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López-Codony V, de Andrés-Pablo Á, Ferrando-Díez A, Fernández-Montolí ME, López-Querol M, Tous S, Ortega-Expósito C, Torrejón-Becerra JC, Pérez Y, Ferrer-Artola A, Sole-Sedeno JM, Grau C, Rupérez B, Saumoy M, Sánchez M, Peremiquel-Trillas P, Bruni L, Alemany L, Bosch FX, Pavón MA. Assessing the reduction of viral infectivity in HPV16/18-positive women after one, two, and three doses of Gardasil-9 (RIFT): Study protocol. PLoS One 2024; 19:e0304080. [PMID: 38768231 PMCID: PMC11104652 DOI: 10.1371/journal.pone.0304080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
Human Papillomavirus (HPV) prophylactic vaccination has proven effective in preventing new infections, but it does not treat existing HPV infections or associated diseases. Hence, there is still an important reservoir of HPV in adults, as vaccination programs are mainly focused on young women. The primary objective of this non-randomized, open-label trial is to evaluate if a 3-dose regimen of Gardasil-9 in HPV16/18-positive women could reduce the infective capacity of their body fluids. We aim to assess if vaccine-induced antibodies could neutralize virions present in the mucosa, thus preventing the release of infective particles and HPV transmission to sexual partners. As our main endpoint, the E1^E4-HaCaT model will be used to assess the infectivity rate of cervical, anal and oral samples, obtained from women before and after vaccination. HPV DNA positivity, virion production, seroconversion, and the presence of antibodies in the exudates, will be evaluated to attribute infectivity reduction to vaccination. Our study will recruit two different cohorts (RIFT-HPV1 and RIFT-HPV2) of non-vaccinated adult women. RIFT-HPV1 will include subjects with an HPV16/18 positive cervical test and no apparent cervical lesions or cervical lesions eligible for conservative treatment. RIFT-HPV2 will include subjects with an HPV16/18 positive anal test and no apparent anal lesions or anal lesions eligible for conservative treatment, as well as women with an HPV16/18 positive cervical test and HPV-associated vulvar lesions. Subjects complying with inclusion criteria for both cohorts will be recruited to the main cohort, RIFT-HPV1. Three doses of Gardasil-9 will be administered intramuscularly at visit 1 (0 months), visit 2 (2 months) and visit 3 (6 months). Even though prophylactic HPV vaccines would not eliminate a pre-existing infection, our results will determine if HPV vaccination could be considered as a new complementary strategy to prevent HPV-associated diseases by reducing viral spread. Trial registration: https://clinicaltrials.gov/ct2/show/NCT05334706.
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MESH Headings
- Humans
- Female
- Papillomavirus Infections/prevention & control
- Papillomavirus Infections/virology
- Papillomavirus Infections/immunology
- Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18/administration & dosage
- Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18/immunology
- Human papillomavirus 16/immunology
- Human papillomavirus 18/immunology
- Adult
- Young Adult
- Adolescent
- Antibodies, Viral/immunology
- Papillomavirus Vaccines/administration & dosage
- Papillomavirus Vaccines/immunology
- DNA, Viral
- Vaccination/methods
- Cervix Uteri/virology
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Affiliation(s)
- Victoria López-Codony
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Programa de Doctorat en Biomedicina, Universitat de Barcelona (UB), Barcelona, Spain
| | - Álvaro de Andrés-Pablo
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Programa de Doctorat en Biomedicina, Universitat de Barcelona (UB), Barcelona, Spain
| | - Angelica Ferrando-Díez
- Medical Oncology Department, Catalan Institute of Oncology, Germans Trias i Pujol University Hospital (HGTiP), Badalona, Barcelona, Spain
| | | | - Marta López-Querol
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Tous
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Carlos Ortega-Expósito
- Department of Gynaecology, Bellvitge University Hospital (HUB), L’Hospitalet de Llobregat, Barcelona, Spain
| | | | - Yolanda Pérez
- Department of Gynaecology, Bellvitge University Hospital (HUB), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Ferrer-Artola
- Bellvitge Biomedical Research Institute (IDIBELL), Pharmacy Unit, Bellvitge University Hospital (HUB), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Josep Maria Sole-Sedeno
- Department of Obstetrics and Gynaecology, Hospital del Mar–Mar Health Park, Barcelona, Spain
| | - Clara Grau
