Incremental benefits of male HPV vaccination: accounting for inequality in population 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.

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

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

A reproductive justice approach to understanding women's experiences with HPV and cervical cancer prevention

Cervical cancer is a preventable disease. HPV infection has been linked to more than 90% of cervical cancers. A vaccine to prevent the acquisition of HPV has been available since 2006. The purpose of this study was to investigate women's perceptions of cervical cancer prevention, including HPV vaccination. A reproductive justice framework guided data collection and analysis. In 2016, researchers conducted 70 in-depth, semi-structured qualitative interviews with women aged 19-78 years in South Carolina. A purposive sampling approach was employed to maximize requisite variety based on social, economic, and environmental axes of inequality. Participants self-identified as white (53%), African American (33%), and Hispanic (9%). Data analysis included an inductive constant comparative method to identify patterns and themes across the interviews. Misinformation about the prevalence and risk of HPV and cervical cancer led to "othering" of women with HPV-related diagnoses based on the flawed assumption of not being at risk. Participants described a lack of knowledge about the effectiveness and safety of the HPV vaccine. Social norms influenced participants' perceptions of HPV vaccination and cervical cancer, including concerns about sexual activity and intergenerational communication. Participants' social construction of identity, including race/ethnicity, socioeconomic position, ability, age, gender, sexual orientation, and immigration status, impacted their perceptions of cervical cancer screening and the HPV vaccine. In particular, participants believed that the HPV vaccine was "only for girls" and identified gender norms that limited uptake. Participants described barriers to accessing health care and cervical cancer screening, including cost, health insurance, and life changes (e.g., pregnancy, relocating). Many participants experienced an abnormal Papanicolaou test and described follow-up care, including biopsies and treatment for cervical dysplasia. Findings from this study offer insight into women's identity and perceptions of cervical cancer prevention. Results provide practical recommendations to increase women's agency in the development of successful public health interventions.

Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study

BACKGROUND

Health equality is increasingly being considered alongside overall health gain when assessing public health interventions. However, the trade-off between the direct effects of vaccination and herd immunity could lead to unintuitive consequences for the distribution of disease burden within a population. We used a transmission dynamic model of human papillomavirus (HPV) to investigate the effect of ethnic disparities in vaccine and cervical screening uptake on inequality in disease incidence in England.

METHODS

We developed an individual-based model of HPV transmission and disease, parameterising it with the latest data for sexual behaviour (from National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) and vaccine and screening uptake by ethnicity (from Public Health England [PHE]) and fitting it to data for HPV prevalence (from ARTISTIC, PHE, Natsal-3) and HPV-related disease incidence (from National Cancer Registry [ONS]). The outcome of interest was the age-adjusted incidence of HPV-related cancer (both cervical and non-cervical) in all women in England in view of differences and changes in vaccination and screening uptake by ethnicity in England, over time. We also studied three potential public health interventions aimed at reducing inequality in HPV-related disease incidence: increasing uptake in black and Asian females to match that in whites for vaccination; cervical screening in women who turn 25 in 2018 or later; and cervical screening in all ages.

FINDINGS

In the pre-vaccination era, before 2008, women from ethnic minorities in England reported a disproportionate share of cervical disease. Our model suggests that Asian women were 1·7 times (95% credibility interval [CI] 1·1-2·7) more likely to be diagnosed with cervical cancer than white women (22·8 vs 13·4 cases per 100 000 women). Because HPV vaccination uptake is lower in ethnic minorities, we predict an initial widening of this gap, with cervical cancer incidence in Asian women up to 2·5 times higher (95% CI 1·3-4·8) than in white women 20 years after vaccine introduction (corresponding to an additional 10·8 [95% CI 10·1-11·5] cases every year). In time, we predict that herd immunity benefits will diffuse from the larger white sub-population and the disparity will narrow. Increased cervical screening uptake in vaccinated women from ethnic minorities would lead to rapid improvement in equality with parity in incidence after 20 years of HPV vaccination.

INTERPRETATION

Our study suggests that the introduction of HPV vaccination in England will initially widen a pre-existing disparity in the incidence of HPV-related cancer by ethnicity, partly due to herd immunity disproportionately benefiting subgroups with high vaccination rates. Although in time this induced disparity will narrow, increasing cervical screening uptake in girls from ethnic minorities should be encouraged to eliminate the inequality in cervical cancer incidence in the medium term. We recommend that dynamic effects should be considered when estimating the effect of public health programmes on equality.

