneity in vaccination uptake between two sub-populations. We then compared the predicted prevalence of HPV-16 resulting from heterogeneous HPV vaccination uptake in all of Switzerland with homogeneous vaccination at an uptake that is identical to the national average (52%).

RESULTS

In our baseline scenario, HPV-16 prevalence in women is 3.34% when vaccination is introduced and begins to diverge across cantons, ranging from 0.19 to 1.20% after 15 years of vaccination. After the same time period, overall prevalence of HPV-16 in Switzerland is only marginally higher (0.63%) with heterogeneous vaccination uptake than with homogeneous uptake (0.59%). Assuming inter-cantonal sexual mixing, cantons with low vaccination uptake benefit from a reduction in prevalence at the expense of cantons with high vaccination uptake.

CONCLUSIONS

Regional variations in uptake diminish the overall effect of vaccination on HPV-16 prevalence in Switzerland, but the effect size is small. Cantonal efforts towards HPV-prevalence reduction by increasing vaccination uptake are impaired by cantons with low vaccination uptake. Although the expected impact on national prevalence would be relatively small, harmonization of cantonal vaccination programs would reduce inter-cantonal differences in HPV-16 prevalence.

Random Network Models to Predict the Long-Term Impact of HPV Vaccination on Genital Warts

The Human papillomaviruses (HPV) vaccine induces a herd immunity effect in genital warts when a large number of the population is vaccinated. This aspect should be taken into account when devising new vaccine strategies, like vaccination at older ages or male vaccination. Therefore, it is important to develop mathematical models with good predictive capacities. We devised a sexual contact network that was calibrated to simulate the Spanish epidemiology of different HPV genotypes. Through this model, we simulated the scenario that occurred in Australia in 2007, where 12-13 year-old girls were vaccinated with a three-dose schedule of a vaccine containing genotypes 6 and 11, which protect against genital warts, and also a catch-up program in women up to 26 years of age. Vaccine coverage were 73 % in girls with three doses and with coverage rates decreasing with age until 52 % for 20-26 year-olds. A fast 59 % reduction in the genital warts diagnoses occurred in the model in the first years after the start of the program, similar to what was described in the literature.

Investigating Canadian parents' HPV vaccine knowledge, attitudes and behaviour: a study protocol for a longitudinal national online survey

INTRODUCTION

Human papillomavirus (HPV), a sexually transmitted infection, can cause anogenital warts and a number of cancers. To prevent morbidity and mortality, three vaccines have been licensed and are recommended by Canada's National Advisory Committee on Immunisation (for girls since 2007 and boys since 2012). Nevertheless, HPV vaccine coverage in Canada remains suboptimal in many regions. This study will be the first to concurrently examine the correlates of HPV vaccine decision-making in parents of school-aged girls and boys and evaluate changes in parental knowledge, attitudes and behaviours over time.

METHODS AND ANALYSIS

Using a national, online survey utilising theoretically driven constructs and validated measures, this study will identify HPV vaccine coverage rates and correlates of vaccine decision-making in Canada at two time points (August-September 2016 and June-July 2017). 4606 participants will be recruited to participate in an online survey through a market research and polling firm using email invitations. Data cleaning methods will identify inattentive or unmotivated participants.

ETHICS AND DISSEMINATION

The study received research ethics board approval from the Research Review Office, Integrated Health and Social Services University Network for West-Central Montreal (CODIM-FLP-16-219). The study will adopt a multimodal approach to disseminate the study's findings to researchers, clinicians, cancer and immunisation organisations and the public in Canada and internationally.

Health and Economic Impact of a Tender-Based, Sex-Neutral Human Papillomavirus 16/18 Vaccination Program in the Netherlands

Background

Uptake of human papillomavirus (HPV) vaccine among girls in the Dutch immunization program has plateaued at around 60%. Vaccinating boys may be an appealing complementary strategy for the prevention of HPV-related diseases, especially since tender negotiations and reduced dosing schemes have driven down the cost of vaccination.

Methods

We expanded a previously published Bayesian synthesis framework to account for all vaccine type-related cancers and herd immunity effects from vaccinating girls and boys. We evaluated the efficiency of vaccinating boys relative to increasing vaccine uptake among girls and assessed the cost-effectiveness of a sex-neutral program.