- Sexual and Reproductive Health Care Center–ASSIR, Delta del Llobregat, Barcelona, Spain
| | - Blas Rupérez
- Sexual and Reproductive Health Care Center–ASSIR, Delta del Llobregat, Barcelona, Spain
| | - Maria Saumoy
- HIV and STD Unit, Bellvitge University Hospital (HUB), Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Mónica Sánchez
- HIV and STD Unit, Bellvitge University Hospital (HUB), Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Paula Peremiquel-Trillas
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Programa de Doctorat en Biomedicina, Universitat de Barcelona (UB), Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Laia Bruni
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Laia Alemany
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Francesc Xavier Bosch
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Faculty of Health Sciences, Open University of Catalonia (UOC), Barcelona, Spain
| | - Miquel Angel Pavón
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Cancer Epidemiology Research Programme, L’Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
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2
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Reddinger JL, Charness G, Levine D. Vaccination as personal public good provision. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2022.04.21.22274110. [PMID: 35923323 PMCID: PMC9347278 DOI: 10.1101/2022.04.21.22274110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Vaccination against infectious diseases has both private and public benefits. We study whether social preferences-concerns for the well-being of other people-are associated with one's decision regarding vaccination. We measure these social preferences for 549 online subjects with a public-good game and an altruism game. To the extent that one gets vaccinated out of concern for the health of others, contribution in the public-good game is analogous to an individual's decision to obtain vaccination, while our altruism game provides a different measure of altruism, equity, and efficiency concerns. We proxy vaccine demand with how quickly a representative individual voluntarily took the initial vaccination for COVID-19 (after the vaccine was widely available). We collect COVID-19 vaccination history separately from the games to avoid experimenter-demand effects. We find a strong result: Contribution in the public-good game is associated with greater demand to voluntarily receive a first dose, and thus also to vaccinate earlier. Compared to a subject who contributes nothing, one who contributes the maximum ($4) is 58% more likely to obtain a first dose voluntarily in the four-month period that we study (April through August 2021). In short, people who are more pro-social are more likely to take a voluntary COVID-19 vaccination. Behavior in our altruism game does not predict vaccination. We recommend further research on the use of pro-social preferences to help motivate individuals to vaccinate for other transmissible diseases, such as the flu and HPV.
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3
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Pauli S, Kops NL, Bessel M, Lina Villa L, Moreno Alves Souza F, Mendes Pereira GF, Neves Hugo F, Marcia Wendland E. Sexual practices and HPV infection in unvaccinated young adults. Sci Rep 2022; 12:12385. [PMID: 35859090 PMCID: PMC9300667 DOI: 10.1038/s41598-022-15088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/17/2022] [Indexed: 11/30/2022] Open
Abstract
The present study aimed to evaluate the association of genital and oral HPV infection among different sexual practices in both sexes. In total, 6388 unvaccinated men and women aged 16–25 years from all state capitals of Brazil were enrolled in through primary care services between September 2016 and November 2017. Genital and oral HPV genotyping was performed using the Roche Linear Array. Poisson regression analysis with robust variance was conducted to examine factors associated with overall HPV infection. A higher prevalence of genital HPV was found in women who practiced oral sex (57.85%) and in men who practiced all types of sex (65.87%). However, having more sexual partners and being younger were more important than the type of sex practiced. HPV 6 (7.1%) and 16 (10.5%) were significantly more prevalent in women who practiced oral sex, while HPV 6 (23.96%) and 11 (21.49%) were more prevalent in men who practiced anal sex. The type of sex was not associated with oral HPV prevalence. Genital and oral HPV infection were not associated by different sexual practices in the studied population.
