Genital warts incidence and healthcare resource utilisation in Australia

Cost-effectiveness analysis of single-dose or 2-dose of bivalent, quadrivalent, or nonavalent HPV vaccine in a low/middle-income country setting

OBJECTIVE

To compare the health impact and economic benefits among individuals who did not receive the human papillomavirus (HPV) vaccine to those who received a single dose, or 2 doses. The comparison was stratified by 4 types of vaccine in conjunction with primary HPV screening in a low/middle-income country setting.

METHODS

A Markov model was employed to simulate HPV infection and cervical cancer in a cohort of 100,000 12-year-old girls free of HPV. The study scrutinized 9 strategies: 1 dose and 2 doses of 2vHPV (Cervarix®), 2vHPV (Cecolin®), 4vHPV (Gardasil®), 9vHPV vaccine (Gardasil9®), and no vaccination. The primary outcome measure was the quality-adjusted life year (QALY) of each strategy. Incremental cost-effectiveness ratios were estimated over a lifetime horizon, accompanied by sensitivity analyses conducted.

RESULTS

All vaccination programs yielded 41,298-71,057 QALYs gained accompanied by cost savings of 14,914,186-19,821,655 USD compared to no vaccination. Administering 2 doses of 9vHPV vaccine emerged as the most cost-effective strategy, boasting 406 USD/QALY, within a lower willingness to pay threshold. Sensitivity analysis demonstrated an 80% probability of the cost-effectiveness of the 2 doses of 9vHPV vaccine regimen. Furthermore, uncertainty around the costs of vaccination and vaccine efficacy exerted the most substantial influence on the cost-effectiveness findings.

CONCLUSION

Oping for 2 doses of 9vHPV vaccine in conjunction with a primary HPV screening represents the most cost-effective option for implementing a school-based HPV vaccination program targeting 12-year-old girls in Thailand. Such findings provide valuable insights for policymakers in the realm of cervical cancer prevention.

Foot, ankle, and leg problems in Australian primary care: consultation patterns, management practices, and costs

OBJECTIVE

To explore consultation patterns, management practices, and costs of foot, ankle, and leg problems in Australian primary care.

STUDY DESIGN

We analyzed data from the Bettering the Evaluation and Care of Health program, April 2000 to March 2016. Foot, ankle, and leg problems were identified using the International Classification of Primary Care, Version 2 PLUS terminology. Data were summarized using descriptive statistics examining general practitioner (GP) and patient characteristics associated with a foot, ankle, or leg problem being managed. Cost to government was estimated by extracting fees for GP consultations, diagnostic imaging, and pathology services from the Medicare Benefits Schedule (MBS) database. Costs for prescription-only medicines were extracted from the Pharmaceutical Benefits Schedule and for nonprescribed medications, large banner discount pharmacy prices were used.

RESULTS

GPs recorded 1,568,100 patient encounters, at which 50,877 foot, ankle, or leg problems were managed at a rate of 3.24 (95% confidence intervals [CIs] 3.21-3.28) per 100 encounters. The management rate of foot, ankle, or leg problems was higher for certain patient characteristics (older, having a health care card, socioeconomically disadvantaged, non-Indigenous, and being English speaking) and GP characteristics (male sex, older age, and Australian graduate). The most frequently used management practice was the use of medications. The average cost (Australian dollars) per encounter was A$52, with the total annual cost estimated at A$256m.

CONCLUSIONS

Foot, ankle, and leg problems are frequently managed by GPs, and the costs associated with their management represent a substantial economic impact in Australian primary care.

Measuring school level attributable risk to support school-based HPV vaccination programs

Background

In Australia in 2017, 89% of 15-year-old females and 86% of 15-year-old males had received at least one dose of the HPV vaccine. However, considerable variation in HPV vaccination initiation (dose one) across schools remains. It is important to understand the school-level characteristics most strongly associated with low initiation and their contribution to the overall between-school variation.

Methods

A population-based ecological analysis was conducted using school-level data for 2016 on all adolescent students eligible for HPV vaccination in three Australian jurisdictions. We conducted logistic regression to determine school-level factors associated with lower HPV vaccination initiation (< 75% dose 1 uptake) and estimated the population attributable risk (PAR) and the proportion of schools with the factor (school-level prevalence).

Results

The factors most strongly associated with lower initiation, and their prevalence were; small schools (OR = 9.3, 95%CI = 6.1–14.1; 33% of schools), special education schools (OR = 5.6,95%CI = 3.7–8.5; 8% of schools), higher Indigenous enrolments (OR = 2.7,95% CI:1.9–3.7; 31% of schools), lower attendance rates (OR = 2.6,95%CI = 1.7–3.7; 35% of schools), remote location (OR = 2.6,95%CI = 1.6–4.3; 6% of schools,) and lower socioeconomic area (OR = 1.8,95% CI = 1.3–2.5; 33% of schools). The highest PARs were small schools (PAR = 79%, 95%CI:76–82), higher Indigenous enrolments (PAR = 38%, 95%CI: 31–44) and lower attendance rate (PAR = 37%, 95%CI: 29–46).

Conclusion

This analysis suggests that initiatives to support schools that are smaller, with a higher proportion of Indigenous adolescents and lower attendance rates may contribute most to reducing the variation of HPV vaccination uptake observed at a school-level in these jurisdictions. Estimating population-level coverage at the school-level is useful to guide policy and prioritise resourcing to support school-based vaccination programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13088-x.

Psychological health and well-being in patients with sexually transmitted infections: A prospective cross-sectional study

Background

Patients with sexually transmitted infections (STIs) suffer not only with the physical problems but also with various psychological problems. Majority of bacterial STIs are treatable in a short period, while viral STIs may persist for longer duration or have frequent recurrences.

Aims and Objectives

The aim of the study was To study different aspects of psychological health and well-being in patients with STIs.

Materials and Methods

Study design was a prospective cross-sectional hospital-based study. Data were collected during July 2016-April 2018. STIs were divided into four groups (genital herpes, genital warts, and genital discharge and syphilis). One way analysis of variance and Scheffe Test were used for analysis of the data.

Results

A total of 410 patients were included in the study. Majority of patients were suffering with genital herpes (139), followed by warts (104), discharge (92), and syphilis (75). Genital herpes and genital warts indicated significantly more cognitive affective (CA) depression as compared to the patients suffering with syphilis. Satisfaction with life was more with genital discharge and syphilis in comparison to the patients with genital warts and genital herpes. Genital herpes showed more perceived stress in comparison to genital discharge. Genital warts indicated more somatic depression as compared to syphilis and genital discharge patients while genital herpes showed more somatic depression than in patients suffering with genital discharge. Genital warts and genital herpes indicated significantly more overall depression as compared to the patients suffering with syphilis.

Conclusion

Overall depression was more in patients with genital herpes and warts. The findings provide empirical bases for extended studies on behavioral intervention programs.

Estimation of mid-and long-term benefits and hypothetical risk of Guillain-Barre syndrome after human papillomavirus vaccination among boys in France: A simulation study

BACKGROUND

The burden of human papillomavirus (HPV) infection can be substantially reduced through vaccination of girls, and gender-neutral policies are being adopted in many countries to accelerate disease control among women and expand direct benefits to men. Clinical direct benefit of boys HPV vaccination has been established for ano-genital warts and anal cancer. HPV vaccines are considered safe, but an association with Guillain-Barre syndrome has been found in French reimbursement and hospital discharge data.

METHODS

We conducted a Monte-Carlo simulation assuming a stable French population of 11- to 14-year-old boys, adult men and men having sex with men. We modelled and quantified the mid-term benefits as the annually prevented ano-genital warts among the 8.72 M men aged 15-35 years and the long-term benefits as the annually prevented anal cancer cases among the 17.4 M men aged 25-65 years. We also estimated the number of Guillain-Barre syndrome cases hypothetically induced by vaccination.