Results

Vaccinating 40% of boys along with 60% of girls yielded the same gain in life-years (LYs) as increasing the uptake in girls from 60% to 80%. The incremental cost-effectiveness ratio (ICER) of vaccinating boys was €9134/LY (95% credible interval [CrI], €7323/LY-€11231/LY) under 3% discounting. The ceiling vaccination costs at which the ICER remained below the per capita gross domestic product threshold was €240 (95% CrI, €200-€280) per vaccinated boy. If girls' uptake increased to 90%, the ceiling costs decreased to €70 (95% CrI, €40-€100) per vaccinated boy.

Conclusions

Vaccinating boys along with girls is only modestly less efficient than increasing uptake among girls and highly likely to be cost-effective under current vaccine costs and uptake in the Netherlands.

The economic burden of human papillomavirus-related precancers and cancers in Sweden

Background

High-risk (HR) human papillomavirus (HPV) infection is an established cause of malignant disease. We used a societal perspective to estimate the cost of HR HPV-related cervical, vulvar, vaginal, anal, and penile precancer and cancer, and oropharyngeal cancer in Sweden in 2006, 1 year before HPV vaccination became available in the country.

Materials and methods

This prevalence-based cost-of-illness study used diagnosis-specific data from national registries to determine the number of HR HPV-related precancers and cancers. The HR HPV-attributable fractions of these diseases were derived from a literature review and applied to the total burden to estimate HR HPV-attributable costs. Direct costs were based on health care utilization and indirect costs on loss of productivity due to morbidity (i.e., sick leave and early retirement) and premature mortality.

Results

The total annual cost of all HR HPV-attributable precancers and cancers was €94 million (€10.3/inhabitant). Direct costs accounted for €31.3 million (€3.4/inhabitant) of the total annual cost, and inpatient care amounted to €20.7 million of direct costs. Indirect costs made up €62.6 million (€6.9/inhabitant) of the total annual cost, and premature mortality amounted to €36 million of indirect costs. Cervical precancer and cancer was most costly (total annual cost €58.4 million). Among cancers affecting both genders, anal precancer and cancer, and oropharyngeal cancer were the most costly (€11.2 million and €11.9 million, respectively). For oropharyngeal cancer, males had the highest health care utilization and represented 71% of the total annual cost. Penile precancer and cancer was least costly (€2.6 million).

Conclusion

The economic burden of HR HPV-related precancers and cancers is substantial. The disease-related management and treatment costs we report are relevant as a point of reference for future economic evaluations investigating the overall benefits of HPV vaccination in females and males in Sweden.

Disease burden of human papillomavirus infection in the Netherlands, 1989-2014: the gap between females and males is diminishing

PURPOSE

Besides cervical cancer, HPV infection is linked to a multitude of diseases in both males and females, suggesting that vaccination programmes should be re-evaluated, with a judicious assessment made of the disease burden stratified by sex, age, and genotype. Projections of burden into the near future are also needed to provide a benchmark for evaluating the impact of vaccination programmes, and to assess the need for scaling-up preventive measures.

METHODS

Using the disability-adjusted life-years (DALY) measure, we estimated the total HPV-associated disease burden in the Netherlands. Annual cancer registrations over the period 1989-2014 for all cancers with an aetiological link to HPV infection were retrieved, supplemented by incidence data on high-grade cervical intraepithelial neoplasia (CIN) and anogenital warts.

RESULTS

Over the recent period 2011-2014, the average annual HPV disease burden was 10,600 DALYs (95% credible interval (CrI):10,260-10,960) in females and 3,346 DALYs (95% CrI: 2,973-3,762) in males. Burden was dominated by cervical cancer, but its share amongst women decreased from 89% in 1989 to 77% in 2014. The male share of the total disease burden increased from 9.8% in 1989 to 26% in 2014. In 2023 (before the expected clinical impact from vaccinating girls), total burden is forecasted at 1.3-fold larger than in 2014.

CONCLUSIONS

The HPV-associated disease burden is higher than that reported for any other infectious disease in the Netherlands, with a larger burden observed in women than in men. The rapidly rising male share of the total burden underlines the prioritization of male HPV-related disease in prevention programmes.

