Safety of the 9-Valent Human Papillomavirus Vaccine

Immunogenicity and Safety of a Quadrivalent Meningococcal Conjugate Vaccine Versus Nimenrix in Healthy Adolescents: A Randomized Phase IIIb Multicenter Study

INTRODUCTION

Many immunization programs in Europe recommend quadrivalent meningococcal vaccinations, which are often administered concomitantly with other vaccines. We compared the immune response of a tetanus toxoid conjugated quadrivalent meningococcal vaccine (MenACYW-TT, MenQuadfi®) with another quadrivalent meningococcal conjugate vaccine (MCV4-TT; Nimenrix®) when administered alone or concomitantly with Tdap-IPV and 9vHPV vaccines in adolescents.

METHODS

In this phase IIIb trial, healthy adolescents (MenC-naïve or MenC-primed before 2 years of age) from Spain, Italy, Hungary, and Singapore were randomized in a 3:3:2 ratio to receive either MenACYW-TT or MCV4-TT alone, or MenACYW-TT concomitantly with 9vHPV and Tdap-IPV. The primary objective was to demonstrate the non-inferiority of the seroprotection rate (human serum bactericidal assay [hSBA] titer ≥ 1:8) to serogroups A, C, W, and Y 30 days post-vaccination with a single dose of MenACYW-TT or MCV4-TT. Secondary objectives included describing hSBA titers for the four serogroups before and 1 month following vaccination and according to MenC priming status.

RESULTS

A total of 463 participants were enrolled (MenACYW-TT, n = 173; MCV4-TT, n = 173; MenACYW-TT/9vHPV/Tdap-IPV n = 117). Non-inferiority based on seroprotection was demonstrated for MenACYW-TT versus MCV4-TT for all serogroups. Immune responses were comparable whether MenACYW-TT was administered alone or concomitantly with Tdap-IPV and 9vHPV. Post-vaccination hSBA GMTs were higher in MenACYW-TT vs. MCV4-TT for serogroups C, Y, and W and comparable for serogroup A. The percentages of participants with an hSBA vaccine seroresponse were higher in MenACYW-TT vs. MCV4-TT for all serogroups. For serogroup C, higher GMTs were observed in both MenC-naïve or -primed participants vaccinated with MenACYW-TT vs. MCV4-TT. Seroprotection and seroresponse were higher in MenC-naïve participants vaccinated with MenACYW-TT vs. MCV4-TT and comparable in MenC-primed. The safety profiles were comparable between groups and no new safety concerns were identified.

CONCLUSIONS

These data support the concomitant administration of MenACYW-TT with 9vHPV and Tdap-IPV vaccines in adolescents.

TRIAL REGISTRATIONS

Clinicaltrials.gov, NCT04490018; EudraCT: 2020-001665-37; WHO: U1111-1249-2973.

HPV Vaccine Awareness, Past Behaviors, and Future Intentions Among a Diverse Sample of Fathers Aged 27 to 45 Years: A National Survey

Men aged 27 to 45 are eligible for human papillomavirus (HPV) vaccination as of 2019, yet relatively little is known about whether they have received or intend to receive it. We conducted a cross-sectional, online survey among fathers aged 27 to 45 between March and April 2022, to assess associations between HPV vaccination awareness, behaviors, intentions, and psychosocial constructs from the Health Belief Model. We examined the characteristics of those who had (a) heard of the HPV vaccine, (b) already received ≥ 1 dose, and (c) intentions for future vaccination among those who had never been vaccinated. Among 400 men who completed the survey, 32% were not aware of the HPV vaccine. Among those who were aware, 41% had received ≥ 1 dose. Sixty-three percent of unvaccinated men reported that they intended to get vaccinated in the future. Multivariable logistic regression analyses revealed that age and race/ethnicity were associated with having been vaccinated previously. Among the unvaccinated, multivariable logistic regression analyses revealed that those with a higher perceived risk of HPV-associated cancer had 3.73 greater odds of reporting they would seek vaccination compared to those with lower perceived risk (95% confidence interval [CI] = [1.28, 12.3]). We did not find perceived benefits, barriers, or decision self-efficacy to be related to future vaccine intentions. Since recommendations for this group include shared clinical decision-making, public health efforts should focus on raising awareness of vaccine eligibility, emphasizing risk factors for HPV-associated cancers so that individuals have an accurate perception of risk, and encouraging conversation between men and their providers.

Missed opportunities for human papillomavirus vaccination using Iowa's Immunization Registry Information System

PURPOSE

Adolescent human papillomavirus (HPV) vaccination rates continue to remain lower than other adolescent vaccines, both nationwide and in Iowa. This study examined predictors of missed opportunities for first-dose HPV vaccine administrations in Iowa in order to conduct more targeted outreach and improve adolescent HPV vaccine uptake.

METHODS

A retrospective study was conducted to identify predictors of missed opportunities for first-dose HPV vaccination in Iowa adolescents using Iowa's Immunization Registry Information System. The study population included 154,905 adolescents aged 11-15 years between 2019 and 2022. Missed opportunity for first-dose HPV vaccination was defined as a vaccination encounter where an adolescent received a Tdap and/or MenACWY vaccine but did not receive the first-dose HPV vaccine during the same encounter.