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Affiliation(s)
- Sílvia Pauli
- Hospital Moinhos de Vento, Rua Ramiro Barcelos 910, Porto Alegre, RS, 90035-004, Brazil
| | - Natália Luiza Kops
- Hospital Moinhos de Vento, Rua Ramiro Barcelos 910, Porto Alegre, RS, 90035-004, Brazil
| | - Marina Bessel
- Hospital Moinhos de Vento, Rua Ramiro Barcelos 910, Porto Alegre, RS, 90035-004, Brazil
| | - Luisa Lina Villa
- Department of Radiology and Oncology, Medical School, Universidade de São Paulo (USP), and Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP, Brazil
| | - Flávia Moreno Alves Souza
- Department of Chronic Conditions and Sexually Transmitted Infections, Ministry of Health, Brasília, DF, Brazil
| | | | - Fernando Neves Hugo
- Department of Preventive and Social Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Eliana Marcia Wendland
- Hospital Moinhos de Vento, Rua Ramiro Barcelos 910, Porto Alegre, RS, 90035-004, Brazil. .,Department of Public Health, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
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4
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Chow EPF, Phillips TR, Bowesman H, Ong JJ, Tran J, Aung ET, Chen MY, Fairley CK. Human papillomavirus vaccine coverage in male-male partnerships attending a sexual health clinic in Melbourne, Australia. Hum Vaccin Immunother 2022; 18:2068929. [PMID: 35714275 PMCID: PMC9302508 DOI: 10.1080/21645515.2022.2068929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We aimed to investigate the sexual mixing by human papillomavirus (HPV) vaccination status in male-male partnerships and estimate the proportion of male-male partnerships protected against HPV. We analyzed male-male partnerships attending the Melbourne Sexual Health Center between 2018 and 2019. Data on self-reported HPV vaccination status were collected. Newman’s assortativity coefficient was used to examine the sexual mixing by HPV vaccination status. Assortativity refers to the tendency of individuals to have partners with similar characteristics (i.e. same vaccination status). Of 321 male-male partnerships where both men reported their HPV vaccination status, 52.6% (95% CI: 47.0–58.2%) partnerships had both men vaccinated, 32.1% (95% CI: 27.0–37.5%) partnerships had only one man vaccinated, and 15.3% (95% CI: 11.5–19.7%) had both men unvaccinated. The assortativity on HPV vaccination status was moderate (assortativity coefficient = 0.265, 95% CI: 0.196–0.335). There were about 15% of male-male partnerships where both men were not protected against HPV. Interventions targeting vaccinated individuals to encourage their unvaccinated partners to be vaccinated might increase the HPV vaccine coverage.
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Affiliation(s)
- Eric P F Chow
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tiffany R Phillips
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Henry Bowesman
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Jason J Ong
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Julien Tran
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Ei T Aung
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Marcus Y Chen
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
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5
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MacCosham A, El-Zein M, Burchell AN, Tellier PP, Coutlée F, Franco EL. Protection to Self and to One's Sexual Partner After Human Papillomavirus Vaccination: Preliminary Analysis From the Transmission Reduction And Prevention with HPV Vaccination Study. Sex Transm Dis 2022; 49:414-422. [PMID: 35235550 DOI: 10.1097/olq.0000000000001620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unknown whether recently human papillomavirus (HPV)-vaccinated individuals confer protection against vaccine-preventable HPV types to their partners. METHODS Participants 18 to 45 years old who were living in Montreal, Canada, and in a heterosexual relationship of 6 months or less were randomly assigned to receive the intervention HPV vaccine, Gardasil or Gardasil 9, or active control (AC), Avaxim, a hepatitis A vaccine. Couples attended a maximum of 6 clinic visits (baseline and at 2, 4, 6, 9, and 12 months) and provided genital samples for detection of 36 HPV genotypes. Participants were vaccinated at baseline and at 2 and 6 months. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between the administered vaccine and infections at the HPV episode level. RESULTS We restricted analyses to 273 participants (intervention: n = 141, AC: n = 132) who had at least 2 visits with valid HPV data. The HR of becoming positive for a given vaccine-preventable HPV type in the intervention group among those who received at least 1 dose compared with AC was 0.47 (95% CI, 0.23-0.97). Comparing individuals with HPV-vaccinated versus AC-vaccinated partners, there was no difference in risk of becoming positive for a given vaccine-preventable HPV type among those whose partners received at least 1 (HR, 1.46; 95% CI, 0.73-2.94) or 2 (HR, 0.78; 95% CI, 0.31-1.96) doses. CONCLUSIONS Our study provides inconclusive evidence that individuals whose partner recently received an HPV vaccine are protected from vaccine-preventable types but demonstrates that vaccinated individuals are at a lower risk of incident infections.Trial Registration Number: NCT01824537.