RESULTS

With a vaccine coverage of 30%, an annual number of 9310 (95% uncertainty interval [7050-11,200]) first ano-genital warts episodes among the 8.72 M men aged 15-35 years are prevented. According to more or less optimistic hypotheses on the proportion of HPV cancers covered by the vaccine, between 15.1 [11.7-17.7] and 19.2 [15.0-22.6] cases of anal cancer among the 17.4 M men aged 25-65 years would be annually avoided. Among men having sex with men, the corresponding figures were 1907 (1944-2291) for ano-genital warts and between 2.0 [0.23-4.5] and 2.6 [0.29-5.7] for anal cancer. Among 11- to 14-year-old boys, 0.82 (0.15-2.3) Guillain-Barre syndrome cases would be induced annually.

INTERPRETATION

A long-term program of HPV vaccination among boys in France would avoid substantially more cancer cases than hypothetically induce Guillain-Barre syndrome cases, in the general and specifically the homosexual population. Additional benefits may arise with the possible vaccine protection against oro-laryngeal and -pharyngeal cancer.

School-Level Variation in Coverage of Co-Administered dTpa and HPV Dose 1 in Three Australian States

BACKGROUND

Australian adolescents are routinely offered HPV and dTpa (diphtheria, tetanus, pertussis) vaccines simultaneously in the secondary school vaccination program. We identified schools where HPV initiation was lower than dTpa coverage and associated school-level factors across three states.

METHODS

HPV vaccination initiation rates and dTpa vaccination coverage in 2016 were calculated using vaccine databases and school enrolment data. A multivariate analysis assessed sociodemographic and school-level factors associated with HPV initiation being >5% absolute lower than dTpa coverage.

RESULTS

Of 1280 schools included, the median school-level HPV initiation rate was 85% (interquartile range (IQR):75-90%) and the median dTpa coverage was 86% (IQR:75-92%). Nearly a quarter (24%) of all schools had HPV vaccination initiation >5% lower than dTpa coverage and 11 % had >10% difference. School-level factors independently associated with >5% difference were remote schools (aOR:3.5, 95% CI = 1.7-7.2) and schools in major cities (aOR:1.8, 95% CI = 1.0-3.0), small schools (aOR:3.3, 95% CI = 2.3-5.7), higher socioeconomic advantage (aOR:1.7, 95% CI = 1.1-2.6), and lower proportions of Language-background-other-than-English (aOR:1.9, 95% CI = 1.2-3.0).

CONCLUSION

The results identified a quarter of schools had lower HPV than dTpa initiation coverage, which may indicate HPV vaccine hesitancy, and the difference was more likely in socioeconomically advantaged schools. As hesitancy is context specific, it is important to understand the potential drivers of hesitancy and future research needs to understand the reasons driving differential uptake.

Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states

BACKGROUND

Schools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake.

METHODS

Initiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015-2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25thpercentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage.

RESULTS

Median initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates.

CONCLUSION

This study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage.

Genital warts trends in Australian and overseas-born people in Australia: A cross-sectional trend analysis to measure progress towards control and elimination

Background: Substantial declines in genital warts have been observed in countries with quadrivalent/nonavalent human papillomavirus (q/n HPV) vaccination programmes, with Australia showing the most pronounced and long-term reductions. No study has assessed progress towards elimination of genital warts in a nation-wide sample of patients, and migrants' contribution to population-level control of genital warts. We assessed Australia's progress towards genital warts elimination by examining trends in diagnoses in Australian- and overseas-born patients of sexual health clinics (SHCs) across Australia. Methods: A cross-sectional trend analysis of new genital warts diagnoses among first-time patients of 34 SHCs, between 2004 and 2018, was performed. Rate ratios (RR) were calculated using Poisson regression models, for comparing trends in proportions of new genital warts diagnoses in Australian- and overseas-born patients during the pre-vaccination era (2004-2007) and the vaccination era (2008-2018), and by 2018 relative to 2004-2007. Findings: A total of 439,957 new patients (Australian-born: 230,230; overseas-born: 209,727) were seen at SHCs, 6•4% were diagnosed with genital warts (Australian-born: 7•1%; overseas-born: 5•6%). By 2018, there had been a 64% reduction in the proportion of all SHC patients with a genital warts diagnosis relative to 2004-2007 (RR: 0•36, 95% CI: 0•35-0•38). The decline was more pronounced at 72% (RR: 0•28, 95% CI: 0 •27-0•30) among Australian-born patients, with the greatest reduction in women and men aged <21 years, at 98% (RR: 0•02, 95% CI: 0•01-0•03) and 92% (RR: 0•08, 95% CI: 0•06-0•11), respectively. By 2018, there was a 49% reduction in the proportion of overseas-born patients diagnosed with genital warts (RR: 0•51, 95% CI:0•48-0•54), and a 21% reduction in overseas-born patients from countries with no or bivalent HPV (bHPV) vaccination programme (RR: 0•79, 95% CI: 0•71-0•90). Interpretation: The substantial reductions in Australian-born people is a testament to the efficacy of quadrivalent (qHPV) and nonavalent (nHPV) vaccines and the high and wide-spread vaccination coverage in Australia. However, population-wide elimination of genital warts in Australia is dependent on other countries initiating or expanding their own HPV vaccination programmes. Funding: The Australian Government Department of Health and Seqirus Australia.

[HPV vaccination and the prevention of genital warts and precancerous lesions-current evidence and evaluation]

Human papillomaviruses (HPVs) can cause both benign and malignant tumors. To date, more than 200 HPV types have been discovered, of which 12 are currently classified as high risk for cervical cancer. HPV types that affect the anogenital tract are sexually transmitted. Since 2006, prophylactic HPV vaccines have been available and should be administered before first sexual contact.HPVs infect epithelial cells and are worldwide the most common sexually transmitted viruses. Apart from cervical cancer, HPVs cause other anogenital cancers such as vulvar, vaginal, and anal cancer but also oropharyngeal cancer (or head and neck cancers). HPV types 16 and 18 are also found at these sites. HPV types 6 and 11 are associated with genital warts; other HPV types can cause harmless skin warts.HPV vaccines are safe and highly effective, if they are administered before exposure to HPV. Systematic reviews and meta-analyses have shown that HPV vaccination effectively prevents HPV infection, but also precancerous lesions of the anogenital tract and genital warts. Recent vaccination data also demonstrate reductions in cervical cancer incidence.The uptake rates of HPV vaccination vary worldwide by program and acceptance. In comparison to other European countries, Germany has a low uptake rate. The Standing Committee on Vaccination (STIKO) recommends HPV vaccinations for all girls and boys ages 9 to 14 years in Germany. In 2018, only half of all 18-year-old girls in Germany were completely immunized against HPV.Organized vaccination programs, whether population-based or school-based, are necessary in order to increase vaccination uptake rates.

Estimating the Burden of Illness Related to Genital Warts in Russia: A Cross-Sectional Study

BACKGROUND

Human papillomavirus (HPV) infections are the etiologic agents of genital warts (GW). HPV is one of the most frequent sexually transmitted viral infections, and nearly 65% of individuals with partners who have GW also develop GW. In Russia, as in many other countries, overall GW prevalence data are scarce. Given the lack of Russian data, our study estimated GW prevalence in physician practices and GW-related health care resource use in Russia among male and female patients aged 18-60 years.

METHODS

Russian physicians recorded daily patient logs for a two-week period and conducted a 30-minute survey to estimate GW prevalence and related resource use between January and June 2012. Age, gender, and GW diagnosis status was recorded. Prevalence was obtained for each physician and calculated into a single estimate across all physician types. Overall prevalence estimate and 95% confidence interval were weighted by the estimated number of physicians in each specialty and the proportion of total patients visiting each specialist type. Health care resource use was reported and compared among different physician specialties.

RESULTS

The overall GW prevalence estimate was 9162 cases per 100 000 for male and female patients aged 18-60 years, with 9917 for obstetrician/gynecologists (OB/GYN), 8298 for urologists (URO), and 7833 for dermatologists (DERM). For males, GW prevalence was 8769 cases per 100 000, with the highest prevalence in the 30-34 age group. In females, GW prevalence was 9304 cases per 100 000, with the highest prevalence in the 18-24 age group. Among overall existing GW cases, 63.1% were recurrent and 34.2% were resistant. For all patients in our study, GW prevalence was higher in females. Male patients had the highest prevalence for those aged 30-34 years, and female patients for those aged 18-24 years. These results are consistent with data reported in other countries. Study limitations include estimates and results representative of the urban population of Russia. Despite its limitations, this study provides a GW prevalence estimate in Russia not previously available.

