Safety of human papillomavirus vaccines: a review

Vaccine hesitancy and equity: lessons learned from the past and how they affect the COVID-19 countermeasure in Indonesia

INTRODUCTION

Indonesia has made progress in increasing vaccine coverage, but equitable access remains challenging, especially in remote areas. Despite including vaccines in the National Immunization Program (NIP), coverage has not met WHO and UNICEF targets, with childhood immunization decreasing during the COVID-19 pandemic. COVID-19 vaccination has also experienced hesitancy, slowing efforts to end the pandemic.

SCOPE

This article addresses the issue of vaccine hesitancy and its impact on vaccination initiatives amidst the COVID-19 pandemic. This article utilizes the vaccine hesitancy framework to analyze previous outbreaks of vaccine-preventable diseases and their underlying causes, ultimately providing recommendations for addressing the current situation. The analysis considers the differences between the pre-pandemic circumstances and the present and considers the implementation of basic and advanced strategies.

KEY FINDINGS AND CONCLUSION

Vaccine hesitancy is a significant challenge in the COVID-19 pandemic, and public health campaigns and community engagement efforts are needed to promote vaccine acceptance and uptake. Efforts to address vaccine hesitancy promote trust in healthcare systems and increase the likelihood of individuals seeking preventive health services. Vaccine hesitancy requires a comprehensive, culturally sensitive approach that considers local contexts and realities. Strategies should be tailored to specific cultural and societal contexts and monitored and evaluated.

Adaptation and Formative Evaluation of Online Decision Support to Implement Evidence-Based Strategies to Increase HPV Vaccination Rates in Pediatric Clinics

Human papilloma virus (HPV) vaccination rates remain below national goals in the United States despite the availability of evidence-based strategies to increase rates. The Adolescent Vaccination Program (AVP) is a multi-component intervention demonstrated to increase HPV vaccination rates in pediatric clinics through the implementation of six evidence-based strategies. The purpose of this study, conducted in Houston, Texas, from 2019-2021, was to adapt the AVP into an online decision support implementation tool for standalone use and to evaluate its feasibility for use in community clinics. Phase 1 (Adaptation) comprised clinic interviews (n = 23), literature review, Adolescent Vaccination Program Implementation Tool (AVP-IT) design documentation, and AVP-IT development. Phase 2 (Evaluation) comprised usability testing with healthcare providers (HCPs) (n = 5) and feasibility testing in community-based clinics (n = 2). AVP-IT decision support provides an Action Plan with tailored guidance on implementing six evidence-based strategies (immunization champions, assessment and feedback, continuing education, provider prompts, parent reminders, and parent education). HCPs rated the AVP-IT as acceptable, credible, easy, helpful, impactful, and appealing (≥80% agreement). They rated AVP-IT supported implementation as easier and more effective compared to usual practice (p ≤ 0.05). The clinic-based AVP-IT uses facilitated strategy implementation by 3-month follow-up. The AVP-IT promises accessible, utilitarian, and scalable decision support on strategies to increase HPV vaccination rates in pediatric clinic settings. Further feasibility and efficacy testing is indicated.

Combination therapy between prophylactic and therapeutic human papillomavirus (HPV) vaccines with special emphasis on implementation of nanotechnology

Human papillomavirus (HPV) is the most prevalent sexually transmitted disease in the world. Even though preventive vaccines against HPV are effective, the effective treatment of HPV infections is much less satisfactory due to multi-drug resistance and secondary adverse effects. Nanotechnology was employed for the delivery of anti-cancer drugs to increase the effectiveness of the treatment and minimize the side effects. Nanodelivery of both preventive and therapeutic HPV vaccines has also been studied to boost vaccine efficacy. Overall, such developments suggest that the nanoparticle-based vaccine might emerge as the most cost-effective way to prevent and treat HPV cancer, assisted or combined with another nanotechnology-based therapy. This review focuses on the current knowledge on pathogenesis and vaccines against HPV, highlighting the current value and perspective regarding the widespread diffusion of HPV vaccines-based nanomaterials. The ongoing advancements in the design of vaccines-based nanomaterials are expanding their therapeutic roles against HPV.

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

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

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

Real-Life Safety Profile of the 9-Valent HPV Vaccine Based on Data from the Puglia Region of Southern Italy

Human Papillomavirus (HPV) is responsible for epithelial lesions and cancers in both males and females. The latest licensed HPV vaccine is Gardasil-9^®, a 9-valent HPV vaccine which is effective not only against the high-risk HPV types, but also against the ones responsible for non-cancerous lesions. This report describes adverse events following Gardasil-9^® administration reported in Puglia, southern Italy, from January 2018 to November 2021. This is a retrospective observational study. Data about the adverse events following immunization (AEFIs) with Gardasil-9^® were collected from the Italian Drug Authority database. AEFIs were classified as serious or non-serious accordingly to World Health Organization guidelines, and serious ones underwent causality assessment. During the study period, 266,647 doses of 9vHPVv were administered in Puglia and 22 AEFIs were reported, with a reporting rate (RR) of 8.25 per 100,000 doses. The most reported symptoms were neurological ones (7/22). A total of 5 (22.7%) AEFIs were classified as serious, and 2 of these led to the patient’s hospitalization. In one case, permanent impairment occurred. Following causality assessment, only 2 out of 5 serious AEFIs were deemed to be consistently associated with the vaccination (RR: 0.750 per 100,000 doses). The data gathered in our study are similar to the pre-licensure evidence as far as the nature of the AEFIs is concerned. The reporting rate, though, is far lower than the ones described in clinical trials, likely due to the different approach to data collection: in our study, data were gathered via passive surveillance, while pre-marketing studies generally employ active calls for this purpose. Gardasil-9^®’s safety profile appears to be favorable, with a low rate of serious adverse events and a risk/benefits ratio pending for the latter.

COVID-19 Vaccine Hesitancy and Resistance in India Explored through a Population-Based Longitudinal Survey

BACKGROUND

The World Health Organization has recommended that individual governments identify vaccine hesitancy areas. It is proposed that the governments, with the aid of local organizations, educate and implement social insights on the vaccination so that high population levels are covered with this safe immune program.

METHODS

A longitudinal online survey covered 3000 adults from India. We examined the demography, behavioral (socio-economic) attitude, vaccine hesitancy, vaccine resistance for the COVID-19 vaccine. The specific reasons for the COVID-19 vaccine decline were also evaluated.

RESULTS

Our survey revealed 59% definite response, 29% low-level response, and 7% high-level response for vaccine hesitancy, while 6% had resistant views on the COVID-19 vaccine. Individuals who had higher income levels, lived in a society, maintained social distancing, had downloaded the COVID-19 update app, showed a positive attitude towards their government, and more confidence in their healthcare system were more inclined towards the vaccination. On the contrary, individuals who had overstated the risks of COVID-19 and had a religious and populistic attitude towards vaccination were more hesitant/resistant to vaccination. The respondents who declined vaccine administration were further evaluated for their specific reason for their response. The most common reasons for declining the COVID-19 vaccine were post-vaccine scare of adverse health effects and accepting the information spread by social media.