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Affiliation(s)
- Aaron MacCosham
- From the Division of Cancer Epidemiology, McGill University, Montreal, Quebec
| | - Mariam El-Zein
- From the Division of Cancer Epidemiology, McGill University, Montreal, Quebec
| | | | | | - François Coutlée
- Service de Microbiologie Médicale et Service d'Infectiologie, Départements de Médecine et de médecine de laboratoire, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Eduardo L Franco
- From the Division of Cancer Epidemiology, McGill University, Montreal, Quebec
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6
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The association between viral load and concurrent human papillomavirus infection at the genital and anal sites of young women and the impact of vaccination. Tumour Virus Res 2021; 13:200233. [PMID: 34958987 PMCID: PMC8732794 DOI: 10.1016/j.tvr.2021.200233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022] Open
Abstract
Concurrent genital-anal human papillomavirus (HPV) infections may impose an increased anal cancer risk in women with HPV-related genital lesions. High viral load may facilitate genital-anal HPV concurrence. Genital and anal HPV is reduced by a bivalent HPV16/18 vaccine, yet the effect on concurrent genital-anal HPV remains unclear. This study analyzed viral load in concurrent genital-anal HPV infections, relative to genital-only and anal-only HPV infections and the impact of vaccination in young women. We included 1074 women, who provided both genital and anal swabs. HPV detection and genotyping was performed using the SPF10-DEIA-LiPA25. HPV copy numbers were measured with type-specific qPCRs and corrected for cellular content to obtain the viral load. Concurrent genital-anal HPV often had significantly higher genital viral load (0.09–371 c/cell) than genital-only HPV (3.17E-04-15.9 c/cell, p < 0.0001 to p < 0.05). Moreover, nearly all concurrent genital-anal HPV types had higher genital copy numbers per PCR reaction (157-416E04 c/rxn) than anal copy numbers (0.90–884E01 c/rxn, p < 0.0001 to p < 0.001). Vaccinated women had significantly less infections with HPV16/18 vaccine-types (2.8% vs 13.7%, p < 0.0001) and HPV31/35/45 cross-protective types (7.4% vs 21.1%, p < 0.0001) than unvaccinated women. In conclusion, particularly high genital viral load is found in concurrent genital-anal HPV infections, which are effectively reduced by vaccination. Concurrent genital-anal HPV infections may impose a higher risk of anal cancer. These infections have increased genital viral load. The genital site is likely the main source of a concurrent genital-anal HPV infection. Vaccination effectively reduces concurrent genital-anal HPV infections.
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7
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Ramírez M, de la Fuente J, Andía D, Hernández JJ, Fiol G, Torné A. "HPV vaccination coverage in women between 15-55 years in Spain. Temporal trend during the period 2007-2020". Int J Gynaecol Obstet 2021; 158:705-713. [PMID: 34905216 DOI: 10.1002/ijgo.14067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/26/2021] [Accepted: 12/12/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Mar Ramírez
- Gynecology Oncology Unit. Institute of Women's Health José Botella Llusiá. Sanitary Research Institute of the San Carlos Clinical Hospital (IdISSC), Complutense University, Madrid, Spain
| | - Jesús de la Fuente
- Gynecology and Obstetrics Department, University Hospital Infanta Leonor, Madrid, Spain
| | - Daniel Andía
- Gynecology and Obstetrics Department, Basurto University Hospital, Bilbao, Spain
| | - Juan José Hernández
- Gynecology and Obstetrics Department, University Hospital Infanta Leonor, Madrid, Spain
| | - Gabriel Fiol
- Gynecology Oncology Unit, Torrecárdenas University Hospital, Almeria, Spain
| | - Aureli Torné
- Gynecology Oncology Unit, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Faculty of Medicine, University of Barcelona, Spain
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8
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Martinón-Torres F, García-Sastre A, Pollard AJ, Martín C, Osterhaus A, Ladhani SN, Ramilo O, Gómez Rial J, Salas A, Bosch FX, Martinón-Torres M, Mina MJ, Cherry J. TIPICO XI: report of the first series and podcast on infectious diseases and vaccines (aTIPICO). Hum Vaccin Immunother 2021; 17:4299-4327. [PMID: 34762551 PMCID: PMC8828069 DOI: 10.1080/21645515.2021.1953351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
TIPiCO is an annual expert meeting and workshop on infectious diseases and vaccination. The edition of 2020 changed its name and format to aTIPiCO, the first series and podcasts on infectious diseases and vaccines. A total of 13 prestigious experts from different countries participated in this edition launched on the 26 November 2020. The state of the art of coronavirus disease-2019 (COVID-19) and the responsible pathogen, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and the options to tackle the pandemic situation were discussed in light of the knowledge in November 2020. Despite COVID-19, the status of other infectious diseases, including influenza infections, respiratory syncytial virus disease, human papillomavirus infection, measles, pertussis, tuberculosis, meningococcal disease, and pneumococcal disease, were also addressed. The essential lessons that can be learned from these diseases and their vaccines to use in the COVID-19 pandemic were also commented with the experts.