CONCLUSIONS

GW is a significant public health concern in Russia, and the GW prevalence was higher in female patients compared to male patients.

Defining Elimination of Genital Warts-A Modified Delphi Study

Background: Substantial declines in genital warts (GW) have been observed in countries with quadrivalent HPV vaccination programmes, with Australia showing the highest reductions due to early commencement and high vaccination coverage. There is a real potential to achieve GW elimination; however, no GW elimination definition exists. Taking Australia as a case study, we aimed to reach expert consensus on a proposed GW elimination definition using a modified Delphi process. Method: We used modelling and epidemiological data to estimate the expected number of new GW cases, from pre-vaccination (baseline) in 2006 to the year 2060 in Australian heterosexuals, men who have sex with men (MSM), and newly arrived international travellers and migrants. We used these data and the literature, to develop a questionnaire containing ten elimination-related items, each with 9-point Likert scales (1-strongly disagree; 9-strongly agree). The survey was completed by 18 experts who participated in a full day face-to-face modified Delphi study, in which individuals and then small groups discussed and scored each item. The process was repeated online for items where consensus (≥70% agreement) was not initially achieved. Median and coefficient of variation (COV) were used to describe the central tendency and variability of responses, respectively. Findings: There was a 95% participation rate in the face-to-face session, and 84% response rate in the final online round. The median item score ranged between 7.0 and 9.0 and the COV was ≤0.30 on all items. Consensus was reached that at ≥80% HPV vaccination coverage, GW will be eliminated as a public health problem in Australia by 2060. During this time period there will be a 95% reduction in population-level incidence compared with baseline, equivalent to <1 GW case per 10,000 population. The reductions will occur most rapidly in Australian heterosexuals, with 73%, 90% and 97% relative reductions by years 2021, 2030 and 2060, respectively. The proportion of new GW cases attributable to importation will increase from 3.6% in 2006 to ~49% in 2060. Interpretation: Our results indicate that the vaccination programme will minimise new GW cases in the Australian population, but importation of cases will continue. This is the first study to define GW elimination at a national level. The framework developed could be used to define GW elimination in other countries, with thresholds particularly valuable for vaccination programme impact evaluation. Funding: LK supported through an Australian Government Research Training Programme Scholarship; unconditional funding from Seqirus to support the Delphi Workshop.

Scientific evidence supporting recommendations on the use of the 9-valent HPV vaccine in a 2-dose vaccine schedule in Australia

The Australian Technical Advisory Group on Immunisation (ATAGI) updated recommendations on the use of human papillomavirus (HPV) vaccines in the Australian Immunisation Handbook in 2018, regarding the use of the recently available 9-valent (9vHPV) vaccine, Gardasil 9, and a 2-dose schedule for young adolescents for HPV vaccines. This report provides an overview of the relevant scientific evidence that underpinned these updated recommendations. The 9vHPV vaccine includes 5 HPV types (HPV 31, 33, 45, 52 and 58) additional to the 4 that are also covered by the 4vHPV (Gardasil) vaccine (HPV 6,11,16,18). Accordingly, the 9vHPV vaccine is expected to prevent an additional 15% of cervical cancers and up to 20% of other HPV-related cancers. Non-inferior antibody responses after two 9vHPV vaccine doses given 6-12 months apart in girls and boys aged 9-14 years compared to women aged 16-26 years after three doses support the 2-dose schedule for adolescents of this age group. In clinical trials 9vHPV vaccine was well-tolerated with a similar safety profile to 4vHPV vaccine. The switch to 9vHPV vaccine and a 2-dose schedule is anticipated to improve public acceptability of the program and reduce HPV-related disease in the long-term.

Estimating the burden of illness related to genital warts in the Philippines: a nationally representative cross-sectional study

Background

This study estimated genital warts prevalence, genital-warts-related healthcare resource use and costs, and self-reported human-papillomavirus-related psychosocial impact among male and female patients aged 18-60 years in the Philippines.

Methods

Prevalence was estimated using daily logs numbering genital warts patients treated by participating physicians in 4 Philippine regions over a 5-week period (09JUL2011-24SEP2012). Physicians also completed a survey assessing patient referral patterns, healthcare resource use, treatment, and follow-up care. Psychosocial impact was estimated using the human papillomavirus impact profile and the EQ-5D questionnaires. HIP and EQ-5D scores were compared according to the presence of GW (males) and HPV disease (females). CECA scores were also compared by gender and age groups.

Results

Overall genital warts prevalence was estimated at 4.78% (95% confidence interval [CI]: 4.58-4.98%) for men and women aged 18-60 years. Genital warts prevalence was 3.39% (95% CI: 3.13-3.65%) and 8.0% (95% CI: 7.69-8.31%) among women and men, respectively. Prevalence estimates were highest in infectious disease specialist practices 18.67% (95% CI: 18.66-18.69%). Two thirds of the 233 (69.14%) male and 166 (67.20%) female patients were newly-diagnosed genital warts cases. Median costs for genital warts diagnosis and treatment reached 7121 and 7000 Philippine pesos among men and women, respectively. In the Cuestionario Específico para Condiloma Acuminado questionnaire, no statistically significant differences between patients were observed. In the EQ-5D questionnaire, male genital warts patients reported lower mean visual analogue scale scores than those without genital warts (78.20 vs 86.34, p < 0.0001). Mean visual analogue scale score values and utility values were lower for women with human-papillomavirus-related diseases than those without (77.98 vs 78.93, and 0.84 vs 0.88, respectively).

Conclusions

Genital warts is prevalent in the Philippines; more than 60% of cases were newly diagnosed, contributing to high genital-warts-related healthcare resource costs. Diagnosis of genital warts and human papillomavirus negatively impacted psychosocial indices such as patient well-being and health-related quality of life.

Incidence, psychosocial burden, and economic impact of genital warts in Mexico

OBJECTIVE

To estimate the burden of genital warts (GW)in Mexico.

MATERIALS AND METHODS

We estimated the annual incidence of GW based on data reported by specialist physicians. We also assessed GW treatment practices, the average cost of treatment, and the psychosocial burden of GW among patients.

RESULTS

The annual incidence of GW in Mexico was estimated to be 547 200 cases. Treatment procedures vary by specialist and patient gender. The estimated annual cost was $195 million USD. The psychosocial impact of GW was slightly greater in males than females.

CONCLUSIONS

This is the first evaluation of the burden of GW in Mexico. Our data suggest that GW are common, with significant health-related costs and psychosocial impact.

Estimating the burden of genital warts in Taiwan

Background This study aimed to estimate the prevalence of genital warts in Taiwan among those seeking healthcare, as well as genital-warts-related healthcare resource use and costs, and self-reported genital-warts-related psychosocial impact.

METHODS

Genital warts prevalence estimates were extracted from a daily record of patients examined from 31 October 2011 to 4 May 2012 by 67 physicians in Taiwan. Physicians recorded the total number of patients and genital warts patients seen daily for 2 weeks. These physicians also completed a survey regarding healthcare resource use, treatment, follow-up care, and referral patterns. Patient psychosocial impact was estimated using a self-administered survey.

RESULTS

The overall prevalence of genital warts in Taiwan was estimated at 1.1%, with a higher prevalence among men. A total of 146 genital warts case patients were included in the study (76 men, 70 women). Median costs for diagnosis and treatment were US$222 for male and US$351.8 for female patients. Male genital warts subjects reported a negative psychosocial impact on their well-being and health-related quality of life - psychosocial impact results are reported in the Supplementary Material file.

CONCLUSIONS

Genital warts prevalence was higher among male patients; female patients incurred higher costs. Among men, genital warts had a negative psychosocial impact on well-being and health-related quality of life.

Cross-sectional study estimating the psychosocial impact of genital warts and other anogenital diseases in South Korea

OBJECTIVES

To estimate self-reported human papillomavirus (HPV) disease-related psychosocial impact among male and female patients in South Korea.