FINDINGS

Over a third of the study population experienced a missed opportunity for HPV vaccination between 2019 and 2022. Missed opportunity for vaccination was most common among individuals living in a rural county (aOR = 1.36), underinsured adolescents (aOR = 1.74), males (aOR = 1.12), teens 13-15 years of age (aOR = 1.76), and White race and non-Hispanic ethnicity.

CONCLUSION

This study builds on previously reported predictors of missed opportunity for HPV vaccination in adolescents. Increased understanding of provider needs and barriers to administering HPV vaccination and further analysis of how the Vaccines for Children Program can play a role in HPV vaccination uptake is necessary to improve HPV vaccination rates among adolescents in Iowa and more specifically in rural communities.

Can prophylactic HPV vaccination reduce the recurrence of cervical lesions after surgery? Review and prospect

Women with HSIL typically undergo conization/LEEP to remove cervical lesions, but the risk of HSIL lesions returning after surgical treatment remains higher than in the general population. HPV vaccination is essential to prevent cervical cancer. However, the effect of prophylactic HPV vaccination on reducing the risk of recurrent cervical lesions after surgical treatment remains unclear. This review aims to analyze and summarize the latest literature on the role of prophylactic HPV vaccine in reducing the recurrence of cervical lesions after surgery in patients with HSIL, and to review and update the history, efficacy, effectiveness and safety of HPV vaccine, focusing on the current status of global HPV vaccine implementation and obstacles.

Human Papillomavirus Vaccines

Human papillomavirus (HPV) vaccines are highly effective in preventing the transmission of HPV and thus downstream HPV-related lower genital tract neoplasias. First introduced in 2006, the HPV vaccine has demonstrated clinical efficacy in both men and women. Several commercially available vaccines now exist, but only one is available in the United States. Both prelicensure and postlicensure studies demonstrate robust safety profiles. HPV vaccines should be made available to everyone between the ages of 9 and 26 years of age. Newer vaccination recommendations in expanded populations rely on patient-provider shared decision making. Currently, available HPV vaccines offer little therapeutic benefit. Recent research has identified several new DNA vaccines and delivery modifications with early demonstrated success at eliminating prevalent HPV infections and precancerous lesions. Despite the success of the HPV vaccine, vaccination hesitancy and disinformation continue to threaten our ability to eliminate these deadly cancers. Informational, behavioral, and environmental interventions have mixed success in increasing vaccination rates, but several strategies do exist to increase rates of vaccination.

Barriers to human papillomavirus vaccine uptake: role of state religiosity and healthcare professionals' participation in a state vaccine program

BACKGROUND

Despite the known benefits of preventing human papillomavirus (HPV)-related cancers, HPV vaccine coverage is low in the United States. Grounded in Social Ecological theory, we assessed the macro-level (state) and meso-level (organization) factors associated with HPV vaccine initiation and up-to-date.

METHODS

Data from 2020 National Immunization Survey-Teen were used to study a sample of 20 163 US adolescents (aged 13-17 years). The data were collected from each teen's parents or guardians and health-care professionals. Weighted prevalence estimates were calculated, and multivariable regression analyses were conducted.

RESULTS

The prevalence of HPV vaccine initiation was 75.1% and of remaining up-to-date was 58.6%. At the macro level, teens living in states with high and moderate religiosity had lower odds of HPV vaccine initiation (high religiosity adjusted odds ratio [AOR] = 0.63, 95% confidence interval [CI] = 0.50 to 0.78; moderate religiosity AOR = 0.68, 95% CI = 0.55 to 0.85) and up-to-date (high religiosity AOR = 0.69, 95% CI = 0.56 to 0.85; moderate religiosity AOR = 0.74, 95% CI = 0.61 to 0.91) than states with low religiosity. At the meso level, when none of their healthcare professionals ordered vaccine from the state, teens had lower odds of initiation (AOR = 0.68, 95% CI = 0.53 to 0.87) and up-to-date (AOR = 0.76, 95% CI = 0.60 to 0.95) than teens whose healthcare professionals ordered vaccine from the state. In addition, race and ethnicity, age, mother's education level, household income, well-child examination status, and doctor's recommendation were significantly associated with HPV vaccine uptake.

CONCLUSION

A multiprong approach is needed to address religious and systemic barriers to HPV vaccination and expand healthcare professionals' access and enrollment in state vaccine initiatives, such as the Vaccine for Children program.

Cancer Prevention Begins in Middle School: The Personal Advantages of HPV Immunization in Males

The human papillomavirus (HPV) is the most common sexually transmitted infection in the United States despite most cases being preventable by vaccination. HPV vaccine efficacy varies in relationship to when the vaccine is administered, with greater efficacy obtained if administered prior to sexual debut. Historically, this vaccine was created to protect women from cervical cancer. As scientific knowledge of HPV-related cancers has advanced, it has become evident that HPV vaccination is a priority for both genders. HPV is known to contribute to male cancers of the mouth, throat, anus, and penis, as well as causing genital warts. This article aims to explain the benefits of HPV immunization for the gender the farthest from meeting vaccination goals, boys, and young men. This article expounds on the school nurses' role in promoting vaccination to prevent HPV infection and the sequela of related cancers.