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Affiliation(s)
- Federico Martinón-Torres
- Department of Paediatrics Translational Paediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Adolfo García-Sastre
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, Universidad de Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Carlos Martín
- Department of Microbiology, Faculty of Medicine, IIS Aragon, Universidad de Zaragoza, CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Albert Osterhaus
- Research Center Emerging Infections and Zoonoses (RIZ, University of Veterinary Medicine Hannover, Hannover, Germany
| | | | - Octavio Ramilo
- Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio, US
| | - Jose Gómez Rial
- Immunology Department, Hospital Clínico Universitario de Santiago de Compostela, Spain
| | - Antonio Salas
- Unidade de Xenética, Instituto de Ciencias Forenses (INCIFOR), Facultade de Medicina, Universidade de Santiago de Compostela, and GenPoB Research Group, Instituto de Investigacinó Sanitaria (IDIS), Hospital Clínico Universitario de Santiago (SERGAS), Galicia, Spain
| | | | | | - Michael J Mina
- Harvard School of Public Health and Harvard Medical School, Boston, MA, US
| | - James Cherry
- The David Geffen School of Medicine at UCLA, Los Angeles, CA, US
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Waheed DEN, Schiller J, Stanley M, Franco EL, Poljak M, Kjaer SK, Del Pino M, van der Klis F, Schim van der Loeff MF, Baay M, Van Damme P, Vorsters A. Human papillomavirus vaccination in adults: impact, opportunities and challenges - a meeting report. BMC Proc 2021; 15:16. [PMID: 34384438 PMCID: PMC8359761 DOI: 10.1186/s12919-021-00217-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
For more than a decade human papillomavirus (HPV) vaccine have been implemented in most high-income countries, and more recently also in several low- and middle-income countries. The vaccines are safe and their impact and effectiveness in preventing HPV vaccine type infection and associated diseases has been thoroughly established. Currently, the primary recommended cohorts for immunisation are adolescents, 9-15 years of age but HPV is an ubiquitous infection that is mainly (but not exclusively) sexually transmitted. Sexually active adults remain susceptible to infection and continued transmission of the virus, representing a reservoir of infection in the population. A recent meeting, conducted by the HPV Prevention and Control Board (HPV-PCB), reviewed the current status of HPV vaccination of adults, discussed limitations, challenges and benefits of HPV vaccination of adults, evaluated the effectiveness of HPV vaccination after treatment of post cervical cancer and precancerous lesions, and discussed the potential impact of adult vaccination on cervical cancer elimination strategies in light of the current and future HPV vaccine shortage. HPV-PCB is an independent multidisciplinary board of international experts that disseminates relevant information on HPV to a broad array of stakeholders and provides guidance on strategic, technical and policy issues in the implementation of HPV prevention and control programs. The HPV-PCB concluded that, given the current data available on adult HPV vaccination and the ongoing vaccine supply constraints, it is too early to implement routine vaccination of adults. Many research gaps need to be filled before we have a better understanding of the efficacy and broader public health impact of HPV vaccination in adult women.