FUNDING

Cancer Research UK.

Human papillomavirus vaccination: the population impact

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

Extending the Human Papillomavirus Vaccination Programme to Include Males in High-Income Countries: A Systematic Review of the Cost-Effectiveness Studies

BACKGROUND AND OBJECTIVES

Giving the human papillomavirus (HPV) vaccination to females has been shown to be cost-effective in most countries. The epidemiological evidence and economic burden of HPV-related diseases have gradually been shown to be gender neutral. Randomized clinical trials report high efficacy, immunogenicity and safety of the HPV vaccine in males aged 16-26 years. Some pioneering countries extended their HPV vaccination programme to include males, regardless of the cost-effectiveness analysis results. Nevertheless, decision makers need evidence provided by modelling and economic studies to justify the funding of mass vaccination. This systematic review aims to assess the cost-effectiveness of extending the HPV vaccination programme to include males living in high-income countries.

METHODS

A systematic review of the cost-effectiveness analyses of HPV vaccination in males was performed. Data were extracted and analysed using a checklist adapted from the Consolidated Health Economic Evaluation Reporting Standards Statement.

RESULTS

Seventeen studies and 12 underlying mathematical models were identified. Model filiation showed evolution in time from aggregate models (static and dynamic) to individual-based models. When considering the health outcomes HPV vaccines are licensed for, regardless of modelling approaches and assumptions, extending vaccinations to males is rarely found to be cost-effective in heterosexual populations. Cost-effectiveness ratios become more attractive when all HPV-related diseases are considered and when vaccine coverage in females is below 40%.

CONCLUSION

Targeted vaccination of men who have sex with men (MSM) seems to be the best cost-effectiveness option. The feasibility of this strategy is still an open question, since early identification of this specific population remains difficult.

Effectiveness Modelling and Economic Evaluation of Primary HPV Screening for Cervical Cancer Prevention in New Zealand

Background

New Zealand (NZ) is considering transitioning from 3-yearly cervical cytology screening in women 20–69 years (current practice) to primary HPV screening. We evaluated HPV-based screening in both HPV-unvaccinated women and cohorts offered HPV vaccination in New Zealand (vaccination coverage ~50%).

Methods

A complex model of HPV transmission, vaccination, cervical screening, and invasive cervical cancer was extensively validated against national population-based datasets. Sixteen potential strategies for HPV screening were considered.

Results

Most primary HPV strategies were more effective than current practice, for both unvaccinated women and cohorts offered vaccination. The optimal strategy for both groups was 5-yearly HPV screening in women aged 25–69 years with partial genotyping for HPV 16/18 and referral to colposcopy, and cytological triage of other oncogenic types. This is predicted to reduce cervical cancer incidence and mortality by a further 12–16% and to save 4–13% annually in program costs (excluding overheads). The findings are sensitive to assumptions about future adherence to initiating screening at 25 years.

Conclusion

Primary HPV screening with partial genotyping would be more effective and less costly than the current cytology-based screening program, in both unvaccinated women and cohorts offered vaccination. These findings have been considered in a review of cervical screening in NZ.

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

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

Human papilloma virus vaccination: impact and recommendations across the world

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

Human papillomavirus vaccination for men: advancing policy and practice

ABSTRACT 

The quadrivalent HPV vaccine (HPV4) is safe and highly efficacious, and can significantly reduce the burden of HPV-related genital warts and cancers among men, in addition to promoting herd immunity. Nevertheless, HPV4 coverage among boys remains low in most settings. Research to date has focused predominantly on HPV vaccination of girls to prevent cervical cancer. Most countries with publicly funded healthcare where HPV4 is licensed cover the costs of HPV vaccination programs for girls only. We critically review the evidence for extending publicly funded HPV vaccination programs to boys in addition to girls. After an overview of research on HPV prevalence and associated cancers among men, we review cost–effectiveness studies, benefits of universal versus targeted vaccination approaches and multifaceted health equity concerns, along with directions in vaccine delivery programs and intervention research to promote HPV vaccine uptake for boys. Comprehensive evaluation of the systematic exclusion of boys from publicly financed HPV vaccination programs is warranted given tremendous public health implications of new infections and subsequent cancers that could have otherwise been averted.