Safety of 9-valent human papillomavirus vaccine administered to males and females in routine use

BACKGROUND

The nine-valent human papillomavirus vaccine (HPV9, Gardasil®9) was licensed in the USA in December 2014. This study was a multiyear post-licensure study to assess HPV9 safety following routine administration.

METHODS

This retrospective cohort study compared the risk of emergency department visits and hospitalizations during the interval soon after vaccination with risk during a later interval. Kaiser Permanente Northern California (KPNC) members aged ≥ 9 years who received ≥ 1 HPV9 dose between 10/1/2015-9/30/2017 were included. Outcomes were grouped into predefined diagnostic categories. We compared the odds of events in postvaccination risk intervals (days 0-14, days 1-60) with odds of events during control intervals (days 61-75, days 61-120) using conditional logistic regression. We characterized prespecified events on the day of vaccination (allergic reaction and syncope) and all deaths in the study period.

RESULTS

The study included 215,965 individuals receiving ≥ 1 dose of HPV9, of whom 140,628 had no prior HPV vaccination. We observed similar numbers of males and females and racial/ethnic diversity consistent with the underlying population. At first dose median age was 12-13 years and 77% received ≥ 1 concomitant vaccine. Eighteen event categories were significantly elevated, including skin disorders (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.00, 3.53) and ill-defined conditions (OR 1.36, 95% CI 1.13, 1.64; category includes abdominal pain, allergic reactions, syncope, etc.). On review, most findings were previously known, preceded vaccination, or had other causes. Allergic reactions and syncope at vaccination were infrequent but many were potentially related. No deaths (n = 37) were considered related to HPV9 and were consistent with the background rate.

CONCLUSIONS

We did not identify new safety concerns related to HPV9. The results are consistent with the HPV9 safety profile as established from previous studies/surveillance.

REGISTRATION

European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS13151, protocol V503-028).

Assessment of human papillomavirus vaccination rates of adolescents in California, 2018-2019

Accurate documentation of state-level human papillomavirus (HPV) vaccination is required for public health planning and to inform corrective actions. To examine the representativeness of the California Immunization Registry, we compared the National Immunization Survey (NIS)-Teen, commercial HMOs in California, Medi-Cal, and California Immunization Registry data for HPV vaccine series completion. Our objectives were to evaluate the vaccine registries, compare and report their completeness, and make recommendations on how to improve and use these studies. Vaccination values were extrapolated for all adolescents aged 13 to 17 years from 2018 to 2019 from NIS-Teen, adolescents aged 13 years from 2018 to 2019 reported in the California Immunization Registry, and adolescents aged 13 years for 2018 for commercial HMOs and Medi-Cal. HPV series completion among 13-year-olds in 2018 for commercial HMOs was 50 %, Medi-Cal was 45 %, and the California Immunization Registry was 28 %, with NIS-Teen rates for 13 to 17-year-olds at 50 % in 2018 and 54 % in 2019. Both rural and urban geographic regions were found to have low completion rates of the HPV series, with trends ranging from 13 % to 45 %. The California Immunization Registry's lower HPV vaccine series completion among 13-year-olds compared to the other reporting sources is most likely due differences in reporting and data collection. Importantly, this data will serve as a comparator for future, similar studies of various sources of HPV vaccination rates following the passing of Bill-1797, which will mandate immunization reporting starting in January 2023.

Perceptions about human papillomavirus vaccine and oropharyngeal cancers, and the role of dental care providers in human papillomavirus prevention among US adults

BACKGROUND

The authors examined adults' perceptions about the importance of the human papillomavirus (HPV) vaccine in preventing oropharyngeal cancers and dental care providers' role in HPV prevention and identified associated factors.

METHODS

Adults (≥ 18 years) completed a national survey of consumer and patient attitudes, experiences, and behaviors on oral health. Descriptive and multivariable logistic regression models determined associations between perceptions regarding HPV and attitudes toward dental care providers' role and HPV knowledge, HPV vaccine recommendation, and sociodemographic characteristics.

RESULTS

One in 3 adults (32.8%; n = 5,320) said the HPV vaccine was very important, 1 in 2 said it was somewhat important (48.1%), and 1 in 5 said it was not important (19.1%) in preventing mouth and throat cancers. More than one-half (56.7%) of adults had positive perceptions about dental care providers' role in HPV education and were comfortable discussing the HPV vaccine with a dental care provider (59.4%). Adults with knowledge about HPV and oral health linkage and those who received HPV vaccine recommendation from a dental care provider had 2.0 to 2.5 times higher odds of reporting positively for all 3 outcomes (P < .001).

CONCLUSIONS

Most adults are comfortable discussing HPV and the HPV vaccine with their oral health care provider. Perceptions about the HPV vaccine's importance in preventing oropharyngeal cancers and the role of dental care providers in HPV prevention can be improved by means of increasing adults' knowledge about the relationship between HPV and oral health.

PRACTICAL IMPLICATIONS

Dental care providers' engagement in HPV conversations with patients may increase their knowledge about the HPV and oral health linkage and their understanding of the role of the HPV vaccine in preventing oropharyngeal cancers.