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Affiliation(s)
- Dur-E-Nayab Waheed
- Centre for Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - John Schiller
- Center for Cancer Research National Cancer Institute, Bethesda, MD, 20814, USA
| | - Margaret Stanley
- Division of Cellular and Molecular Pathology, University of Cambridge, Cambridge, UK
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Susanne K Kjaer
- Danish Cancer Society Research Center, Unit of Virus, Lifestyle and Genes, and Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marta Del Pino
- Gynecology Oncology Unit. Institute Clinic of Gynecology, Obstetrics, and Neonatology (ICGON), Hospital Clínic of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Fiona van der Klis
- National Institute for Public Health and the Environment (RIVM)
- RIVM and Centre for Infectious Disease Control (CIb), Utrecht, Netherlands
| | - Maarten F Schim van der Loeff
- Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, and Amsterdam UMC, and University of Amsterdam, and Internal Medicine, Amsterdam institute for Infection and Immunity (AII), and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Marc Baay
- P95, Epidemiology and Pharmacovigilance Consulting and Services, Leuven, Belgium
| | - Pierre Van Damme
- Centre for Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Alex Vorsters
- Centre for Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium.
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Robles C, Bruni L, Acera A, Riera JC, Prats L, Poljak M, Mlakar J, Oštrbenk Valenčak A, Eriksson T, Lehtinen M, Louvanto K, Hortlund M, Dillner J, Faber MT, Munk C, Kjaer SK, Petry KU, Denecke A, Xu L, Arbyn M, Cadman L, Cuzick J, Dalstein V, Clavel C, de Sanjosé S, Bosch FX. Determinants of Human Papillomavirus Vaccine Uptake by Adult Women Attending Cervical Cancer Screening in 9 European Countries. Am J Prev Med 2021; 60:478-487. [PMID: 33358719 DOI: 10.1016/j.amepre.2020.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/27/2020] [Accepted: 08/21/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Human papillomavirus-vaccinated cohorts, irrespective of age, will likely reduce their subsequent screening requirements, thus opening opportunities for global cost reduction and program sustainability. The determinants of uptake and completion of a 3-dose human papillomavirus vaccination program by adult women in a European context were estimated. STUDY DESIGN This was an intervention study. SETTING/PARTICIPANTS Study participants were women aged 25-45 years, attending opportunistic or population-based cervical cancer screening in Belgium, Denmark, Finland, France, Germany, Slovenia, Spain, Sweden, and the United Kingdom between April 2016 and May 2018. INTERVENTION Study participants completed a questionnaire on awareness and attitudes on adult female human papillomavirus vaccination and were invited to receive free human papillomavirus vaccination. MAIN OUTCOME MEASURES Main outcome measures were acceptance, uptake, and completion of vaccination schedule. Determinants of vaccine uptake were explored using multilevel logistic models in 2019. RESULTS Among 3,646 participants, 2,748 (range by country=50%-96%) accepted vaccination, and 2,151 (range=30%-93%) received the full vaccination course. The factors associated with higher vaccine acceptance were previous awareness of adult female (OR=1.22, 95% CI=1.00, 1.48) and male (OR=1.59, 95% CI=1.28, 1.97) vaccination. Women in stable relationships (OR=0.56, 95% CI=0.45, 0.69) or with higher educational level (OR=0.76, 95% CI=0.63, 0.93) were more likely to refuse vaccination. Recruitment by postal invitation versus personal invitation from a healthcare professional resulted in lower vaccine acceptance (OR=0.13, 95% CI=0.02, 0.76). Vaccination coverage of >70% of adolescent girls in national public programs was of borderline significance in predicting human papillomavirus vaccine uptake (OR=3.23, 95% CI=0.95, 10.97). The main reasons for vaccine refusal were vaccine safety concerns (range=30%-59%) and the need for more information on human papillomavirus vaccines (range=1%-72%). No safety issues were experienced by vaccinated women. CONCLUSIONS Acceptance and schedule completion were largely dependent on recruitment method, achieved coverage of national vaccination programs, and personal relationship status. Knowledge of benefits and safety reassurance may be critical to expanding vaccination target ages. Study results suggest that there are no major opinion barriers in adult women to human papillomavirus vaccination, especially when vaccination is offered face to face in healthcare settings. TRIAL REGISTRATION EudraCT Number 2014-003177-42.