DESIGN

In this multicentre cross-sectional study, psychosocial impacts were estimated using a one-time survey capturing HPV Impact Profile (HIP) results, CuestionarioEspecifico en Condilomas Acuminados (CECA; in Spanish)-'Specific questionnaire for Condylomata Acuminata' and the EuroQol-5 Dimension (EQ-5D) surveys. Student's t-tests or Mann-Whitney U tests were used for continuous comparisons; χ² or Fisher's exact tests were applied for categorical comparisons.

SETTING

5098 clinics throughout Seoul, Busan, Daegu, Kwangju and Daejeon (South Korea).

PARTICIPANTS

Patients with and without genital warts (GW) (males) and selected HPV diseases (females) visiting primary care physicians, obstetricians/gynaecologists, urologists and dermatologists with 2-30 years experience.

RESULTS

Of 150 male and 250 female patients, HIP scores showed 85.3% of male patients with GW and 32.0% without reported moderate psychological impact (p<0.0001). In categorised total scores, 88.5% of female patients with and 66.0% without selected HPV-related diseases reported moderate or high psychological impacts (p=0.0004). In the CECA questionnaire, male patients had mean (SD) scores of 10.51 (3.79) in 'emotional health' and 15.90 (6.13) in 'sexual activity'. Female patients with GW reported lower scores in both dimensions with mean scores of 7.18 (4.17) in 'emotional health' and 10.97 (5.80) in 'sexual activity' (p<0.0001), indicating worse health-related quality of life (HRQoL). For the EQ-5D, male patients with GW reported lower mean Visual Analogue Scale (VAS) scores than those without (75.1 vs 81.13, p<0.0135). Mean VAS score and utility values were lower for females with HPV-related diseases than those without (72.18 vs 76.86 and 0.90 vs 0.94, respectively).

CONCLUSION

In South Korea, GW in men and HPV-related diseases in women negatively impact patient well-being and HRQoL scores. Among women, those with GW suffered a greater psychosocial impact than those with other selected HPV-related diseases.

Burden of genital warts in Peru: an observational study

Genital warts (GW) are mucosal or skin lesions caused by sexual transmission of human papillomavirus (HPV). This study estimates the frequency of GW cases in physicians' clinics and physicians' usual practices of GW referral and diagnosis in Peru. Participants in this study were a convenience sample of 100 physicians in five specialties: primary care (17), gynecology (37), urology (10), dermatology (31), and infectious diseases (5). Physicians completed a survey and daily log of all patients aged 18-60 years seen over ten days in their offices located in Peru. The survey recorded GW referral patterns and the daily log recorded patient demographic information and GW diagnosis. Among 12,058 patients, the annual GW prevalence (95% confidence interval [CI]) was 2.28% (2.02-2.56) and cumulative incidence (95% CI) was 1.60% (1.38-1.84). Physicians reported that most GW patients were direct consult (73.5% of male and 67.9% of females) and physicians treated most GW patients themselves (73.4% of males and 76.7% of females). As reported, the most common reasons for referring were 'serious cases requiring more specialized treatment' (73.2% of male and 72.2% of female) and 'lack of resources to treat' (26.8% of male and 27.8% of female). We conclude that GW cases are commonly seen by physicians in Peru.

Systematic review and evidence synthesis of non-cervical human papillomavirus-related disease health system costs and quality of life estimates

BACKGROUND

Many economic evaluations of human papillomavirus vaccination should ideally consider multiple disease outcomes, including anogenital warts, respiratory papillomatosis and non-cervical cancers (eg, anal, oropharyngeal, penile, vulvar and vaginal cancers). However, published economic evaluations largely relied on estimates from single studies or informal rapid literature reviews.

METHODS

We conducted a systematic review of articles up to June 2016 to identify costs and utility estimates admissible for an economic evaluation from a single-payer healthcare provider's perspective. Meta-analyses were performed for studies that used same utility elicitation tools for similar diseases. Costs were adjusted to 2016/2017 US$.

RESULTS

Sixty-one papers (35 costs; 24 utilities; 2 costs and utilities) were selected from 10 742 initial records. Cost per case ranges were US$124-US$883 (anogenital warts), US$6912-US$52 579 (head and neck cancers), US$12 936-US$51 571 (anal cancer), US$17 524-34 258 (vaginal cancer), US$14 686-US$28 502 (vulvar cancer) and US$9975-US$27 629 (penile cancer). The total cost for 14 adult patients with recurrent respiratory papillomatosis was US$137 601 (one paper).Utility per warts episode ranged from 0.651 to 1 (12 papers, various utility elicitation methods), with pooled mean EQ-5D and EQ-VAS of 0.86 (95% CI 0.85 to 0.87) and 0.74 (95% CI 0.74 to 0.75), respectively. Fifteen papers reported utilities in head and neck cancers with range 0.29 (95% CI 0.0 to 0.76) to 0.94 (95% CI 0.3 to 1.0). Mean utility reported ranged from 0.5 (95% CI 0.4 to 0.61) to 0.65 (95% CI 0.45 to 0.75) (anal cancer), 0.59 (95% CI 0.54 to 0.64) (vaginal cancer), 0.65 (95% CI 0.60 to 0.70) (vulvar cancer) and 0.79 (95% CI 0.74 to 0.84) (penile cancer).

CONCLUSIONS

Differences in values reported from each paper reflect variations in cancer site, disease stages, study population, treatment modality/setting and utility elicitation methods used. As patient management changes over time, corresponding effects on both costs and utility need to be considered to ensure health economic assumptions are up-to-date and closely reflect the case mix of patients.

Incidence of diseases primarily affecting the skin by age group: population-based epidemiologic study in Olmsted County, Minnesota, and comparison with age-specific incidence rates worldwide

Understanding the effects of age on the epidemiology of diseases primarily affecting the skin is important to the practice of dermatology, both for proper allocation of resources and for optimal patient-centered care. To fully appreciate the effect that age may have on the population-based calculations of incidence of diseases primarily affecting the skin in Olmsted County, Minnesota, and worldwide, we performed a review of all relevant Rochester Epidemiology Project-published data and compared them to similar reports in the worldwide English literature. Using the Rochester Epidemiology Project, population-based epidemiologic studies have been performed to estimate the incidence of specific skin diseases over the past 50 years. In older persons (>65 years), nonmelanoma skin cancer, lentigo maligna, herpes zoster, delusional infestation, venous stasis syndrome, venous ulcer, and burning mouth syndrome were more commonly diagnosed. In those younger than 65 years, atypical nevi, psoriatic arthritis, pityriasis rosea, herpes progenitalis, genital warts, alopecia areata, hidradenitis suppurativa, infantile hemangioma, Behçet's disease, and sarcoidosis (isolated cutaneous, with sarcoidosis-specific cutaneous lesions and with erythema nodosum) had a higher incidence. Many of the incidence rates by age group of diseases primarily affecting the skin derived from the Rochester Epidemiology Project were similar to those reported elsewhere.

Incidence of anogenital warts in Liuzhou, south China: a comparison of data from a prospective study and from the national surveillance system

To determine the incidence of anogenital warts (AGWs) in the Chinese general population, we compared the data from a prospective study and from the National Notifiable Disease Report System (NNDRS). A cohort study including 2378 women and 2309 men aged 18-55 years old enrolled from Liuzhou, China, was conducted with three scheduled visits at 6-month intervals from May 2014 to March 2016. And, a questionnaire survey was performed to collect the diagnosis history of AGWs at the enrollment visit. The data on reported AGW cases of Liuzhou in the NNDRS from 2006 to 2015 were also analyzed. Overall, the incidence rates of AGWs in the prospective study, in the self-reported diagnosis during past 12 months and in the NNDRS were 1.26 per 1000 person-years (95% confidence interval (CI): 0.16-2.37), 2.35 (95% CI: 1.17-4.20) and 0.183 (95% CI: 0.178-0.187), respectively. Human papillomavirus 6 or 11 were found in all the AGW biopsy samples (10/10). The onset time of AGWs in women was earlier, and the cumulative risk increased more quickly at a young age along with each subsequent younger birth cohort (P<0.0001), whereas slight differences were observed in the different male birth cohorts (P=0.0785). The sexual behavior of individuals and their sexual partners had a strong relationship with self-reported AGWs. Our study indicates that the incidence of AGWs in China is as high as that in developed countries, and the data based on the national surveillance system seriously underestimate the real disease burden of AGWs.