Updates on HPV Vaccination

Cervical cancer still poses a significant global challenge. Developed countries have mitigated this challenge by the introduction of structured screening programmes and, more recently, the HPV vaccine. Countries that have successfully introduced national HPV vaccination programmes are on course for cervical cancer elimination in a few decades. In developing countries that lack structured screening and HPV vaccination programmes, cervical cancer remains a major cause of morbidity and mortality. The HPV vaccine is key to addressing the disproportionate distribution of cervical cancer incidence, with much to be gained from increasing vaccine coverage and uptake globally. This review covers the history and science of the HPV vaccine, its efficacy, effectiveness and safety, and some of the considerations and challenges posed to the achievement of global HPV vaccination coverage and the consequent elimination of cervical cancer.

Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network

OBJECTIVE

To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS

In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS

Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS

Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

Post-marketing surveillance for the safety of the 9-valent human papillomavirus vaccine: a retrospective real-world study in China

BACKGROUND

The 9-valent human papillomavirus (9vHPV) vaccine was introduced in China in 2018. This study was conducted to monitor the occurrence of new-onset autoimmune diseases (AIs) in Chinese women vaccinated with the 9vHPV vaccine and adverse pregnancy outcomes in infants born to mothers with inadvertent pregnancy exposure.

RESEARCH DESIGN AND METHODS

Women who received the first dose of the 9vHPV vaccine at age 16-26 years in Ningbo between January 2019 and March 2021 were monitored in the Ningbo Regional Health Information Platform. New-onset cases of seven pre-specified AIs diagnosed within six months after vaccination were collected. Cases of stillbirth and 23 major congenital anomalies diagnosed within three months of birth in target infants were collected.

RESULTS

A total of 102,670 doses of the 9vHPV vaccine were administered to 41,609 women who had received no other HPV vaccine. New-onset AIs were diagnosed in 36 women, comprising 21 Hashimoto's, 11 Graves', and 4 uveitis disease cases. Among 50 women with maternal vaccination exposure, no stillbirths were observed. One case of microtia was observed.

CONCLUSIONS

In this first post-marketing surveillance of the 9vHPV vaccine in China, no safety signals were identified when putting the results in context to published data.

Extended surveillance to assess safety of 9-valent human papillomavirus vaccine

The safety of 9-valent HPV vaccine (9vHPV) has been established with regard to common and uncommon adverse events. However, investigation of rare and severe adverse events requires extended study periods to capture rare outcomes. This observational cohort study investigated the occurrence of three rare and serious adverse events following 9-valent human papillomavirus (9vHPV) vaccination compared to other vaccinations, in US individuals 9-26 years old, using electronic health record data from the Vaccine Safety Datalink (VSD). We searched for occurrences of Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and stroke following 9vHPV vaccination from October 4, 2015, through January 2, 2021. We compared the risks of GBS, CIDP, and stroke following 9vHPV vaccination to risks of those outcomes following comparator vaccines commonly given to this age group (Td, Tdap, MenACWY, hepatitis A, and varicella vaccines) from January 1, 2007, through January 2, 2021. We observed 1.2 cases of stroke, 0.3 cases of GBS, and 0.1 cases of CIDP per 100,000 doses of 9vHPV vaccine. After observing more than 1.8 million doses of 9vHPV, we identified no statistically significant increase in risks associated with 9vHPV vaccination for any of these adverse events, either combined or stratified by age (9-17 years of age vs. 18-26 years of age) and sex (males vs. females). Our findings provide additional evidence supporting 9vHPV vaccine safety, over longer time frames and for more serious and rare adverse events.

Real-world safety profile of the 9-valent human papillomavirus vaccine: A study in Zhejiang, China from 2019 to 2021

The safety profile of the 9-valent human papillomavirus vaccine (9vHPV) was evaluated based on the reporting rate of adverse events following immunization (AEFI) obtained from the passive surveillance data in Zhejiang. The 9vHPV AEFI reports in Zhejiang were collected and reviewed from the National Adverse Event Following Immunization Surveillance System (NAEFISS) from 2019 to 2021. Reporting rates of AEFI were analyzed under multiple aspects, including age, city, number of vaccinations, AEFI categories, and diagnosis categories. This study used the reporting odds ratio (ROR) for anomalous signal assessment. The NAEFISS collected 331 AEFI reports after administering 1,064,851 doses of 9vHPV, with a crude AEFI rate of 3.12/10,000 doses. The third dose had the highest reporting rate of minor vaccine-related reaction (n = 80, 3.06 per 10,000), followed by the first dose (n = 134, 2.98 per 10,000), and second dose (n = 76, 2.15 per 10,000). Fever/redness/induration was the most common minor adverse event (281 records, 2.64/10,000 doses). Nine cases of urticaria, ten cases of allergic rash, and ten cases of syncope were recorded. This study found a positive signal association between 9vHPV immunization and adverse events such as syncope, encephalitis, sterile abscess, and urticaria. This study did not identify any new emerging safety concerns. In the future, more research is needed to validate and further explore adverse reactions associated with 9vHPV.

Delayed Vasovagal Reaction with Reflex Syncope Following COVID-19 Vaccination

Coronavirus disease 2019 (COVID-19) has become a pandemic, and vaccines remain the only effective tools available for ending it. However, their side effects, such as syncope, which mimics sudden cardiac death, are serious concerns. We herein report 6 cases of delayed vasovagal syncope and presyncope (VVR) caused by COVID-19 vaccination among 25,530 COVID-19 patients. The prevalence of delayed VVR due to COVID-19 vaccination was 0.026%. In addition, no delayed VVR was found among 17,386 patients who received the influenza vaccine. Delayed VVR is likely to be overlooked if medical staff are not aware of this symptom. This report provides significant information regarding effects of COVID-19 vaccination.

Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico

The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008-2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.

Vaccines

The safety of COVID-19 vaccines, as was the case last year, remains a large part of the focus in this volume. COVID-19 placed a large magnifying glass on both vaccines, specifically vaccine safety. This was most readily apparent as the number of records in VAERS ballooned to about 10 times the size from 2020 to 2021 (Vaccine Adverse Event Reporting System (VAERS), 2022) [S]. While we have added and/or improved VAERS during COVID-19, including adding or improving other vaccine safety surveillance tools like v-safe and vaccine safety datalink (Blumenthal, Phadke, et al., 2021) [MC], there is still room for improvement in these pharmacovigilance tools (Rizk et al., 2021) [r]. A major global initiative in this realm is the Global Vaccines Safety Blueprint 2.0 (GVSB2.0) (Organization, 2021, pp. 2021–2023) [S]. We wholeheartedly endorse these initiatives, which could significantly improve vaccine safety.

As noted in past SEDA issues, clinicians should be mindful of the risks of AEs and SAEs associated with each individual vaccine.

Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer

Human papillomavirus (HPV) is the most common sexually transmitted infection, with 15 HPV types related to cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancers. However, cervical cancer remains one of the most common cancers in women, especially in developing countries. Three HPV vaccines have been licensed: bivalent (Cervarix, GSK, Rixensart, Belgium), quadrivalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)), and nonavalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)). The current HPV vaccine recommendations apply to 9 years old and above through the age of 26 years and adults aged 27–45 years who might be at risk of new HPV infection and benefit from vaccination. The primary target population for HPV vaccination recommended by the WHO is girls aged 9–14 years, prior to their becoming sexually active, to undergo a two-dose schedule and girls ≥ 15 years of age, to undergo a three-dose schedule. Safety data for HPV vaccines have indicated that they are safe. The most common adverse side-effect was local symptoms. HPV vaccines are highly immunogenic. The efficacy and effectiveness of vaccines has been remarkably high among young women who were HPV seronegative before vaccination. Vaccine efficacy was lower among women regardless of HPV DNA when vaccinated and among adult women. Comparisons of the efficacy of bivalent, quadrivalent, and nonavalent vaccines against HPV 16/18 showed that they are similar. However, the nonavalent vaccine can provide additional protection against HPV 31/33/45/52/58. In a real-world setting, the notable decrease of HPV 6/11/16/18 among vaccinated women compared with unvaccinated women shows the vaccine to be highly effective. Moreover, the direct effect of the nonavalent vaccine with the cross-protection of bivalent and quadrivalent vaccines results in the reduction of HPV 6/11/16/18/31/33/45/52/58. HPV vaccination has been shown to provide herd protection as well. Two-dose HPV vaccine schedules showed no difference in seroconversion from three-dose schedules. However, the use of a single-dose HPV vaccination schedule remains controversial. For males, the quadrivalent HPV vaccine possibly reduces the incidence of external genital lesions and persistent infection with HPV 6/11/16/18. Evidence regarding the efficacy and risk of HPV vaccination and HIV infection remains limited. HPV vaccination has been shown to be highly effective against oral HPV type 16/18 infection, with a significant percentage of participants developing IgG antibodies in the oral fluid post vaccination. However, the vaccines’ effectiveness in reducing the incidence of and mortality rates from HPV-related head and neck cancers should be observed in the long term. In anal infections and anal intraepithelial neoplasia, the vaccines demonstrate high efficacy. While HPV vaccines are very effective, screening for related cancers, as per guidelines, is still recommended.

Using the Theory of Planned behavior to identify correlates of HPV vaccination uptake among college students attending a rural university in Alabama

INTRODUCTION

Humanpapillomavirus (HPV) has infected nearly 80 million people in the U.S., and is associated with most cervical cancer cases. Alabama ranks first in the country for cervical cancer mortality and third for incidence. Although the HPV vaccine can prevent HPV and reduce cancer rates, Alabama is well-below the national average for HPV vaccination. Using the Theory of Planned Behavior (TPB), this Alabama-based study aimed to examine college students' intentions to get the HPV vaccine; to examine the relationship between the relationship between religious beliefs and HPV vaccination uptake status among college students.

METHODS

Students (n = 257) from a university in rural Alabama completed the survey. Multiple regression analysis, Mann-Whitney U tests, and moderation analysis were used to examine associations among the variables of interest.

FINDINGS

Consistent with TPB, results showed that attitudes and subjective norms were significant predictors of intention to get vaccinated. Knowledge that both sexes can experience HPV-related health problems, that HPV can cause genital warts, and that the vaccine protects against HPV were each associated with higher attitude scores. The results indicated that the odds of getting at least one HPV shot were higher for females than for males for non-Caucasians than for Caucasians. Students who were not vaccinated were more likely to report that religion influenced their health beliefs. *Abstract.

CONCLUSION

TPB was helpful in understanding HPV-related intentions. Communication and education efforts are needed to increase understanding of HPV illnesses and HPV vaccination benefits among peers, parents, and other loved ones of students. in the rural areas of Alabama.