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Affiliation(s)
- Claudia Robles
- Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Laia Bruni
- Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Amelia Acera
- Atenció a la Salut Sexual i Reproductiva (ASSIR) SAP Cerdanyola-Ripollet, Institut Catala de la Salut, Barcelona, Spain; Unitat de Suport a la Recerca Metropolitana Nord, IDIAP Jordi Gol, Barcelona, Spain
| | - Joan Carles Riera
- Atenció a la Salut Sexual i Reproductiva (ASSIR) SAP Girones-Pla de l'Estany, Institut Catala de la Salut, Girona, Spain
| | - Laia Prats
- Centre Ginecològic Gine-3, Barcelona, Spain
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jana Mlakar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anja Oštrbenk Valenčak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tiina Eriksson
- Department of Health Science, University of Tampere, Tampere, Finland
| | - Matti Lehtinen
- Department of Health Science, University of Tampere, Tampere, Finland
| | - Karolina Louvanto
- Department of Obstetrics and Gynecology, University of Tampere, Tampere, Finland
| | - Maria Hortlund
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Dillner
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mette T Faber
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Christian Munk
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne K Kjaer
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karl Ulrich Petry
- Department of Gynecologic Oncology, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Agnieszka Denecke
- Department of Gynecologic Oncology, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Lan Xu
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
| | - Louise Cadman
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Véronique Dalstein
- Centre Hospitalier Universitaire (CHU) Reims, Université de Reims Champagne-Ardenne INSERM P3Cell and UMR-S 1250, SFR CAP-SANTE, Reims, France
| | - Christine Clavel
- Centre Hospitalier Universitaire (CHU) Reims, Université de Reims Champagne-Ardenne INSERM P3Cell and UMR-S 1250, SFR CAP-SANTE, Reims, France
| | - Silvia de Sanjosé
- PATH, Seattle, Washington; Centro de Investigación Biomédica en Red en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain
| | - F Xavier Bosch
- Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain; Faculty of Health Sciences, Universitat Oberta de Catalunya (UOC), Barcelona, Spain
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Balaji R, MacCosham A, Williams K, El-Zein M, Franco EL. Directionality of Genital Human Papillomavirus Infection Transmission Within Heterosexual Couples: A Systematic Review and Meta-analysis. J Infect Dis 2021; 222:1928-1937. [PMID: 32492710 DOI: 10.1093/infdis/jiaa302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Limited evidence indicates greater female-to-male (F-M) transmission of genital infection with human papillomavirus (HPV) relative to male-to-female (M-F). We verified the hypothesis of a differential transmission rate in couple-based studies by conducting a systematic review and meta-analysis. METHODS We searched MEDLINE, EMBASE, Scopus, and Cochrane Library databases for studies published until December 2019. We calculated pooled estimates of F-M and M-F transmission rates and their rate differences per 100 person-months, with 95% confidence intervals (CI), using a random-effects model. We counted occurrences of directionality preponderance for each HPV type. RESULTS We identified 7 eligible studies published between 2008 and 2019, providing data for 752 couples. Pooled estimates for F-M and M-F transmission rates were 3.01 (95% CI, 1.19-7.64; I2 = 97%) and 1.60 (95% CI, 0.86-2.98; I2 = 89%), respectively. The overall rate difference was 0.61 (95% CI, -0.27 to 1.49; I2 = 75%). Three studies provided rates by sex and HPV genotype; 2 favored a preponderance of F-M and 1 favored M-F transmission. CONCLUSIONS There was slight evidence for a differential transmission rate favoring higher F-M than M-F transmission with substantial statistical heterogeneity across studies.
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Affiliation(s)
- Rajshree Balaji
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Aaron MacCosham
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Khandideh Williams
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
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Kim CJ, Campbell SP, Allkanjari A, Lentz AC. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021; 10:240-254. [PMID: 33752995 DOI: 10.1016/j.sxmr.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions. OBJECTIVES We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options. METHODS We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020. RESULTS Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy. CONCLUSION Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021;xxx:xxx-xxx.