CONCLUSIONS

The results in our study show that by identifying population "hot spots" that have negative or unclear information on the COVID-19 vaccination, these "hot spots" can be addressed by involving friendly organizations that can clear their strong disbeliefs and increase the percentage of vaccine-definite people within the population. The role of government-induced COVID-19 vaccine policy measures can always be beneficial to cause this shift from disbelief to confidence within the population.

Plant-Derived Natural Compounds in Genetic Vaccination and Therapy for HPV-Associated Cancers

Simple Summary

DNA vaccination represents a useful approach for human papillomavirus (HPV) cancer therapy. The therapeutic potential of plant-based natural compounds for control of HPV- associated cancers has been also widely explored. Genetic vaccines for HPV-associated tumors that include plant protein-encoding gene sequences, used alone or in combinations with plant metabolites, are being investigated but are still in their infancy. Main focus of this paper is to provide an overview of the current state of novel therapeutic strategies employing genetic vaccines along with plant-derived compounds and genes. We highlight the importance of multimodality treatment regimen such as combining immunotherapy with plant-derived agents.

Abstract

Antigen-specific immunotherapy and, in particular, DNA vaccination provides an established approach for tackling human papillomavirus (HPV) cancers at different stages. DNA vaccines are stable and have a cost-effective production. Their intrinsic low immunogenicity has been improved by several strategies with some success, including fusion of HPV antigens with plant gene sequences. Another approach for the control of HPV cancers is the use of natural immunomodulatory agents like those derived from plants, that are able to interfere in carcinogenesis by modulating many different cellular pathways and, in some instances, to reduce chemo- and radiotherapy resistance of tumors. Indeed, plant-derived compounds represent, in many cases, an abundantly available, cost-effective source of molecules that can be either harvested directly in nature or obtained from plant cell cultures. In this review, an overview of the most relevant data reported in literature on the use of plant natural compounds and genetic vaccines that include plant-derived sequences against HPV tumors is provided. The purpose is also to highlight the still under-explored potential of multimodal treatments implying DNA vaccination along with plant-derived agents.

Human papillomavirus (HPV) vaccine status and knowledge of students at a university in rural Thailand

Background

Human papillomavirus (HPV) is a sexually transmitted virus that causes cancers of the cervix, anus, vagina, penis, and oropharynx. HPV vaccination prevents HPV types that commonly cause these cancers. HPV vaccines have been approved in Thailand since 2007. However, the vaccination rate remains low, particularly in young people.

Objectives

This study aimed to investigate the information level regarding HPV infection and vaccination in the younger Thai population, the self-reported vaccination rate, the vaccine intention, and factors affecting the intention.

Methods

This cross-sectional study enrolled a total of 521 undergraduate students (77% female). We used a 34 items self-administered questionnaire (18 questions assessing knowledge level).

Results

The mean score of knowledge was 7.53 ± 4.95 (total score 18), indicating a low-to-moderate level of knowledge. Female gender and health-related majors were significant factors associated with greater knowledge. The self-reported vaccination rate was 1.9% among only female participants. Only 30.3% of the unvaccinated subjects had the intention to receive the vaccine. The factors affecting vaccine intention were female gender and having knowledge score ≥7. The barriers to HPV vaccination were cost (52.2%), and the perception of no need due to low-risk behavior (45.1%).

Conclusion

Education programs on HPV infection and vaccination should be included in the curriculum earlier, if possible, since primary school because the vaccine works best before the onset of sexual activity. In university students, the education programs may encourage the sexually inexperienced students to receive the vaccines, as they are still the ideal group for catch-up vaccination. Moreover, parental education is essential, as national vaccination programs usually target younger people. Knowledge sharing by educated people and organizations could enhance the information level in the communities. Consequently, people become aware of primary prevention by vaccination, which may lead to an increase in vaccination rates and eventually decrease HPV-related cancers.

HPV knowledge and vaccine acceptance among European adolescents and their parents: a systematic literature review

BACKGROUND

Since the introduction of HPV vaccines, several studies have been conducted in different countries to assess HPV knowledge and vaccine acceptance. The aim of this study was to perform a systematic literature review to summarize results and identify factors associated with HPV knowledge and vaccine acceptance in adolescents and their parents and to compile the measurement tools used in the published research studies performed in European countries where HPV is licensed.

METHODS

A systematic literature review was conducted for studies published between January 1st 2006 and December 31st 2017.

RESULTS

Seventy non-interventional studies performed in 16 European countries met the inclusion criteria. Thirty-eight of them reported data on HPV knowledge and 40 reported data on HPV vaccine acceptance. Further, 51.8% of adolescents (range 0% to 98.6%) and 64.4% of parents (range 1.7% to 99.3%) knew about HPV infection. Insufficient information and safety concerns were the main barriers to vaccination acceptance.

CONCLUSION

HPV knowledge and vaccine acceptance are still modest and vary widely between studies across EU countries. Coordinated efforts should be made to provide the relevant population with information for informed decision-making about HPV vaccination.

Signal detection of human papillomavirus vaccines using the Korea Adverse Events Reporting System database, between 2005 and 2016

Background Adverse events (AEs) not listed on drug labels have recently been reported in young girls vaccinated against HPV, but signal detection related to the human papillomavirus (HPV) vaccine has never been conducted in South Korea using the Korea Adverse Event Reporting System database of Korea Institute of Drug Safety & Risk Management at Ministry of Food and Drug Safety. Objective To analyze signals associated with HPV vaccines using the Korean spontaneous AEs reporting system and data-mining methods and compare the results to current vaccine label information in South Korea and the United States of America, United Kingdom, European Union, and Japan to detect signals not currently listed on the labels. Setting We evaluated the Korea Institute of Drug Safety & Risk Management database from January 2005 to December 2016. After pre-screening the data, the adjusted total numbers of HPV-related AE reports and AEs were 2566 and 4748 and those of all other vaccine-related AE reports and AEs were 21,878 and 120,688, respectively. Methods Three data mining algorithms (proportional reporting ratio, reporting odds ratio and information component) were used to assess AEs. A signal was defined when the criteria for all three indicators were satisfied. The detected signals were compared to the label information of HPV vaccines from South Korea, the United States of America, United Kingdom, European Union, and Japan. Main outcome measure Signals of AE after HPV vaccination, which met all three data mining indices. Results In this study, we found a total 97 signals of AE after HPV vaccination. Of these, 78 AEs were already present on the HPV vaccine labels of South Korea and the following 19 AEs were not listed: neuralgia, tremor, neuritis, depersonalization, axillary pain, personality disorder, increased salivation, peptic ulcer, circulatory failure, hypotension, peripheral ischemia, cerebral hemorrhage, micturition disorder, facial edema, ovarian cyst, weight increase, pain anxiety, oral edema, and back pain. Moreover, AE information on the current HPV vaccine labels of South Korea, the United States of America, United Kingdom, European Union, and Japan was inconsistent. When comparing the 19 AE signals that were not listed on the drug label in South Korea with the labels from the other countries, neuritis, axillary pain, cerebral hemorrhage, facial edema, pain anxiety, and back pain appreared on the U.S. Food and Drug Administration HPV vaccine labels but not on the United Kingdom labels, and hypotension was listed only on labels in the European Union and Japan. Conclusions South Korea should develop a system for proactively updating HPV labels. These results also suggest potential research directions such as vaccination label expansion, pharmacovigilance studies, and identification of causality in AEs associated with HPV vaccination.