The characteristics of COVID-19 vaccine-related headache: Clues gathered from the healthcare personnel in the pandemic

Introduction

Headache is a frequent adverse event after viral vaccines. We aimed to investigate the frequency and clinical associations of COVID-19 vaccine-related headache.

Methods

The characteristics, associations of this headache, main comorbidities, headache history following the influenza vaccine and during COVID-19 were investigated using a web-based questionnaire.

Results

A total of 1819 healthcare personnel (mean age: 44.4 ± 13.4 years, 1222 females), vaccinated with inactivated virus, contributed to the survey; 209 (11.4%) had been infected with COVID-19. A total of 556 participants (30.6%) reported headache with significant female dominance (36.1% vs. 19.3%), 1.8 ± 3.5 (median: 1; IQR: 0–2) days following vaccination. One hundred and forty-four participants (25.9%) experienced headache lasting ≥3 days. Headache was mostly bilateral without accompanying phenomena, less severe, and shorter than COVID-19-related headache. The presence of primary headaches and migraine were significantly associated with COVID-19 vaccine-related headache (ORs = 2.16 [95% CI 1.74–2.68] and 1.65 [1.24–2.19], respectively). Headache during COVID-19 or following influenza vaccine also showed significant association with headache following COVID-19 vaccine (OR = 4.3 [95% CI 1.82–10.2] and OR = 4.84 [95% CI 2.84–8.23], respectively). Only thyroid diseases showed a significant association (OR = 1.54 [95% CI 1.15–2.08]) with vaccine-related headache among the common comorbidities.

Conclusion

Headache is observed in 30.6% of the healthcare workers following COVID-19 vaccine and mostly experienced by females with pre-existing primary headaches, thyroid disorders, headache during COVID-19, or headache related to the influenza vaccine.

Significant Declines in Juvenile-onset Recurrent Respiratory Papillomatosis Following Human Papillomavirus (HPV) Vaccine Introduction in the United States

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare and serious disease caused by human papillomavirus (HPV) presumably acquired during vaginal delivery. HPV vaccination of females through age 26 years, recommended in the United States since 2006, can prevent HPV transmission. We assessed trends in JORRP cases before and after HPV vaccine introduction in the United States.

METHODS

Case-patients were identified from 26 pediatric otolaryngology centers in 23 U.S. states. Demographics and clinical history were abstracted from medical records. Case-patients were grouped by year of birth, and birth-cohort incidences were calculated using number of births from either national or state-level natality data from the 23 states. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) in 2-year intervals.

RESULTS

We identified 576 U.S. JORRP case-patients born in 2004-2013. Median age at diagnosis was 3.4 years (interquartile range: 1.9, 5.5). Number of identified JORRP case-patients declined from a baseline of 165 born in 2004-2005 to 36 born in 2012-2013. Incidence of JORRP per 100 000 births using national data declined from 2.0 cases in 2004-2005 to 0.5 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4); incidence using state-level data declined from 2.9 cases in 2004-2005 to 0.7 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4).

CONCLUSIONS

Over a decade, numbers of JORRP case-patients and incidences declined significantly. Incidences calculated using national denominator data are likely underestimates; those calculated using state-level denominator data could be overestimates. These declines are most likely due to HPV vaccination. Increasing vaccination uptake could lead to elimination of this HPV-related disease.

Trends in Human Papillomavirus Vaccine Safety Concerns and Adverse Event Reporting in the United States

IMPORTANCE

In the US, safety concern has been identified as a primary barrier to initiating the human papillomavirus (HPV) vaccine. It is unclear if the public's sentiment concerning HPV vaccine safety aligns with postmarketing vaccine safety surveillance data.

OBJECTIVE

To perform a parallel assessment of trends in HPV vaccine safety concerns and HPV vaccine adverse event (AE) reporting.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of the National Immunization Survey (NIS) and Vaccine Adverse Event Reporting System (VAERS). Participants in the NIS were adolescents aged 13 to 17 years. AEs were reported to VAERS by patients, health care clinicians, or other sources. Statistical analysis was performed from October 2020 to May 2021.

MAIN OUTCOMES AND MEASURES

Secular trends in HPV vaccine safety concerns and spontaneous AE reporting for HPV vaccination from 2015 to 2018.

RESULTS

Caregivers of 39 364 unvaccinated adolescents with a mean (SD) age of 15.57 (0.08) years (26 996 White adolescents [62.9%], 22 707 male adolescents [56.1%], 11 392 privately insured [62.6%], and 32 674 above the poverty level [79.3%]) reported their reasons for not initiating the HPV vaccine series in the 2015-2018 NIS. Citing safety concerns as the primary reason for not initiating the HPV vaccine series increased from 13.0% (95% CI, 12.1%-14.0%) in 2015 to 23.4% (95% CI, 21.8%-25.0%) in 2018 (P for trend < .001), equating to a change from 170 046 to 259 157 US adolescents not initiating the vaccine because of safety concerns. The proportion of parents citing safety concerns as the main reason for HPV vaccine hesitancy increased in 30 states. The largest increases (more than 200%) were observed in California, Hawaii, South Dakota, and Mississippi. During 2015 to 2018, 16 621 AE reports following HPV vaccination were reported to VAERS. The AE reporting rate per 100 000 doses distributed decreased from 44.7 in 2015 to 29.4 in 2018 (P for trend < .001). The serious AE reporting rate, including those leading to hospitalizations, disability, life-threatening condition, or death did not change.