A cross-sectional study estimating the burden of illness related to genital warts in South Korea

OBJECTIVES

Estimate the prevalence of genital warts (GW) and GW-related healthcare resource use and costs among male and female patients seeking treatment in South Korea.

DESIGN

To estimate GW prevalence, physicians in five major South Korean regions recorded daily logs of patients (n=71 655) seeking care between July 26 and September 27, 2011. Overall prevalence estimates (and 95% CIs) were weighted by the estimated number of physicians in each specialty and the estimated proportion of total patients visiting each specialist type. Healthcare resource use was compared among different specialties. Corresponding p values were calculated using Mann-Whitney U tests.

SETTING

The database covers 5098 clinics and hospitals for five major regions in South Korea: Seoul, Busan, Daegu, Gwangju and Daejeon.

PARTICIPANTS

Primary care physicians (general practice/family medicine), obstetricians/gynaecologists, urologists and dermatologists with 2-30 years' experience.

RESULTS

The estimated overall GW prevalence was 0.7% (95% CI 0.7% to 0.8%). Among women, GW prevalence was 0.6% (95% CI 0.6% to 0.7%); among men prevalence was 1.0% (95% CI 0.9% to 1.0%), peaking among patients aged 18-24 years. Median costs for GW diagnosis and treatment for male patients were US$58.2 (South Korean Won (KRW) ₩66 857) and US$66.3 (KRW₩76 113) for female patients.

CONCLUSIONS

The estimated overall GW prevalence in South Korea was 0.7% and was higher for male patients. The overall median costs associated with a GW episode were higher for female patients than for male patients.

Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study

BACKGROUND

Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015.

METHODS

All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period.

RESULTS

An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; -3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (-68.2%).

CONCLUSION

GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation

BACKGROUND

Typically occurring on the external genitalia, anogenital warts (AGWs) are benign epithelial skin lesions caused by human papillomavirus infection. AGWs are usually painless but can be unsightly and physically uncomfortable, and affected people might experience psychological distress. The evidence base on the clinical effectiveness and cost-effectiveness of treatments for AGWs is limited.

OBJECTIVES

To systematically review the evidence on the clinical effectiveness of medical and surgical treatments for AGWs and to develop an economic model to estimate the cost-effectiveness of the treatments.

DATA SOURCES

Electronic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Web of Science) were searched from inception (or January 2000 for Web of Science) to September 2014. Bibliographies of relevant systematic reviews were hand-searched to identify potentially relevant studies. The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov were searched for ongoing and planned studies.

REVIEW METHODS

A systematic review of the clinical effectiveness literature was carried out according to standard methods and a mixed-treatment comparison (MTC) undertaken. The model implemented for each outcome was that with the lowest deviance information criterion. A de novo economic model was developed to assess cost-effectiveness from the perspective of the UK NHS. The model structure was informed through a systematic review of the economic literature and in consultation with clinical experts. Effectiveness data were obtained from the MTC. Costs were obtained from the literature and standard UK sources.

RESULTS

Of 4232 titles and abstracts screened for inclusion in the review of clinical effectiveness, 60 randomised controlled trials (RCTs) evaluating 19 interventions were included. Analysis by MTC indicated that ablative techniques were typically more effective than topical interventions at completely clearing AGWs at the end of treatment. Podophyllotoxin 0.5% solution (Condyline(®), Takeda Pharmaceutical Company Ltd; Warticon(®) solution, Stiefel Laboratories Ltd) was found to be the most effective topical treatment evaluated. Networks for other outcomes included fewer treatments, which restrict conclusions on the comparative effectiveness of interventions. In total, 84 treatment strategies were assessed using the economic model. Podophyllotoxin 0.5% solution first line followed by carbon dioxide (CO2) laser therapy second line if AGWs did not clear was most likely to be considered a cost-effective use of resources at a willingness to pay of £20,000-30,000 per additional quality-adjusted life-year gained. The result was robust to most sensitivity analyses conducted.

LIMITATIONS

Limited reporting in identified studies of baseline characteristics for the enrolled population generates uncertainty around the comparability of the study populations and therefore the generalisability of the results to clinical practice. Subgroup analyses were planned based on type, number and size of AGWs, all of which are factors thought to influence treatment effect. Lack of data on clinical effectiveness based on these characteristics precluded analysis of the differential effects of treatments in the subgroups of interest. Despite identification of 60 studies, most comparisons in the MTC are informed by only one RCT. Additionally, lack of head-to-head RCTs comparing key treatments, together with minimal reporting of results in some studies, precluded comprehensive analysis of all treatments for AGWs.

CONCLUSIONS

The results generated by the MTC are in agreement with consensus opinion that ablative techniques are clinically more effective at completely clearing AGWs after treatment. However, the evidence base informing the MTC is limited. A head-to-head RCT that evaluates the comparative effectiveness of interventions used in clinical practice would help to discern the potential advantages and disadvantages of the individual treatments. The results of the economic analysis suggest that podophyllotoxin 0.5% solution is likely to represent a cost-effective first-line treatment option. More expensive effective treatments, such as CO2 laser therapy or surgery, may represent cost-effective second-line treatment options. No treatment and podophyllin are unlikely to be considered cost-effective treatment options. There is uncertainty around the cost-effectiveness of treatment with imiquimod, trichloroacetic acid and cryotherapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005457.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Ongoing decline in genital warts among young heterosexuals 7 years after the Australian human papillomavirus (HPV) vaccination programme

BACKGROUND

Australia has provided free quadrivalent human papillomavirus (HPV) vaccines to school girls since mid-2007 and a catch-up programme in the community to women aged up to 26 years in 2007-2009. We describe the temporal trend of genital warts in different populations in Melbourne.

METHODS

We analysed the proportion diagnosed with genital warts for all new patients attending Melbourne Sexual Health Centre from July 2004 to June 2014, stratified by different risk groups and age. Adjusted ORs were calculated to compare the annual trend in the proportion of patients with genital warts in different risk groups in the prevaccination period (before June 2007) and the vaccination period (after July 2007).

RESULTS

The proportion with genital warts decreased in women aged <21 years, from 18.4% in 2004/2005 to 1.1% in 2013/2014 (p<0.001), but increased in women aged >32 years, from 4.0% to 8.5% (p=0.037). The odds per year for diagnosis of genital warts adjusted for number of sexual partners in the vaccination period were 0.55 (95% CI 0.47 to 0.65) and 0.63 (95% CI 0.54 to 0.74) in women and heterosexual men aged <21 years, respectively. There was no change in adjusted odds of genital warts in both women and men aged >32 years. A small annual decline in genital warts was observed in men who have sex with men (aOR=0.92; 95% CI 0.88 to 0.97).

CONCLUSIONS

Genital warts have now become rare in young Australian women and heterosexual men 7 years after the launch of the national HPV vaccination programme but in stark contrast, remain common in men who have sex with men.

Decreased management of genital warts in young women in Australian general practice post introduction of national HPV vaccination program: results from a nationally representative cross-sectional general practice study

Objectives

Since the introduction of Australia's human papillomavirus vaccination program, the management rate of genital warts in sexual health clinics and private hospitals has decreased in women of vaccine-eligible age. However, most genital warts in Australia are managed in general practice. This study examines whether a similar decrease occurred in Australian general practice after the introduction of the program.

Methods

Analysis of a nationally representative cross-sectional database of Australian general practice activity (1,175,879 patient encounters with 11,780 general practitioners). Genital warts management rates were estimated for the periods before and after introduction of the program (Pre-program, July 2002-June 2006; Post-program, July 2008-June 2012). Control conditions included genital herpes and gardnerella/bacterial vaginosis in female patients and genital herpes and urethritis in male patients. Trends in management rates by year, pre-vaccine (July 2000-June 2007) and post-vaccine (July 2007-June 2012) were also calculated.