Papillomavirus and cancers: should we extend vaccination to boys in France?

Background

In 2006, the HPV (Human papillomavirus) 6/11/16/18 quadrivalent vaccine was approved by the European Medicines Agency and obtained its marketing authorization in both girls and boys. Currently, the French guidelines recommend and refund vaccination of girls aged 11 to 14 with a catch-up program for females from 15 to 19 years old.

Discussion

In France, HPV vaccination coverage tends to decrease. At the end of 2015, the vaccination coverage with three doses reached only 14% in 16-year-old girls (three doses). Although men are also affected by HPV-related diseases such as anal cancer, ano-genital warts, penile cancer or upper aerodigestive tract cancer, vaccine recommendations in France are for girls only. To face the high prevalence of anal cancer and related diseases, the best option is vaccination. Moreover, by offering men a way to prevent diseases against which they do not have any protection yet, universal vaccination could better take into account the ethical issues of prevention. In this paper, we present the point of view of different medical specialties concerning the potential benefit of extending vaccination to boys.

Conclusion

HPV vaccination of both genders could benefit from a better public acceptance and contribute to a better coverage, especially in countries with low vaccination rates.

Post Marketing Surveillance Study of 2nd Dose Quadrivalent Human Papilloma Virus Vaccine in Elementary School Children in Jakarta, Indonesia: Safety Result and Implementation of School-Based HPV Immunization Program

Objective: Quadrivalent human papillomavirus (QHPV) vaccine has been advised for routine vaccination of pre-adolescent girls globally, and a two-dose QHPV vaccination schedule has been introduced in Indonesia to vaccinate 5th and 6th grade elementary school female students. This post-marketing surveillance study evaluated the possible adverse events following immunization with the two-dose QHPV vaccine in Indonesia. Methods: Girls studying in grade 6 of five designated elementary schools in Jakarta, receiving their 2nd dose of QHPV vaccine and provided informed consent (represented by their parents), were included in the study. Students who had received other immunizations either simultaneously or <1 month ago were excluded. Local and systemic reactions noted at 30 min, and 72 h to 28th day, after the immunization were recorded using a Children Symptom Dairy Card/Kartu Harian Anak Sekolah (KHAS/ Student Daily Card). Results: A total of 500 students from 20 schools were included. No serious adverse events were reported during the study period. Fever (systemic reaction) of mild intensity was noted in 1.6 % (n=8) of participants, which subsided after day 6. Local reactions such as pain, redness and swelling were noted in 59.6% (n=295), 23.6% (n=118), and 17.2% (n=86) of participants, respectively. These resolved without any intervention in majority of the cases after day 5. Conclusion: These results along with the safety data from the pre-licensure clinical trials confirm the favorable safety profile of QHPV vaccine in pre-adolescent girls. The school-based two-dose QHPV immunization program in Indonesia is a safe and effective strategy for optimizing HPV vaccine coverage among pre-adolescent girls.

Situation of Human Papilloma Virus: Generalities and current treatments

Human papillomavirus represents the commonest STD, and it is the principal causative agent of different genital lesions, including genital warts and cervical cancer. Two high-risk HPV genotypes are responsible for the 70% of cervical cancer, and the prevalence of these types reaches alarming levels in many developing countries (e.g., 43.58% in Ecuador). However, the information about HPV in developing countries is limited, becoming an obstacle for breakthrough treatments or prevention strategies. Current strategies include the development of new vaccines, combined chemo- and radiotherapy, and the use of CRISPR/Cas9. Moreover, HPV can be used to treat other non-related cancers, such as ovarian cancer. The present review aims to describe the different prevention strategies and treatments for HPV available worldwide, cover the usage of HPV for the treatment of other diseases, as well as comment on their possible application in Ecuador.

Persuasive messaging for human papillomavirus vaccination by adolescent providers in a five-country multi-site study

OBJECTIVE

Strong persuasive messaging by providers is a key predictor for patient acceptance of prophylactic human papillomavirus vaccination. We aimed to determine optimal messaging to promote human papillomavirus adolescent vaccination across different geographical sites.

METHODS

Adolescent providers (n = 151) from Argentina, Malaysia, South Africa, South Korea, and Spain were surveyed on messages, family decision makers, and sources of communication to best motivate parents to vaccinate their adolescent daughters overall, and against human papillomavirus. Multivariate logistic regression assessed the likelihood of recommending messages specifically targeted at cervical cancer with providers' characteristics: gender, medical specialization, and previous administration of human papillomavirus vaccination.

RESULTS

Mothers were considered the most important human papillomavirus vaccination decision makers for their daughters (range 93%-100%). Television was cited as the best source of information on human papillomavirus vaccination in surveyed countries (range 56.5%-87.1%), except Spain where one-on-one discussions were most common (73.3%). Prevention messages were considered the most likely to motivate parents to vaccinate their daughters overall, and against human papillomavirus, in all five countries (range 30.8%-55.9%). Optimal messages emphasized cervical cancer prevention, and included strong provider recommendation to vaccinate, vaccine safety and efficacy, timely vaccination, and national policy for human papillomavirus vaccination. Pediatricians and obstetricians/gynecologists were more likely to cite that the best prevention messages should focus on cervical cancer (OR: 4.2, 95% CI: 1.17 to 15.02 vs other medical specialists).

CONCLUSIONS

Provider communication messages that would motivate parents to vaccinate against human papillomavirus were based on strong recommendation emphasizing prevention of cervical cancer. To frame convincing messages to increase vaccination uptake, adolescent providers should receive updated training on human papillomavirus and associated cancers, while clearly addressing human papillomavirus vaccination safety and efficacy.

Medicine and the media: the ethics of virtual medical encounters

The expansion of new forms of public media, including social media, exposes clinicians to more illness experiences/narratives than ever before and increases the range of ways to interact with the people depicted. Existing professional regulations and ethics codes offer very limited guidance for such situations. We discuss the ethics of responding to such scenarios through presenting three cases of clinicians encountering television or social media stories involving potential unmet healthcare needs. We offer a structured framework for health workers to think through their responses to such situations, based around four key questions for the clinician to deliberate upon: who is vulnerable to harm; what can be done; who is best placed to do it; and what could go wrong? We illustrate the application of this framework to our three cases.

Advances in Designing and Developing Vaccines, Drugs and Therapeutic Approaches to Counter Human Papilloma Virus

Human papillomavirus (HPV) is a viral infection with skin-to-skin based transmission mode. HPV annually caused over 500,000 cancer cases including cervical, anogenital and oropharyngeal cancer among others. HPV vaccination has become a public-health concern, worldwide, to prevent the cases of HPV infections including precancerous lesions, cervical cancers, and genital warts especially in adolescent female and male population by launching national programs with international alliances. Currently, available prophylactic and therapeutic vaccines are expensive to be used in developing countries for vaccination programs. The recent progress in immunotherapy, biotechnology, recombinant DNA technology and molecular biology along with alternative and complementary medicinal systems have paved novel ways and valuable opportunities to design and develop effective prophylactic and therapeutic vaccines, drugs and treatment approach to counter HPV effectively. Exploration and more researches on such advances could result in the gradual reduction in the incidences of HPV cases across the world. The present review presents a current global scenario and futuristic prospects of the advanced prophylactic and therapeutic approaches against HPV along with recent patents coverage of the progress and advances in drugs, vaccines and therapeutic regimens to effectively combat HPV infections and its cancerous conditions.