CONCLUSIONS AND RELEVANCE

In this descriptive cross-sectional study, a rise in citing safety concerns was observed among parents with HPV vaccine hesitancy, contrary to the nonserious and serious AE reporting trends. These findings suggest an urgent need to combat the rising sentiment of safety concerns among caregivers to increase HPV vaccine confidence.

Prevention and Screening of HPV Malignancies

It is estimated that 5% of the global cancer burden, or approximately 690,000 cancer cases annually, is attributable to human papillomavirus (HPV). Primary prevention through prophylactic vaccination is the best option for reducing the burden of HPV-related cancers. Most high-income countries (HICs) have introduced the HPV vaccine and are routinely vaccinating adolescent boys and girls. Unfortunately, although they suffer the greatest morbidity and mortality due to HPV-related cancers, many lower- and middle-income countries (LMICs) have been unable to initiate and sustain vaccination programs. Secondary prevention in the form of screening has led to substantial declines in cervical cancer incidence in areas with established screening programs, but LMICs with absent or inadequate screening programs have high incidence rates. Meanwhile, HICs have seen incidence rates of anal and oropharyngeal cancers rise owing to the limited availability of organized screening for anal cancer and no validated screening options for oropharyngeal cancer. The implementation of screening programs for individuals at high risk of these cancers has the potential to reduce the burden of cervical cancer in LMICs, of anal and oropharyngeal cancers in HICs, and of anal cancer for highly selected HIV+ populations in LMICs. This review will discuss primary prevention of HPV-related cancers through vaccination and secondary prevention through screening of cervical, anal, and oropharyngeal cancers. Areas of concern and highlights of successes already achieved are included.

Using a Harm Reduction Model to Reduce Barriers to Vaccine Administration

Vaccination is a strategic public health measure designed to reduce the adverse effects of many infectious diseases. Although national recommendations exist for vaccine administration across the life span, immunization rates are affected by barriers to vaccine access and hesitancy in vaccine acceptance. Midwives and women's health clinicians are optimally poised to assess their client's vaccination status and provide vaccinations during clinical encounters. In order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Socioeconomic factors, social policies, and historic and continued experiences related to racism have been identified as barriers to ready access to vaccinations and vaccine acceptance. Midwives can act as leaders within their practice sites and communities through participation in projects that reduce barriers to vaccine access and uptake. Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance. This article focuses on identifying barriers to vaccine uptake and describing harm reduction measures designed to improve uptake of vaccines. A variety of leadership activities are discussed that can improve clinicians' understanding of their role in optimizing vaccination.

Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles.

A validated modification of the vaccine hesitancy scale for childhood, influenza and HPV vaccines

INTRODUCTION

Vaccine hesitancy contributes to outbreaks of preventable disease worldwide. The Vaccine Hesitancy Scale (VHS), developed by the international WHO SAGE Working Group, has been validated previously for measuring hesitancy towards childhood vaccines; some psychometric properties were suboptimal.

METHODS

We collected data using large, nationally-representative samples of parents in the U.S. We adapted the VHS items, and additional hesitancy items, to assess hesitancy towards influenza and HPV vaccines in addition to routine childhood vaccines. We then used exploratory and confirmatory factor analysis to identify latent constructs and create modified scales for childhood (VHS-child), influenza (VHS-flu) and HPV (VHS-HPV) vaccines with improved psychometric properties. Finally, we compared hesitancy scores on the VHS-child, VHS-flu, and VHS-HPV, to self-reported receipt of each vaccine category, and compared subscale scores to assess whether drivers of hesitancy differed by vaccine category.

RESULTS

2052 parents of children <18 years old completed the VHS-child and VHS-flu while 2020 parents of adolescents completed the VHS-HPV. A two-factor structure of 'risks' and a 'lack of confidence' was found for each vaccine category. Slight modifications to the VHS improved psychometric properties. Hesitancy was strongly associated with vaccine receipt: e.g., 76% of parents not hesitant towards influenza vaccine had vaccinated their child the past season, versus 9% of hesitant parents (p < 0.0001). Subscale scores also differed significantly between vaccines: lack of confidence was greater towards influenza (Median (IQR): 2.0 (1.2, 3.3)) and HPV (2.0 (1.3, 3.0)) vaccines than childhood (1.2 (1.0, 1.8), p < 0.0001 for both) vaccines; perceived risks of HPV vaccines (2.7 (1.7, 3.7)) were greater than for childhood vaccines (2.0 (1.3, 3.0), p < 0.0001).

CONCLUSIONS

Our modified VHS scales perform well psychometrically and allow for consistent measurement of the extent and reasons for hesitancy between vaccine categories. We suggest that future work use these scales to examine hesitancy towards other vaccines and to monitor hesitancy over time.

Current and future vaccine clinical research with the licensed 2-, 4-, and 9-valent VLP HPV vaccines: What's ongoing, what's needed?