The whole story: a systematic review of economic evaluations of HPV vaccination including non-cervical HPV-associated diseases

INTRODUCTION

Many economic evaluations of HPV vaccination have been published, but most have focused on the prevention of cervical disease as a primary health outcome. The cost-effectiveness of vaccination is likely to be underestimated if not all HPV-associated diseases are taken into account. In this review, we assess the influence of non-cervical HPV-associated diseases on the incremental cost-effectiveness ratio (ICER) of preadolescent HPV vaccination. Areas covered: We systematically searched the literature and identified 18 studies that included non-cervical diseases in the estimates of cost-effectiveness of HPV-vaccination. When taking other HPV-related diseases into account compared to not including such other diseases, the mean ICERs were 2.85 times more favorable for girls only vaccination and 3.89 times for gender neutral vaccination. Expert commentary: Including non-cervical diseases in economic evaluations of HPV vaccination programs makes it more likely that the ICER falls beneath accepted cost-effectiveness thresholds and therefore increases the scope for gender neutral vaccination.

HPV-Related Oropharynx Cancer in the United Kingdom: An Evolution in the Understanding of Disease Etiology

A rising incidence of oropharyngeal squamous cell carcinoma (OPSCC) incidence has occurred throughout the developed world, where it has been attributed to an increasing impact of human papillomavirus (HPV) on disease etiology. This report presents the findings of a multicenter cross-sectional retrospective study aimed at determining the proportion of HPV-positive and HPV-negative OPSCC within the United Kingdom. Archival tumor tissue blocks from 1,602 patients previously diagnosed with OPSCC (2002-2011) were collated from 11 centers. HPV status was determined with three validated commercial tests to provide valid data for 1,474 cases in total. Corresponding national incidence data from the same decade were obtained from UK Cancer registries. The overall proportion of HPV+ OPSCC between 2002 and 2011 was 51.8% [95% confidence interval (CI), 49.3-54.4], and this remained unchanged throughout the decade [unadjusted RR = 1.00 (95% CI, 0.99-1.02)]. However, over the same period, the incidence of OPSCC in the broader UK population underwent a 2-fold increase [age-standardized rate 2002: 2.1 (95% CI, 1.9-2.2); 2011: 4.1 (95% CI, 4.0-4.3)]. Although the number of OPSCCs diagnosed within the United Kingdom from 2002 to 2011 nearly doubled, the proportion of HPV+ cases remained static at approximately 50%. Our results argue that the rapidly increasing incidence of OPSCC in the United Kingdom cannot be solely attributable to the influence of HPV. The parallel increase in HPV+ and HPV- cases we documented warrants further investigation, so that appropriate future prevention strategies for both types of disease can be implemented. Cancer Res; 76(22); 6598-606. ©2016 AACR.

HPV vaccination intention among male clients of a large STI outpatient clinic in Amsterdam, the Netherlands

We explored HPV vaccination intention and its determinants among male clients of the sexually transmitted infections (STI) clinic in Amsterdam. In 2015, male clients aged ≥18 years were invited to complete a web-based questionnaire regarding HPV vaccination intention and socio-psychological determinants. Determinants (scale -3 to +3) were assessed with linear regression, stratified for men who have sex with men (MSM) (including men who have sex with men and women) and men who only have sex with women (MSW). Additionally, we explored the effect of out-of-pocket payment on intention. Of 1490 participants (median age 33 years [IQR:25-44]), 1,053(71%) were MSM. HPV vaccination intention was high (mean 1.68, 95%CI:1.55-1.81 among MSW; mean 2.35, 95%CI:2.29-2.42 among MSM). In multivariable analyses, socio-psychological determinants had similar effects on intention in both groups (R²=0.70 among MSW; R²=0.68 among MSM), except for subjective norms, self-efficacy, and HPV knowledge (significantly stronger associations among MSW). HPV vaccination intention decreased significantly when vaccination would require out-of-pocket payment; intention was negative at the current list price (€350). HPV vaccination intention among male clients of the Amsterdam STI-clinic is high and variance in intention was mostly be explained by socio-psychological factors. Out-of-pocket payment had a strong negative effect on HPV vaccination intention.