Achieving high HPV vaccine completion rates in a pediatric clinic population

Objective: To evaluate the efficacy of an intervention utilizing patient navigators (PNs) to 1) educate families on human papillomavirus (HPV) vaccination in a clinic setting and 2) provide personalized reminders for follow-up. Method: Families with 9-17 year-old children who had no record of completing the HPV vaccination series receiving primary or specialty care in 3 pediatric clinics were approached by PNs between February 1, 2015 and August 31, 2016. Demographic characteristics, visit type, preferred contact method, rates and correlates of completion, and appointments missed were analyzed. In addition, qualitative interviews of 21 providers and PNs assessed their perceptions of the program. Results: 1,391 adolescents were identified out of 2,162 patients approached as unvaccinated or partially vaccinated prior starters; among the unvaccinated, 930 received the 1st dose after being counseled by the PN (66.9%), either immediately or at a follow-up visit soon thereafter. This included 118 siblings of patients who did not have an appointment that day. Of initiators approached between 2/1/2015 and 8/31/2016, 93% (864/930) completed the series by 8/31/2017. No differences in series completion among initiators were observed by gender or race/ethnicity, but older patients (15-17 years old) were less likely to complete than 11-12 year olds. Of the 688 patients identified as prior starters, 85% completed the series through the program. Qualitative interviews demonstrated that providers felt the program addressed major barriers to HPV vaccination. Conclusion: Employing PNs dramatically increased HPV vaccine series completion among boys and girls with historically low HPV vaccination rates at pediatric clinics in Texas. Clinic providers felt this program addressed many barriers they observed prior to program implementation. This approach could markedly improve HPV vaccine series completion rates in the US.

What is the most useful tool in HPV vaccine promotion? Results from an experimental study

Introduction: Human papillomavirus infection (HPV) affects 70-80% of female population throughout the lifetime, exposing them to the risk of developing genital warts and cervical cancer. Despite these correlated risks and the demonstrated efficacy of the vaccine, coverage rates for two-three doses are around 70% in Italy and 67% in Piemonte (below the expected 95%). Aim of the study is to investigate whether this situation is due to a lack of information and awareness among young adults. Results: Students showed increased knowledge after the intervention and more than 90% found the 3 informative materials as sources of useful information. After the intervention students would strongly recommend HPV vaccination (OR = 3.45; p < 0.001). Discussion: Higher rates of correct answers after the distribution of informative material underline the importance of knowledge delivery. Differences among the kind of material were reported; it appears that a combination of leaflet's positive features, such as clarity and intelligibility, and article's completeness of information represents the best solution to reach communication goals in vaccination campaigns targeted on educated populations. Methods: Researchers conducted an experimental study on a large population of undergraduate students from University of Turin. Participants' knowledge about HPV was assessed with questionnaires before and after the examination of 3 different kinds of informative material (journal article describing HPV infection, gynecologist video-interview and institutional leaflet about HPV prevention) on HPV and vaccine. Differences among groups were explored by using univariate tests, differences in pre- post- knowledge were assessed with McNemar tests. Relevant associations were searched with logistic regression models.

Simultaneous Bilateral Optic Neuritis Following Human Papillomavirus Vaccination in a Young Child

Vaccination-induced optic neuritis is not common. The development of optic neuritis following various vaccinations have been reported, suggesting a possible association between optic neuritis and vaccination. Of those reported cases, influenza vaccines have been the most common. Although rare, those patients who developed optic neuritis following HPV vaccination also presented with other central nervous system (CNS) demyelinating syndromes, especially following a booster dose. We present a rare case of simultaneous isolated bilateral optic neuritis following the first dose of an HPV vaccination in a young child. She received treatment with a systemic corticosteroid that resulted in a good clinical outcome without developing any demyelinating disease.

Safety of bivalent human papillomavirus vaccine in the US vaccine adverse event reporting system (VAERS), 2009-2017

AIMS

Human papillomavirus (HPV) vaccines prevent infection with oncogenic virus types. We analysed reports to the US Vaccine Adverse Event Reporting System (VAERS) of adverse events (AE) following bivalent HPV vaccine (2vHPV).

METHODS

We conducted descriptive analysis of 2vHPV reports, reviewed individual reports, calculated crude AE reporting rates and conducted empirical Bayesian data mining.

RESULTS

Of 241 2vHPV reports, 158 were in females, 64 in males (2vHPV is approved for females only) and 19 with unknown sex; 95.8% were classified as nonserious. Dizziness, headache, nausea and injection site reactions were the most common symptoms. Crude AE reporting rates were 33.3 reports per 100 000 doses distributed overall, and 1.4 per 100 000 for serious reports. Empirical Bayesian data mining identified disproportional reporting for three types of medical errors; assessment indicated findings that were probably driven by inadvertent 2vHPV use in males.

CONCLUSIONS

We did not identify any new or unexpected safety concerns in our review of 2vHPV reports to VAERS.

The association of adverse events with bivalent human papilloma virus vaccination: A nationwide register-based cohort study in Finland

BACKGROUND

A bivalent HPV vaccine (Cervarix®; HPV2, GlaxoSmithKline) was introduced into the Finnish national vaccination programme (NVP) in November 2013 for girls aged 11-13 years with a catch-up for 14-15 year-olds. We evaluated the association between HPV2 and selected autoimmune diseases and clinical syndromes by conducting a nation-wide retrospective register-based cohort study.

METHODS

First life-time occurrences of the relevant ICD-10 codes in girls aged 11-15 years between Nov-2013 and Dec-2016 were obtained from the national hospital discharge register. Population denominators were obtained from the Population Information System and vaccination records from the National Vaccination Register. Registers were linked using unique personal identity codes. Association between HPV2 and 38 selected outcomes were studied using Cox regression, with age as the main time-scale and the first vaccination dose as the time-dependent exposure. The hazard ratios (HR) with 95%CI were assessed according to the time since exposure (entire follow-up, 0-180/181-365/>365 days).

RESULTS

Of 240 605 girls eligible for HPV2 vaccination, 134 615 (56%) were vaccinated. After adjustment for geographical area (6 hospital districts), country of origin (Finnish-born/not) and number of hospital contacts from 9 through 10 years of age, HRs ranged from 0.34 (95%CI 0.11-1.05) to 8.37 (95%CI 0.85-82.54) and HPV2 vaccination was not statistically significantly associated with a higher risk of any outcome during the entire follow-up.

CONCLUSIONS

This study found no significantly increased risk for the selected outcomes after the HPV vaccination in girls 11-15 years of age. These results provide valid evidence to counterbalance public scepticism, fears of adverse events and possible opposition to HPV vaccination and consequently can contribute to increase HPV vaccination coverage in Finland as well as elsewhere.

Amyotrophic Lateral Sclerosis after Receiving the Human Papilloma Virus Vaccine: A Case Report of a 15-year-old Girl

We herein report a 15-year-old girl who developed rapid progressive muscle weakness soon after the third injection of a bivalent human papilloma virus (HPV) vaccine. Although immunotherapies were performed for possible vaccine-related disorders, she died of respiratory failure 14 months after the onset of the disease. A genetic analysis identified a heterozygous p.P525L mutation of the fused in sarcoma (FUS) gene, and a histopathological analysis was also consistent with FUS-associated amyotrophic lateral sclerosis (ALS) without any evidence of neuroinflammation. We concluded the diagnosis to be FUS-ALS, although we cannot completely rule out the possibility that the vaccination worked as a trigger.