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Affiliation(s)
- Christopher J Kim
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Scott P Campbell
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Armand Allkanjari
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Aaron C Lentz
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
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Kuter BJ, Garland SM, Giuliano AR, Stanley MA. Current and future vaccine clinical research with the licensed 2-, 4-, and 9-valent VLP HPV vaccines: What's ongoing, what's needed? Prev Med 2021; 144:106321. [PMID: 33678229 DOI: 10.1016/j.ypmed.2020.106321] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 01/28/2023]
Abstract
Prophylactic HPV vaccination has been a great public health success. For >20 years, clinical trials were conducted with the 2-, 4-, and/or 9-valent vaccines in young-adult females, mid-adult women, males, and adolescents. In all studies, the vaccines were highly efficacious, immunogenic, and well tolerated. Following vaccine licensure and utilization in national vaccine programs globally (real-world settings primarily in high income countries), numerous studies demonstrated that the vaccines continue to have an excellent safety profile and have dramatically reduced the incidence of genital warts, HPV vaccine-type prevalence, and precancerous lesions. Thirty-eight clinical trials with the currently licensed HPV vaccines are ongoing. Key questions being addressed in new trials include: efficacy against persistent infection and immunogenicity of a 1-dose regimen; efficacy of 3 doses in 20-45-year-old females; use in postpartum women and immunocompromised individuals (HIV, liver and kidney transplants); dose sparing via intradermal administration; use in combination with a PD1 monoclonal antibody in patients with cervical cancer; impact on recurrent disease in women undergoing cervical conization; persistence of protection; and use to prevent oropharyngeal cancer. Additional clinical research that should be conducted includes: long-term follow-up, particularly of 1- and 2-dose regimens; further evaluation of flexible 2-dose regimens; immunogenicity of 1- or 2-dose regimens in persons ≥15 years old and immunocompromised populations; safety and immunogenicity of 1 or 2 doses in children <9 years old; assessment of the vaccine in the prevention of transmission; interchangeability with newer HPV vaccines; additional concomitant use studies; and prevention of penile cancer and recurrent respiratory papillomatosis.
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Affiliation(s)
- Barbara J Kuter
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Suzanne M Garland
- The University of Melbourne, The Royal Women's Hospital, and Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, United States of America
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MacCosham A, El-Zein M, Burchell AN, Tellier PP, Coutlée F, Franco EL. Transmission reduction and prevention with HPV vaccination (TRAP-HPV) study protocol: a randomised controlled trial of the efficacy of HPV vaccination in preventing transmission of HPV infection in heterosexual couples. BMJ Open 2020; 10:e039383. [PMID: 32788190 PMCID: PMC7422656 DOI: 10.1136/bmjopen-2020-039383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Human papillomavirus (HPV) is a causal agent of malignancies including cervical, vulvar, vaginal, penile, anal and oropharyngeal cancer, as well as benign conditions such as anogenital warts. HPV vaccination protects individuals against infections with the target HPV types and their clinical outcomes. However, little is known about the protection an immunised individual confers to their sexual partner or its impact on HPV transmission dynamics. In this context, the Transmission Reduction and Prevention with HPV vaccination (TRAP-HPV) study was designed to determine the efficacy of an HPV vaccine in reducing transmission of genital and oral HPV infection in sexual partners of vaccinated individuals. METHODS AND ANALYSIS The TRAP-HPV study is an ongoing randomised controlled trial among heterosexual couples living in Montreal, Canada. Sexually active couples, aged between 18 and 45 years, who have been in a relationship no longer than 6 months are considered eligible. Participants are independently randomised to receive either the intervention HPV vaccine, Gardasil 9, or a placebo hepatitis A vaccine, Avaxim, creating four vaccination groups among couples: intervention-intervention, intervention-placebo, placebo-intervention and the placebo-placebo. Participants provide genital (vaginal/penile) and oral samples at baseline and five follow-up visits over a 1-year duration. Linear Array HPV genotyping is used to detect 36 HPV types. Cox proportional hazard regression models will be used to estimate the effect of vaccination on HPV transmission. ETHICS AND DISSEMINATION The TRAP-HPV study received ethical approval by institutional review boards McGill University, Concordia University and Centre Hospitalier de l'Université de Montréal. Before enrolment, all participants provide informed written consent. Results will be published in peer-reviewed journals and presented at national and international conferences. The generated empirical evidence could be used in mathematical models of vaccination to inform policymakers in Canada and elsewhere. TRIAL REGISTRATION NUMBER NCT01824537.
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Affiliation(s)
- Aaron MacCosham
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Ann N Burchell
- Department of Family and Community Medicine and Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | | | - François Coutlée
- Service de Microbiologie Médicale et Service d'Infectiologie, Départements de Médecine et de Médecine de Laboratoire, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
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