Results

Management rate of genital warts among women potentially covered by program (aged 15–27 years) decreased by 61% from 4.33 per 1,000 encounters in the Pre-program period to 1.67 in the Post-program period. Trend analysis of the post-vaccine period showed, among women of vaccine eligible age, a significant year-on-year reduction in the rate of genital warts management (p<0.0001) and a significant increase in the management rate of control conditions per year (p<0.0001). For all other age-sex groups there was no significant change in the management rate of genital warts between the Pre- and Post-program periods.

Conclusion

The large decrease in general practice management of genital warts in women of vaccine-eligible age highlights the success of the program in the wider community.

Fall in genital warts diagnoses in the general and indigenous Australian population following implementation of a national human papillomavirus vaccination program: analysis of routinely collected national hospital data

BACKGROUND

Human papillomavirus (HPV) vaccination targeting females aged 12-13 years commenced in Australia in 2007, with catch-up vaccination of females aged 13-26 years continuing to 2009. Whole-population analyses, including effects on the Indigenous population, have not previously been reported.

METHODS

All hospital admissions between 1999-2011 involving a diagnosis of genital warts were obtained from a comprehensive national database. We compared the age-specific rates before to those after implementation of the vaccination program, according to sex and other characteristics.

RESULTS

Admission rates decreased from mid-2007 in females aged 12-17 years (annual decline, 44.1% [95% confidence interval {CI}, 35.4%-51.6%]) and from mid-2008 in females and males aged 18-26 years (annual declines, 31.8% [95% CI, 28.4%-35.2%] and 14.0% [95% CI, 5.1%-22.1%], respectively). The overall reductions from 2006-2007 to 2010-2011 were 89.9% (95% CI, 84.4%-93.4%) for females aged 12-17 years, 72.7% (95% CI, 67.0%-77.5%) for females aged 18-26 years, and 38.3% (95% CI, 27.7%-47.2%) for males aged 18-26 years. Compared with the average annual number before program implementation, about 1000 fewer hospital admissions involved a warts diagnosis during 2010-2011. Reductions after program implementation were similar for Indigenous (86.7% [95% CI, 76.0-92.7]) and non-Indigenous (76.1% [95% CI, 71.6%-79.9%]) females aged 15-24 years (P(heterogeneity) = .08).

CONCLUSIONS

National population-based hospital data confirm previous clinic-based reports of a marked decline in genital warts diagnoses among young people in Australia after program implementation, including indirect benefits to males. The impact of HPV vaccination appears to be similar in young Indigenous and non-Indigenous females.

Genital warts

Anogenital warts (AGWs) are a very common disease. They are caused mostly by low-risk human papillomaviruses (HPV) 6 and 11, particularly the former. Clinical presentation is mostly of growths in the areas of friction of the anogenital region. The treatment is classified as patient/home applied or administered by a professional. In cases with atypical presentations or resistance to recommended therapies, great care should be taken to establish a differential diagnosis taking into account normal anatomical variations, infectious etiologies, precancers and cancers, as well as benign dermatological growths. The prevention of AGWs can be achieved by the use of the quadrivalent prophylactic HPV vaccine administered prior to sexual debut, as well as the meticulous use of condoms. Where coverage of the quadrivalent vaccine has been high, marked reductions in AGWs are being seen in young women of vaccine-eligible age, as well as in young males (as herd immunity effect).

Number of external anogenital warts is associated with the occurrence of abnormal cervical cytology

BACKGROUND

Anogenital warts (AGWs) are common results of sexually transmitted infection (STI). Human papillomavirus (HPV) types 6 and 11, which are non-oncogenic types, account for 90% of the clinical manifestations. Although the quadrivalent HPV vaccine has been launched, AGW remains prevalent in some countries and shows association with abnormal cervical cytology.

OBJECTIVES

To study the prevalence of abnormal cervical cytology (low grade squamous intraepithelial lesions or worse; LSIL+) in immunocompetent Thai women newly presenting with external AGWs.

MATERIALS AND METHODS

Medical charts of all women attending Siriraj STI clinic during 2007-2011 were reviewed. Only women presenting with external AGWs who were not immunocompromised (pregnant, human immunodeficiency virus positive or being on immunosuppressant drugs) and had not been diagnosed with cervical cancer were included into the study. Multivariate analysis was used to determine the association between the characteristics of the patients and those of AGWs and LSIL+.

RESULTS

A total of 191 women were eligible, with a mean age of 27.0±8.9 years; and a mean body mass index of 20.6±8.9 kg/m2. Half of them finished university. The most common type of AGWs was exophytic (80.1%). The posterior fourchette appeared to be the most common affected site of the warts (31.9%), followed by labia minora (26.6%) and mons pubis (19.9%). The median number of lesions was 3 (range 1-20). Around 40% of them had recurrent warts within 6 months after completing the treatment. The prevalence of LSIL+ at the first visit was 16.3% (LSIL 12.6%, ASC-H 1.1%, HSIL 2.6%). After adjusting for age, parity and miscarriage, number of warts ≥ 5 was the only factor associated with LSIL+ (aOR 2.65, 95%CI 1.11-6.29, p 0.027).

CONCLUSIONS

LSIL+ is prevalent among immunocompetent Thai women presenting with external AGWs, especially those with multiple lesions.

Genital warts and chlamydia in Australian women: comparison of national population-based surveys in 2001 and 2011

OBJECTIVES

Australia introduced a nationwide human papillomavirus (HPV) vaccination programme for women aged 12-26 years in 2007 and has implemented various chlamydia control strategies over the last 10 years. We compared reported diagnoses of warts and chlamydia in two national population-based samples surveyed 10 years apart.

METHODS

An Australia-wide survey of women aged 18-39 years was conducted by random-digit dialling mobile phone numbers in 2011. The proportion of women self-reporting genital warts and chlamydia was compared with that in equivalent-aged women interviewed in another national telephone survey conducted 10 years earlier using logistic regression adjusting for age, and other factors.

RESULTS

2394 women were included in the 2011 survey. 88 (3.7%) reported a genital warts diagnosis, and 127 (5.3%) had at least one chlamydia diagnosis. For women with warts and chlamydia, the majority were seen in general practice (63.3% and 70.0%, respectively). Comparing women surveyed in 2011 to 4874 women surveyed in 2001, among women eligible for free HPV vaccine through the national programme (women aged 18-30 years), there was a 41% decrease in warts (adjusted OR 0.59, 95% CI 0.39 to 0.89) but among ineligible women (31-39 years) there was a 64% increase (aOR 1.64, 95% CI 1.05 to 2.54). Over the same period chlamydia diagnoses increased by 97% (aOR 1.97, 95% CI 1.15 to 3.37) in women aged 18-24 years.

CONCLUSIONS

Our results add to evidence from clinic-based studies showing a significant reduction in genital warts among HPV vaccine-eligible women in the general community and increases in the proportion of Australian women diagnosed with chlamydia.

Cost of illness studies on reproductive, maternal, newborn, and child health: a systematic literature review

BACKGROUND

The term ?reproductive, maternal, newborn, and child health (RMNCH)? describes an integrated continuum of health states which is central to Millennium Development Goals 4 and 5. While the burden of mortality and morbidity associated with RMNCH is well known, knowledge is still limited about the economic burden of RMNCH. Concrete evidence of cost of illness (COI) of RMNCH may help policy makers in supporting investment in RMNCH.

METHODS

A systematic literature search of COI studies was performed in electronic databases. The time frame for the analysis was January 1990 ? April 2011. The databases checked were Medline (Pubmed), Embase and ECONbase, EconLit, the Cumulative Index to Nursing and Allied Health (CINAHL), the National Bureau of Economic Research, the Latin American and Caribbean Literature on Health Sciences Database (LILACS), and Popline. Furthermore, we searched working papers and reference lists of selected articles.

RESULTS

All the studies investigated address particular complications and issues of RMNCH, e.g., preterm birth, non-exclusive breastfeeding, and sexually transmitted diseases (STDs), but not RMNCH as an entire continuum. Most of the studies were conducted in high income countries, with limited data on low and middle income countries. The burden of disease is very high even for single complications. For example, the disease burden related to non-exclusive breastfeeding was given as 14.39 billion international dollars (ID) (2012, purchasing power parity) per year in the USA. Methodological differences in study design, costing approach, perspective of analysis, and time frame make it difficult to compare different studies.