Assessment of Quadrivalent Human Papillomavirus Vaccine Safety Using the Self-Controlled Tree-Temporal Scan Statistic Signal-Detection Method in the Sentinel System

The self-controlled tree-temporal scan statistic-a new signal-detection method-can evaluate whether any of a wide variety of health outcomes are temporally associated with receipt of a specific vaccine, while adjusting for multiple testing. Neither health outcomes nor postvaccination potential periods of increased risk need be prespecified. Using US medical claims data in the Food and Drug Administration's Sentinel system, we employed the method to evaluate adverse events occurring after receipt of quadrivalent human papillomavirus vaccine (4vHPV). Incident outcomes recorded in emergency department or inpatient settings within 56 days after first doses of 4vHPV received by 9- through 26.9-year-olds in 2006-2014 were identified using International Classification of Diseases, Ninth Revision, diagnosis codes and analyzed by pairing the new method with a standard hierarchical classification of diagnoses. On scanning diagnoses of 1.9 million 4vHPV recipients, 2 statistically significant categories of adverse events were found: cellulitis on days 2-3 after vaccination and "other complications of surgical and medical procedures" on days 1-3 after vaccination. Cellulitis is a known adverse event. Clinically informed investigation of electronic claims records of the patients with "other complications" did not suggest any previously unknown vaccine safety problem. Considering that thousands of potential short-term adverse events and hundreds of potential risk intervals were evaluated, these findings add significantly to the growing safety record of 4vHPV.

Cross-sectional associations between psychological traits, and HPV vaccine uptake and intentions in young adults from the United States

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and can lead to the development of genital warts, and cancers throughout the body. Despite the availability of HPV vaccines for over a decade, uptake in the United States among adolescents and young adults remains well below national targets. While most efforts to improve HPV vaccine uptake have rightly focused on adolescents, there is still a tremendous opportunity to improve vaccination among young adults who have not been vaccinated against HPV. To that end, we report an exploratory examination of associations between HPV vaccination status and intentions with psychological traits that may impact HPV vaccine uptake with a national, demographically diverse sample of young adults (N = 1358) who completed an online survey. These psychological traits conceptually mapped onto motivations to: 1) understand health-related information, 2) deliberate, 3) manage uncertainty, and 4) manage threats. We found notable gender differences for the association of these motivations and vaccination status. For women, higher interest in and ability to understand health-related information seemed to distinguish those who reported receiving the HPV vaccine from those who did not. For men, less need to deliberate and greater needs to manage threat and uncertainty seemed to be the distinguishing motives for those who reported receiving the HPV vaccine compared to those who did not. Results for vaccination intentions were less consistent, but there was some evidence to indicate that, regardless of gender, greater health-related information interest and understanding and need to manage uncertainty and threats were associated with increased intention to receive the HPV vaccine, while greater need to deliberate was associated with decreased vaccination intentions. These results suggest that there are psychological differences that are associated with HPV vaccination decisions and that these motivations should be considered in efforts to improve HPV vaccine uptake.

No association between HPV vaccine and reported post-vaccination symptoms in Japanese young women: Results of the Nagoya study

Nagoya City introduced free HPV vaccination in 2010 and in April 2013 the Ministry of Health, Labour and Welfare included the HPV vaccine in the National Immunization Program. However, in June 2013, the Ministry suspended proactive recommendation of the vaccine after unconfirmed reports of adverse events. To investigate any potential association between the vaccine and reported symptoms, Nagoya City conducted a questionnaire-based survey.

Participants were 71,177 female residents of Nagoya City born between April 2, 1994 and April 1, 2001. The anonymous postal questionnaire investigated the onset of 24 symptoms (primary outcome), associated hospital visits, frequency, and influence on school attendance.

Totally, 29,846 residents responded. No significant increase in occurrence of any of the 24 reported post-HPV vaccination symptoms was found. The vaccine was associated with increased age-adjusted odds of hospital visits for “abnormal amount of menstrual bleeding” (OR: 1.43, 95% CI: 1.13–1.82), “irregular menstruation” (OR: 1.29, 95% CI: 1.12–1.49), “severe headaches” (OR: 1.19, 95% CI: 1.02–1.39), and chronic, persisting “abnormal amount of menstrual bleeding” (OR 1.41, 95% CI: 1.11–1.79). No symptoms significantly influenced school attendance and no accumulation of symptoms was observed.

The results suggest no causal association between the HPV vaccines and reported symptoms.

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A large-scale epidemiological study on HPV vaccination and reported post vaccination symptoms was performed.

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Age-adjusted analyses found no significant association between HPV vaccines and occurrence of the 24 reported symptoms.

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Increased odds of hospital visits for some symptoms is unlikely to be due to any biological association.

Human papillomavirus vaccination of adult women and risk of autoimmune and neurological diseases

BACKGROUND

Since 2006, human papillomavirus (HPV) vaccines have been introduced in many countries worldwide. Whilst safety studies have been reassuring, focus has been on the primary target group, the young adolescent girls. However, it is also important to evaluate safety in adult women where background disease rates and safety issues could differ significantly.

OBJECTIVE

We took advantage of the unique Danish and Swedish nationwide healthcare registers to conduct a cohort study comparing incidence rate ratios (RRs) of 45 preselected serious chronic diseases in quadrivalent HPV (qHPV)-vaccinated and qHPV-unvaccinated adult women 18-44 years of age.

METHODS

We used Poisson regression to estimate RRs according to qHPV vaccination status with two-sided 95% confidence intervals (95% CIs).

RESULTS

The study cohort comprised 3 126 790 women (1 195 865 [38%] Danish and 1 930 925 [62%] Swedish) followed for 16 386 459 person-years. Vaccine uptake of at least one dose of qHPV vaccine was 8% in the cohort: 18% amongst Danish women and 2% amongst Swedish. We identified seven adverse events with statistically significant increased risks following vaccination-Hashimoto's thyroiditis, coeliac disease, localized lupus erythematosus, pemphigus vulgaris, Addison's disease, Raynaud's disease and other encephalitis, myelitis or encephalomyelitis. After taking multiple testing into account and conducting self-controlled case series analyses, coeliac disease (RR 1.56 [95% confidence interval 1.29-1.89]) was the only remaining association.

CONCLUSION

Unmasking of conditions at vaccination visits is a plausible explanation for the increased risk associated with qHPV in this study because coeliac disease is underdiagnosed in Scandinavian populations. In conclusion, our study of serious adverse event rates in qHPV-vaccinated and qHPV-unvaccinated adult women 18-44 years of age did not raise any safety issues of concern.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Psychiatric conditions and general practitioner attendance prior to HPV vaccination and the risk of referral to a specialized hospital setting because of suspected adverse events following HPV vaccination: a register-based, matched case-control study

AIM

No association between human papilloma virus (HPV) vaccination and numerous diseases has been found. Still, a large number of Danish women are reporting suspected adverse events. Other factors may play a role, and the aim of this study is to examine the association between psychiatric conditions, general practitioner (GP) attendance and indicators of psychological symptoms prior to HPV vaccination and the risk of referral to an HPV center following vaccination.

STUDY DESIGN AND SETTING

Register-based, matched case-control study. Cases were identified from five Danish, regional HPV centers, and health data for cases and controls were obtained from national registries.

PARTICIPANTS

Cases were defined as women referred to an HPV center between January 1, 2015 and December 31, 2015 (n=1,496). Each case was matched with five controls on age, region and time of first vaccine registration. The total study population consisted of 8,976 women.

RESULTS

Overall, women above 18 years who had been referred to an HPV center were more likely to have used psychiatric medication (odds ratio [OR]: 1.88 [95% CI 1.48-2.40]) or to have been hospitalized because of a psychiatric disorder within 5 years prior to the first vaccine registration (OR: 2.13 [95% CI 1.59-2.86]). Specifically, referred women were more likely to have used antipsychotics, antidepressants, attention deficit hyperactivity disorder (ADHD) medication or anxiolytics, and to have been hospitalized for affective disorders or anxiety, but not to have been hospitalized for schizoid, ADHD or eating disorders. In addition, they were more likely to have had talk therapy or psychometric test performed prior to vaccination (OR: 1.72 [95% CI 0.1.35-2.18] and OR: 1.67 [95% CI 1.30-2.13], respectively). Referred women of all ages had higher use of GP before vaccination. Population attributable fraction analyses indicated that psychiatric medication, hospitalization due to a psychiatric disorder and use of talk therapy, or psychometric test "explained" 13%, 10%, 12% and 11% of the referrals, respectively. Results did not change substantially when adjusted for potential confounders.

CONCLUSION

Women referred to HPV centers because of suspected adverse events after vaccination more often had preexisting psychiatric conditions, psychological symptoms or frequent GP attendance prior to HPV vaccination.

Health care utilization in general practice after HPV vaccination-A Danish nationwide register-based cohort study

OBJECTIVE

The Human Papillomavirus (HPV) vaccine has increasingly been suspected of adverse effects in Denmark since 2013. By using consultations with the general practitioner (GP) as an indicator for morbidity, this study aims to examine the association between HPV vaccination and morbidity in girls in the Danish childhood immunization program.

METHODS

The study is a nationwide register-based cohort study. Both the HPV and the Measles, Mumps and Rubella (MMR) vaccines were offered to 12-year-old girls in Denmark in the study period (2008-2015). Therefore, both vaccines were included as exposures to allow differentiation between potential effects. This resulted in four exposure groups: HPV only vaccinated, HPV+MMR vaccinated, MMR only vaccinated, and Non-vaccinated girls. Outcomes were: daytime consultation rates and frequent GP attendance (> 7 annual GP consultations). We estimated consultation rates by negative binomial regressions analysis and frequent GP attendance by logistic regression analysis. Both analyses were stratified on the years 2008-2013 versus 2014.

RESULTS

The study included 214,240 girls born in 1996-2002. All vaccinated groups consulted the GP more often than the non-vaccinated group, both before and after the vaccination. After the vaccination, an increase in consultations was observed for all three vaccinated groups; most distinct for girls vaccinated in 2014. For girls vaccinated before 2014, we found a slightly higher risk of frequent GP attendance after vaccination in the HPV only group compared to the non-vaccinated group, whereas in 2014, frequent GP attendance was seen for all three vaccinated groups; most substantial for the MMR only vaccinated group.

CONCLUSION

In this study, no exclusive increase in health care utilization was detected after HPV vaccination. However, a general difference in the health care utilization pattern was found between vaccinated and non-vaccinated girls, which increased after the time of vaccination, primarily for girls vaccinated after 2013.

Population-based HPV vaccination programmes are safe and effective: 2017 update and the impetus for achieving better global coverage

Persistent oncogenic human papillomavirus (HPV) is the cause of cervical cancer, as well as cancers of the anus, penis, vulva, vagina and oropharynx. There is good evidence that prophylactic HPV vaccines are immunogenic and effective against targeted-type HPV infections and type-specific genital lesions, including high-grade cervical intraepithelial neoplasia (CIN), when administered prior to HPV infection. There is good evidence that HPV vaccines are safe in population usage, with the most frequent adverse event being injection-site reactions. There is evidence to support some cross-protection against non-targeted types occurring following the administration of HPV vaccines. There is limited evidence suggesting that HPV vaccines may be beneficial in preventing future disease in women treated for high-grade CIN. This chapter focuses on the accumulated evidence regarding the global use of the three licensed HPV vaccines including safety, immunogenicity, duration of protection, effectiveness, coverage to date and barriers to higher coverage.

Current status and future prospects for human papillomavirus vaccines

Cervical cancer is the fourth most frequent cancer among women worldwide. Human papillomaviruses (HPVs) cause almost all cervical cancers in low-income countries. Three prophylactic HPV virus-like particle-based vaccines have been licensed to date, and they have all shown high efficacy and reliable safety profiles. However, isolated safety issues have resulted in a reluctance to use these vaccinations. In addition, the high prices of the vaccinations have caused the inequitable distribution of the vaccine: the prices are unaffordable for low-income countries. Meanwhile, great effort has been put into the development of therapeutic HPV vaccines, including protein/peptide-, live vector-, DNA- and cell-based vaccines. These new vaccines have considerable therapeutic potential but limited practical use. The development of immune checkpoint inhibitors and personalized immunotherapy remain challenges for future study. In this article, the current status of the licensed vaccines, therapeutic HPV vaccines and biosimilars, and new platforms for HPV vaccines, are reviewed, and safety issues related to the licensed vaccines are discussed. In addition, the prospects for HPV vaccines are considered.

HPV vaccination and risk of chronic fatigue syndrome/myalgic encephalomyelitis: A nationwide register-based study from Norway

BACKGROUND

Vaccination has been suggested to be involved in the aetiology of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). HPV vaccine was introduced in the Norwegian Childhood Immunisation Programme and offered 12year old girls from 2009. We studied the association between HPV vaccination and risk of CFS/ME and also assessed medical history in relation to both risk of CFS/ME and HPV vaccine uptake.

METHODS

Individual data from national registries, including the Norwegian Population Registry, the Norwegian Patient Registry and the Norwegian Immunisation Registry were linked using the unique personal identification number. Yearly incidence rates of CFS/ME for 2009-2014 were calculated among the 824,133 boys and girls, aged 10-17 living in Norway during these 6years. A total of 176,453 girls born 1997-2002 were eligible for HPV vaccination and included in further analyses. Hazard ratios (HRs) of CFS/ME were estimated using Cox regression. Risk differences (RDs) of vaccine uptake were estimated with binomial regression.

RESULTS

A similar yearly increase in incidence rate of CFS/ME was observed among girls and boys, IRR=1.15 (95% confidence interval (CI) 1.10-1.19) and 1.15 (95% CI 1.09-1.22), respectively. HPV vaccination was not associated with CFS/ME, HR=0.86 (95% CI 0.69-1.08) for the entire follow-up period and 0.96 (95% CI 0.64-1.43) for the first two years after vaccination. The risk of CFS/ME increased with increasing number of previous hospital contacts, HR=5.23 (95% CI 3.66-7.49) for 7 or more contacts as compared to no contacts. Girls with 7 or more hospital contacts were less likely to be vaccinated than girls with no previous hospital contacts, RD=-5.5% (95% CI -6.7% to -4.2%).