CONCLUSION

The continuum of RMNCH covers a large portion of the lifespan from birth through the reproductive age. From a methodological perspective, an ideal COI study would clearly describe the perspective of analysis and, hence, the cost items (direct or indirect), cost collection procedure, discounting, quality of data, time frame of analysis, related comorbidities, and robust sensitivity analysis for all the assumptions. Further research is needed to measure the economic impact of RMNCH, including identification of the most cost-effective policy and interventions for prevention, reduction, and elimination of the complications of RMNCH.

Towards the eradication of HPV infection through universal specific vaccination

BACKGROUND

The Human Papillomavirus (HPV) is generally recognized to be the direct cause of cervical cancer. The development of effective anti-HPV vaccines, included in the portfolio of recommended vaccinations for any given community, led to the consolidation in many countries of immunization programs to prevent HPV-related cervical cancers. In recent years, increasing evidence in epidemiology and molecular biology have supported the oncogenic role of HPV in the development of other neoplasm including condylomas and penile, anal, vulvar, vaginal, and oro-pharyngeal cancers. Men play a key role in the paradigm of HPV infection: both as patients and as part of the mechanisms of transmission. Data show they are affected almost as often as women. Moreover, no screening procedures for HPV-related disease prevention are applied in men, who fail to undergo routine medical testing by any medical specialist at all. They also do not benefit from government prevention strategies.

DISCUSSION

A panel of experts convened to focus on scientific, medical, and economic studies, and on the achievements from health organizations' intervention programs on the matter. One of the goals was to discuss on the critical issues emerging from the ongoing global implementation of HPV vaccination. A second goal was to identify contributions which could overcome the barriers that impede or delay effective vaccination programs whose purpose is to eradicate the HPV infection both in women and men.

SUMMARY

The reviewed studies on the natural history of HPV infection and related diseases in women and men, the increasing experience of HPV vaccination in women, the analysis of clinical effectiveness vs economic efficacy of HPV vaccination, are even more supportive of the economic sustainability of vaccination programs both in women and men. Those achievements address increasing and needed attention to the issue of social equity in healthcare for both genders.

Global burden of human papillomavirus and related diseases

The worldwide prevalence of infection with human papillomavirus (HPV) in women without cervical abnormalities is 11-12% with higher rates in sub-Saharan Africa (24%), Eastern Europe (21%) and Latin America (16%). The two most prevalent types are HPV16 (3.2%) and HPV18 (1.4%). Prevalence increases in women with cervical pathology in proportion to the severity of the lesion reaching around 90% in women with grade 3 cervical intraepithelial neoplasia and invasive cancer. HPV infection has been identified as a definite human carcinogen for six types of cancer: cervix, penis, vulva, vagina, anus and oropharynx (including the base of the tongue and tonsils). Estimates of the incidence of these cancers for 2008 due to HPV infection have been calculated globally. Of the estimated 12.7 million cancers occurring in 2008, 610,000 (Population Attributable Fraction [PAF]=4.8%) could be attributed to HPV infection. The PAF varies substantially by geographic region and level of development, increasing to 6.9% in less developed regions of the world, 14.2% in sub-Saharan Africa and 15.5% in India, compared with 2.1% in more developed regions, 1.6% in Northern America and 1.2% in Australia/New Zealand. Cervical cancer, for which the PAF is estimated to be 100%, accounted for 530,000 (86.9%) of the HPV attributable cases with the other five cancer types accounting for the residual 80,000 cancers. Cervical cancer is the third most common female malignancy and shows a strong association with level of development, rates being at least four-fold higher in countries defined within the low ranking of the Human Development Index (HDI) compared with those in the very high category. Similar disparities are evident for 5-year survival-less than 20% in low HDI countries and more than 65% in very high countries. There are five-fold or greater differences in incidence between world regions. In those countries for which reliable temporal data are available, incidence rates appear to be consistently declining by approximately 2% per annum. There is, however, a lack of information from low HDI countries where screening is less likely to have been successfully implemented. Estimates of the projected incidence of cervical cancer in 2030, based solely on demographic factors, indicate a 2% increase in the global burden of cervical cancer, i.e., in balance with the current rate of decline. Due to the relative small numbers involved, it is difficult to discern temporal trends for the other cancers associated with HPV infection. Genital warts represent a sexually transmitted benign condition caused by HPV infection, especially HPV6 and HPV11. Reliable surveillance figures are difficult to obtain but data from developed countries indicate an annual incidence of 0.1 to 0.2% with a peak occurring at teenage and young adult ages. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program

BACKGROUND

There has been a rapid decline in the number of young heterosexuals diagnosed with genital warts at outpatient sexual health services since the national human papillomavirus (HPV) vaccination program started in Australia in 2007. We assessed the impact of the vaccination program on the number of in-patient treatments for genital warts.

METHODS

Data on in-patient treatments of genital warts in all private hospitals were extracted from the Medicare website. Medicare is the universal health insurance scheme of Australia. In the vaccine period (2007-2011) and pre-vaccine period (2000-2007) we calculated the percentage change in treatment numbers and trends in annual treatment rates in private hospitals. Australian population data were used to calculate rates. Summary rate ratios of average annual trends were determined.

RESULTS

Between 2000 and 2011, 6,014 women and 936 men aged 15-44 years underwent in-patient treatment for genital warts in private hospitals. In 15-24 year old women, there was a significant decreasing trend in annual treatment rates of vulval/vaginal warts in the vaccine period (overall decrease of 85.3% in treatment numbers from 2007 to 2011) compared to no significant trend in the pre-vaccine period (summary rate ratio (SRR) = 0.33, p < 0.001). In 25-34 year old women, declining trends were seen in both vaccine and pre-vaccine periods (overall decrease of 33% vs. 24.3%), but the rate of change was greater in the vaccine period (SRR = 0.60, p < 0.001). In 35-44 year old women, there was no significant change in both periods (SRR = 0.91, p = 0.14). In 15-24 year old men, there was a significant decreasing trend in annual treatment rates of penile warts in the vaccine period (decrease of 70.6%) compared to an increasing trend in the pre-vaccine period (SRR = 0.76, p = 0.02). In 25-34 year old men there was a significant decreasing trend in the vaccine period compared to no change in the pre-vaccine period (SRR = 0.81, p = 0.04) and in 35-44 year old men there was no significant change in rates of penile warts both periods, but the rate of change was greater in the vaccine period (SRR = 0.70, p = 0.02).

CONCLUSIONS

The marked decline in in-patient treatment of vulval/vaginal warts in the youngest women is probably attributable to the HPV vaccine program. The moderate decline in in-patient treatments for penile warts in men probably reflects herd immunity.

Human papillomavirus in adolescents: lessons learned from decades of evaluation

Knowledge regarding the natural history of human papillomavirus (HPV) infection and its clinical sequelae in adolescents has increased significantly over the last decade; as a result, there have been world-wide recommendations for less aggressive Pap screening and management of cervical dysplasias in young women. It is important that adolescent health providers understand these issues, as knowledge of HPV and its sequelae in the Australian community is limited, despite the introduction of a national immunisation programme. Parents and young women have expressed a desire for further information to make informed choices. This paper reviews the natural history of HPV infection in adolescents and the evidence behind new conservative guidelines for cervical screening, plus prophylactic vaccination in young women.

Systematic review of the incidence and prevalence of genital warts

BACKGROUND

Anogenital warts (AGWs) are a common, highly infectious disease caused by the human papillomavirus (HPV), whose high recurrence rates contribute to direct medical costs, productivity loss and increased psychosocial impact. Because of the lack of a systematic review of the epidemiology of AGWs in the literature, this study reviewed the published medical literature on the incidence and prevalence of AGWs.

METHODS

A comprehensive literature search was performed on the worldwide incidence and prevalence of AGWs between 2001 and 2012 using the PubMed and EMBASE databases. An additional screening of abstracts from relevant sexual health and infectious disease conferences from 2009 to 2011 was also conducted. Only original studies with general adult populations (i.e., at least including ages 20 through 40 years) were included.