CONCLUSIONS

No indication of increased risk of CFS/ME following HPV vaccination was observed among girls in the first 6 birth cohorts offered HPV vaccine through the national immunisation programme in Norway.

Safety and perception: What are the greatest enemies of HPV vaccination programmes?

Vaccines stimulate a person's immune system to produce an adequate reaction against a specific infectious agent; i.e. the person is protected from that disease without having to get it first. As vaccines are administrated to healthy subjects, they are held to the highest standards of safety. Regarding human papillomavirus (HPV) vaccines, at present three prophylactic vaccines are licensed (bivalent HPV 16/18, quadrivalent HPV 6/11/16/18 and the nonovalent HPV 6/11/16/18/31/33/45/52/58 vaccine). Pre- and post-licensure studies (i.e. not yet for nonovalent HPV vaccine) confirm that HPV vaccines are generally safe and well-tolerated, site injections symptoms are the most common adverse events (AEs) reported, and pain is the most frequently referred local symptom. Serious AEs are rare and not associated with severe sequelae, at least no vaccine-related deaths have occurred. Despite these scientific evidences, it is still difficult to explain to the population the importance of a good vaccination programme. There are many determinants for HPV vaccines hesitancy which represent a barrier that must be overcome in order to increase vaccine coverage, including psychological reactions, religious or cultural aspects, and fear of possible AEs (demyelinating diseases, Complex Regional Pain Syndrome - CRPS, or Postural Orthostatic Tachycardia Syndrome - POTS). A weak communication strategy which frequently suffers due to spread of unverified news by media and websites may lead to the failure of a vaccination programme. Such a situation happened in Japan (2013), due to which a great number of women remain vulnerable to HPV-related cancers. In order to resolve the issues around HPV vaccines acceptance, it is necessary to use good communication strategies. Multicomponent and dialogue-based interventions seem to be the most effective, especially if an adequate language is used, customized according to the vaccination programme target.

Using the Theory of Planned Behavior to predict HPV vaccination intentions of college men

OBJECTIVE

The purpose of this study was to test Theory of Planned Behavior (TPB) constructs in predicting human papillomavirus (HPV) vaccination behavioral intentions of vaccine-eligible college men.

PARTICIPANTS

Participants were unvaccinated college men aged 18-26 years attending a large public university in the southeastern United States during Spring 2015.

METHODS

A nonexperimental, cross-sectional study design was employed. Instrumentation comprised a qualitative elicitation study, expert panel review, pilot test, test-retest, and internal consistency, construct validity, and predictive validity assessments using data collected from an online self-report questionnaire.

RESULTS

The sample consisted of 256 college men, and the final structural model exhibited acceptable fit of the data. Attitude toward the behavior (β = .169) and subjective norm (β = 0.667) were significant predictors of behavioral intention, accounting for 58% of its variance.

CONCLUSIONS

Practitioners may utilize this instrument for the development and evaluation of TPB-based interventions to increase HPV vaccination intentions of undergraduate college men.

Immunotherapy against cancer-related viruses

Approximately 12% of all cancers worldwide are associated with viral infections. To date, eight viruses have been shown to contribute to the development of human cancers, including Epstein-Barr virus (EBV), Hepatitis B and C viruses, and Human papilloma virus, among others. These DNA and RNA viruses produce oncogenic effects through distinct mechanisms. First, viruses may induce sustained disorders of host cell growth and survival through the genes they express, or may induce DNA damage response in host cells, which in turn increases host genome instability. Second, they may induce chronic inflammation and secondary tissue damage favoring the development of oncogenic processes in host cells. Viruses like HIV can create a more permissive environment for cancer development through immune inhibition, but we will focus on the previous two mechanisms in this review. Unlike traditional cancer therapies that cannot distinguish infected cells from non-infected cells, immunotherapies are uniquely equipped to target virus-associated malignancies. The targeting and functioning mechanisms associated with the immune response can be exploited to prevent viral infections by vaccination, and can also be used to treat infection before cancer establishment. Successes in using the immune system to eradicate established malignancy by selective recognition of virus-associated tumor cells are currently being reported. For example, numerous clinical trials of adoptive transfer of ex vivo generated virus-specific T cells have shown benefit even for established tumors in patients with EBV-associated malignancies. Additional studies in other virus-associated tumors have also been initiated and in this review we describe the current status of immunotherapy for virus-associated malignancies and discuss future prospects.

Spotlight on the 9-valent HPV vaccine

Starting in 2006, vaccination against human papillomavirus (HPV) has been progressively implemented in most developed countries. Two vaccines have been successfully used, a bivalent vaccine targeting HPV-related cancers (bHPV) and a quadrivalent vaccine (qHPV) targeting both HPV-related cancers and genital warts. Between December 2014 and June 2015, a new nonavalent HPV vaccine (9vHPV) was granted marketing authorization in the USA and Europe. The 9vHPV was developed from the qHPV and includes five additional HPV types that should increase the level of protection toward HPV-related cancers. Efficacy and/or immunogenicity of 9vHPV has been assessed in eight clinical studies. The 9vHPV vaccine induced a very robust immune response against all vaccine types, with seroconversion rates close to 100%. The safety profile of 9vHPV is comparable to that of qHPV. Local reactions, especially swelling, have been more frequently reported after 9vHPV than qHPV, and this slightly increases when the 9vHPV is coadministered with other vaccines. The additional coverage offered by the 9vHPV may prevent a significant proportion of HPV-related cancers (variable between 8% and 18%) depending on the local distribution of high-risk HPV types in the population. It is impossible, at present, to anticipate the actual impact of the wide use of the 9vHPV in comparison with the bHPV or the qHPV, since it depends on many variables including duration of protection, potential cross-protection toward nonvaccine types, and herd immunity effect.

Psychosocial determinants of parental human papillomavirus (HPV) vaccine decision-making for sons: Methodological challenges and initial results of a pan-Canadian longitudinal study

Background

HPV vaccination decision-making is a complex process that is influenced by multiple psychosocial determinants. Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand where Canadian parents were situated in the HPV vaccine decision-making process for their son, how they changed over time and which psychosocial determinants were relevant for this process.

Methods

We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline (T1, February 2014) and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.

Results

At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.

Conclusions

HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users.

Incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease after quadrivalent human papillomavirus vaccination: a cohort study

OBJECTIVE

To assess whether quadrivalent human papillomavirus (qHPV) vaccination is associated with increased incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease.

METHODS

This register-based open cohort study included all girls and women between 10 and 30 years of age in Sweden in 2006-2012 diagnosed with at least one of 49 prespecified autoimmune diseases (n = 70 265). Incidence rate ratios were estimated for new-onset autoimmune disease within 180 days of qHPV vaccination using Poisson regression adjusting for, country of birth, parental country of birth, parental income and parental education.