RESULTS

The overall (females and males combined) reported annual incidence of any AGWs (including new and recurrent) ranged from 160 to 289 per 100,000, with a median of 194.5 per 100,000. New AGW incidence rates among males ranged from 103 to 168 per 100,000, with a median of 137 per 100,000 and among females from 76 to 191 per 100,000, with a median of 120.5 per 100,000 per annum. The reported incidence of recurrent AGWs was as high as 110 per 100,000 among females and 163 per 100,000 among males. Incidence peaked before 24 years of age in females and between 25 and 29 years of age among males. The overall prevalence of AGWs based on retrospective administrative databases or medical chart reviews or prospectively collected physician reports ranged from 0.13% to 0.56%, whereas it ranged from 0.2% to 5.1% based on genital examinations.

CONCLUSIONS

The literature suggests that AGWs are widespread and the prevalence depends on study methodology as suggested by higher rates reported from routine genital examinations versus those from treatment records. However, there remains a need for more population-based studies from certain regions including Africa, Latin America and Southern Asia to further elucidate the global epidemiology of this disease.

Occurrence of dysplasia and human papilloma virus typing in penile condylomas

OBJECTIVE

To determine the incidence of dysplasia as a preneoplastic change and high-risk human papilloma virus (HPV) infection in penile condylomas, which are common HPV-related lesions and considered a risk factor for penile cancer.

METHODS

Histologic analysis was done of 58 consecutive penile condylomas with tissue diagnosis. An immunohistochemical panel that included stains for p53, Ki-67, and p16INK4a was also used. HPV typing was successfully performed in 43 lesions. Genotyping was accomplished through polymerase chain reaction and flow-through hybridization with an HPV GenoArray Diagnostic Test kit.

RESULTS

Dysplasia was observed in 13 of the 58 condylomas (22%). High-risk HPV DNA was detected in 5 of 10 dysplastic lesions (50%) for which tissue blocks were available for study. High-risk HPV was not detected in the nondysplastic lesions (P<.001). Ki-67≥20% above the basal layer of epithelium and p53-positive immunostaining occurred more frequently in dysplastic lesions than in nondysplastic lesions; however, the difference was not statistically significance. Staining for p16INK4a was not helpful.

CONCLUSION

Anogenital condylomas in men are usually treated using destructive methods or with medication. We suggest that at least a part of the lesion must be removed and sent for histopathologic examination. If the histologic result shows significant dysplastic alteration, the lesion should be further investigated to determine the subtype of infective virus, because 50% of such lesions are associated with high-risk HPV. When oncogenic pathogens are found, careful patient follow-up for recurrences and counseling for the patient and his sexual partner(s) may be warranted.

Adaptive Markov chain Monte Carlo forward projection for statistical analysis in epidemic modelling of human papillomavirus

A Bayesian statistical model and estimation methodology based on forward projection adaptive Markov chain Monte Carlo is developed in order to perform the calibration of a high-dimensional nonlinear system of ordinary differential equations representing an epidemic model for human papillomavirus types 6 and 11 (HPV-6, HPV-11). The model is compartmental and involves stratification by age, gender and sexual-activity group. Developing this model and a means to calibrate it efficiently is relevant because HPV is a very multi-typed and common sexually transmitted infection with more than 100 types currently known. The two types studied in this paper, types 6 and 11, are causing about 90% of anogenital warts. We extend the development of a sexual mixing matrix on the basis of a formulation first suggested by Garnett and Anderson, frequently used to model sexually transmitted infections. In particular, we consider a stochastic mixing matrix framework that allows us to jointly estimate unknown attributes and parameters of the mixing matrix along with the parameters involved in the calibration of the HPV epidemic model. This matrix describes the sexual interactions between members of the population under study and relies on several quantities that are a priori unknown. The Bayesian model developed allows one to estimate jointly the HPV-6 and HPV-11 epidemic model parameters as well as unknown sexual mixing matrix parameters related to assortativity. Finally, we explore the ability of an extension to the class of adaptive Markov chain Monte Carlo algorithms to incorporate a forward projection strategy for the ordinary differential equation state trajectories. Efficient exploration of the Bayesian posterior distribution developed for the ordinary differential equation parameters provides a challenge for any Markov chain sampling methodology, hence the interest in adaptive Markov chain methods. We conclude with simulation studies on synthetic and recent actual data.

Pre-vaccination incidence of genital warts in 15-23-year-old women and men attending youth clinics in Stockholm, Sweden

BACKGROUND

Human papillomavirus (HPV) vaccines were introduced to the market in 2006 and 2007. The present pilot study was designed to examine the incidence of genital warts in the population up to 23 y of age in the county of Stockholm before the start of mass HPV vaccination.

METHODS

Data from the electronic health records of 9 youth clinics in the county of Stockholm were collected retrospectively for the y 2006-2008.

RESULTS

In total, 49,985 patients visited the study youth clinics during 2006-2008. Of these, 1817 were denoted genital warts patients. An extrapolation of the study data was done in an attempt to estimate the annual number of genital warts cases in the full Stockholm County population aged 15-23 y. Results showed that there were approximately 1792 genital warts patients in the age group 15-23 y each year in Stockholm County. Female cases represented approximately 62% of all cases in the age group 15-23 y. The peak incidence was at around 20 y of age for females, while males had a more flattened peak incidence around 19-23 y of age.

CONCLUSION

This pilot study demonstrates that, compared to other reported data, genital warts are at least as common in Sweden as in other countries among 15-23 y old females and males.

Impact of genital warts on health related quality of life in men and women in mainland China: a multicenter hospital-based cross-sectional study

Background

Information on the health-related quality of life (HRQoL) of patients with genital warts (GW) in populations in mainland China is still limited. The aim of the study was to use a generic instrument to measure the impact of genital warts on HRQoL in men and women in this setting.

Methods

A multi-centre hospital-based cross-sectional study across 18 centers in China was conducted to interview patients using the European quality of life-5 dimension (EQ-5D) instrument; respondents' demographic and clinical data were also collected.

Results

A total of 1,358 GW patients (612 men, 746 women) were included in the analysis, with a mean age of 32.0 ± 10.6 years. 56.4% of the patients reported some problems in the dimension of Anxiety/Depression (highest), followed by Pain/Discomfort (24.7%) and Mobility (3.5%). The overall visual analogue scale (VAS) score of the study population was found to be 65.2 ± 22.0, and the EQ-5D index score was found to be 0.843 ± 0.129 using Japanese preference weights (the Chinese preference was unavailable yet). Patients with lower VAS means and EQ-5D index scores were more often female, living in urban area, and suffering multiple GW (all p values < 0.05), but the values did not differ notably by age (p values > 0.05).

Conclusions

The HRQoL of patients with GW was substantially lower, compared to a national representative general population in China (VAS = ~80); the findings of different subgroups are informative for future GW prevention and control efforts.

Economic and humanistic burden of external genital warts

External genital warts (EGW) are a sexually transmitted infection caused by various strains of human papillomavirus (HPV). Several studies have described the direct and indirect costs of EGW, while others have reported on the burden of EGW in terms of the impact on the quality of life (QOL) of patients. The arrival of a quadrivalent HPV vaccine that protects against both cervical cancer and EGW requires a proper understanding of the impact of vaccines on costs and QOL. Using pre-defined search terms and inclusion/exclusion criteria, we performed a systematic review of the economic and humanistic burden of EGW. The focus of our review was on literature describing the direct and indirect costs of EGW per episode of care (EoC) or per year, as well as the impact of EGW on disease-specific, generic, or preference-based QOL measures. We also reviewed the literature on the national economic burden of EGW from the perspectives of different countries. Other aspects of EGW management that can inform economic modelling studies, such as length of EoC, number of physician visits and indirect costs, were also explored. Our review sheds light on the high economic and humanistic burden of EGW and important differences in the costs between men and women, as well as the differences in health resource utilization and costs across countries. Our study also highlights the dearth of information on the impact of EGW on the QOL and productivity of patients.