RESULTS

A total of 70 265 girls and women had at least one of the 49 predefined autoimmune diseases; 16% of these individuals received at least one dose of qHPV vaccine. In unvaccinated girls and women, 5428 new-onset autoimmune diseases were observed during 245 807 person-years at a rate of 22.1 (95% CI 21.5-22.7) new events per 1000 person-years. In vaccinated girls and women, there were 124 new events during 7848 person-years at a rate of 15.8 (95% CI 13.2-18.8) per 1000 person-years. There was no increase in the incidence of new-onset autoimmune disease associated with qHPV vaccination during the risk period; on the contrary, we found a slightly reduced risk (incidence rate ratio 0.77, 95% CI 0.65-0.93).

CONCLUSION

In this nationwide study, qHPV vaccination was not associated with increased incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease.

Giving Boys a Shot: The HPV Vaccine's Portrayal in Canadian Newspapers

In January 2012, the National Advisory Committee on Immunization (NACI) of Canada recommended that males aged 9-26 years receive the human papillomavirus (HPV) vaccine to protect against genital warts and HPV-associated cancers. Estimated HPV vaccine uptake rates for Canadian males are extremely low. Using a content analysis of Canadian newspaper articles, this study investigated what information about the HPV vaccine was relayed to the public, and how this content was portrayed following the 2012 male HPV vaccine recommendation. A search was conducted using Proquest Canadian Newsstand Complete for newspaper articles published between January 1, 2012, and September 1, 2014. Researchers coded 232 articles on several relevant dimensions: article information; epidemiological information; public policy information; article topic; article and title tone; and informant testimony. The majority of articles (93%) mentioned that girls are eligible for the HPV vaccine, whereas only half (49%) mentioned male eligibility. While most articles associated HPV with cervical cancer (85%), fewer indicated its relation to other HPV-associated cancers (59%) or genital warts (52%). Most articles (60%) were positive or neutral (22%) in tone toward the HPV vaccine, while few had mixed messages (11%) or were negative (6%). Less than 5% of articles reported on issues of morality, suggesting that fears that the HPV vaccine causes promiscuity have largely subsided. Notably, article tone toward male vaccination became progressively more positive over time. However, half of the articles did not mention the vaccine's approval for males, and articles tended to report HPV's relation to cervical cancer over other HPV-associated cancers. The Canadian public may thus be unaware of male eligibility and the importance of HPV vaccine for males. The collaboration of researchers, health care providers, and policymakers with journalists is critical in order to disseminate complete and accurate HPV and HPV vaccine information.

Taking stock and looking ahead: Behavioural science lessons for implementing the nonavalent human papillomavirus vaccine

The development and licensing of a nonavalent human papillomavirus (HPV) vaccine has the potential to reduce morbidity and mortality from HPV-related cancers beyond that of first generation HPV vaccines. However, this benefit can only be realised if the offer of vaccination is accepted. Uptake of first generation HPV vaccines is not complete and shows huge global variation. In addition to practical and financial challenges to optimising coverage, behavioural issues explain a large proportion of the variance in vaccine receipt. This commentary draws on the findings of over a decade of behavioural science research seeking to understand uptake of first generation HPV vaccines, in order to anticipate challenges to implement the nonavalent HPV vaccine. Challenges include distrust of combination vaccines, uncertainty about long-term efficacy, distrust of a new and (perceived to be) untested vaccine, cost and uncertainty regarding interchanging doses of first generation and nonavalent vaccines and the appropriateness of revaccination. We use behavioural science theory and existing evaluations of interventions to increase uptake of vaccines to identify evidence-based approaches that can be implemented by vaccine stakeholders to address parents' concerns and maximise uptake of the nonavalent HPV vaccine.

HPV-FASTER: broadening the scope for prevention of HPV-related cancer

Human papillomavirus (HPV)-related screening technologies and HPV vaccination offer enormous potential for cancer prevention, notably prevention of cervical cancer. The effectiveness of these approaches is, however, suboptimal owing to limited implementation of screening programmes and restricted indications for HPV vaccination. Trials of HPV vaccination in women aged up to 55 years have shown almost 90% protection from cervical precancer caused by HPV16/18 among HPV16/18-DNA-negative women. We propose extending routine vaccination programmes to women of up to 30 years of age (and to the 45-50-year age groups in some settings), paired with at least one HPV-screening test at age 30 years or older. Expanding the indications for HPV vaccination and much greater use of HPV testing in screening programmes has the potential to accelerate the decline in cervical cancer incidence. Such a combined protocol would represent an attractive approach for many health-care systems, in particular, countries in Central and Eastern Europe, Latin America, Asia, and some more-developed parts of Africa. The role of vaccination in women aged >30 years and the optimal number of HPV-screening tests required in vaccinated women remain important research issues. Cost-effectiveness models will help determine the optimal combination of HPV vaccination and screening in public health programmes, and to estimate the effects of such approaches in different populations.

Health Disparities in the Immunoprevention of Human Papillomavirus Infection and Associated Malignancies

Human papillomavirus (HPV) causes roughly 1.6% of the plus 1.6 million cases of cancer that are diagnosed in the United States each year. Despite the proven safety and efficacy of available vaccines, HPV remains the most common sexually transmitted infection. Underlying the high prevalence of HPV infection is the poor adherence to the Centers for Disease Control recommendation to vaccinate all 11- to 12-year-old males and females. In fact, only about 38 and 14% of eligible females and males, respectively, receive the complete, three-dose immunization. The many factors associated with missed HPV vaccination opportunities – including race, age, family income, and patient education – contribute to widespread disparities in vaccine completion and related health outcomes. Beyond patient circumstance, however, research indicates that the rigor and consistency of recommendation by primary care providers also plays a significant role in uptake of HPV immunization. Health disparities data are of vital importance to HPV vaccination campaigns because they can provide insight into how to address current problems and allocate limited resources where they are most needed. Furthermore, even modest gains in populations with low vaccination rates may yield great benefits because HPV immunization has been shown to provide herd immunity, indirect protection for non-immunized individuals achieved by limiting the spread of an infectious agent through a population. However, the impact of current HPV vaccination campaigns is hindered by stagnant immunization rates, which remain far below target levels despite a slow overall increase. Furthermore, gains in immunization are not equally distributed across gender, age, demographic, and socioeconomic divisions within the recommended group of vaccine recipients. To achieve the greatest impact, public health campaigns should focus on improving immunization coverage where it is weakest. They should also explore more subtle but potentially significant determinants of HPV vaccine initiation and completion, such as the attitudes of parents and healthcare providers and factors that exacerbate HPV-related health outcomes, including smoking and human immunodeficiency virus-mediated immunosuppression. Optimizing the efficacy of vaccination campaigns will require a health disparities approach that both identifies and remedies the underlying causes of population differences in HPV vaccination.

Sauver JL, Finney Rutten LJ. The most effective and promising population health strategies to advance human papillomavirus vaccination

The US is failing to make substantive progress toward improving rates of human papillomavirus vaccine uptake. While the Healthy People 2020 goal for human papillomavirus (HPV) vaccination is 80%, the three-dose completion rate in the US in 2014 for 13- to 17-year-old females is less than 40%, and the rate for males is just above 20%. Experts point to a number of reasons for the poor HPV vaccination rates including parental concerns about safety, necessity, and timing. However, the evidence refuting these concerns is substantial. Efforts focusing on education and communication have not shown promise, but several population health strategies have reminder/recall systems; practice-focused strategies targeting staff, clinicians, and parents; assessment and feedback activities; and school-based HPV vaccination programs.