Prophylactic HPV vaccination has been a great public health success. For >20 years, clinical trials were conducted with the 2-, 4-, and/or 9-valent vaccines in young-adult females, mid-adult women, males, and adolescents. In all studies, the vaccines were highly efficacious, immunogenic, and well tolerated. Following vaccine licensure and utilization in national vaccine programs globally (real-world settings primarily in high income countries), numerous studies demonstrated that the vaccines continue to have an excellent safety profile and have dramatically reduced the incidence of genital warts, HPV vaccine-type prevalence, and precancerous lesions. Thirty-eight clinical trials with the currently licensed HPV vaccines are ongoing. Key questions being addressed in new trials include: efficacy against persistent infection and immunogenicity of a 1-dose regimen; efficacy of 3 doses in 20-45-year-old females; use in postpartum women and immunocompromised individuals (HIV, liver and kidney transplants); dose sparing via intradermal administration; use in combination with a PD1 monoclonal antibody in patients with cervical cancer; impact on recurrent disease in women undergoing cervical conization; persistence of protection; and use to prevent oropharyngeal cancer. Additional clinical research that should be conducted includes: long-term follow-up, particularly of 1- and 2-dose regimens; further evaluation of flexible 2-dose regimens; immunogenicity of 1- or 2-dose regimens in persons ≥15 years old and immunocompromised populations; safety and immunogenicity of 1 or 2 doses in children <9 years old; assessment of the vaccine in the prevention of transmission; interchangeability with newer HPV vaccines; additional concomitant use studies; and prevention of penile cancer and recurrent respiratory papillomatosis.

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Vaccines

In this volume of the Side Effects of Drugs Annual, although other vaccines will be covered, the safety of COVID vaccines is the focus as COVID-19 has led to heightened attention on vaccine safety in general. As such, this chapter will be more relevant than ever before. As noted in past SEDA issues, clinicians should be mindful of the risks of AEs and SAEs associated with each vaccine.

Long-term immunogenicity, effectiveness, and safety of nine-valent human papillomavirus vaccine in girls and boys 9 to 15 years of age: Interim analysis after 8 years of follow-up

BACKGROUND

The nine-valent human papillomavirus (9vHPV) vaccine protects against infection and disease related to HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The pivotal 36-month Phase III immunogenicity study of 9vHPV vaccine in 9- to 15-year-old girls and boys was extended to assess long-term immunogenicity and effectiveness through approximately 10 years after vaccination. We describe results of an interim analysis based on approximately 8 years of follow-up after vaccination.

METHODS

Participants aged 9-15 years who received three doses of 9vHPV vaccine (at day 1, month 2, and month 6) in the base study and consented to follow-up were enrolled in the long-term follow-up study extension (N = 1272 [females, n = 971; males, n = 301]). Serum was collected at months 66 and 90 to assess antibody responses. For effectiveness analysis, genital swabs were collected (to assess HPV DNA by polymerase chain reaction [PCR]) and external genital examination was conducted (to detect external genital lesions) every 6 months starting when the participant reached 16 years of age. Cervical cytology tests were conducted annually when female participants reached 21 years of age; participants with cytological abnormalities were triaged to colposcopy based on a protocol-specified algorithm. External genital and cervical biopsies of abnormal lesions were performed, and histological diagnoses were adjudicated by a pathology panel. Specimens were tested by PCR to detect HPV DNA.

RESULTS

Geometric mean titers for each 9vHPV vaccine HPV type peaked around month 7 and gradually decreased through month 90. Seropositivity rates remained >90% through month 90 for each of the 9vHPV vaccine types by HPV immunoglobulin Luminex Immunoassay. No cases of HPV6/11/16/18/31/33/45/52/58-related high-grade intraepithelial neoplasia or genital warts were observed in the per-protocol population (n = 1107) based on a maximum follow-up of 8.2 years (median 7.6 years) post-Dose 3. Incidence rates of HPV6/11/16/18/31/33/45/52/58-related 6-month persistent infection in females and males were 49.2 and 37.3 per 10,000 person-years, respectively, which were within ranges expected in vaccinated cohorts. There were no vaccine-related SAEs or deaths during the period covered by this interim analysis.

CONCLUSIONS

The 9vHPV vaccine provided sustained immunogenicity and durable effectiveness through approximately 7 and 8 years, respectively, following vaccination of girls and boys aged 9-15 years.

Human Papillomavirus Vaccination: ACOG Committee Opinion, Number 809

Human papillomavirus (HPV) causes significant morbidity and mortality in women and men. The HPV vaccine significantly reduces the incidence of anogenital cancer and genital warts in women and in men. Human papillomavirus vaccines are among the most effective vaccines available worldwide, with unequivocal data demonstrating greater than 99% efficacy when administered to women who have not been exposed to that particular type of HPV. Obstetrician-gynecologists and other health care professionals should strongly recommend HPV vaccination to eligible patients and stress the benefits and safety of the HPV vaccine. Further, obstetrician-gynecologists are encouraged to stock and administer HPV vaccines in their offices when feasible. Ideally, the HPV vaccine should be given in early adolescence because vaccination is most effective before exposure to HPV through sexual activity. Unvaccinated women age 26 years and younger should receive the HPV vaccine series regardless of sexual activity, prior exposure to HPV, or sexual orientation. The HPV vaccine is now licensed in the United States for women and men through age 45 years. For some women aged 27-45 years who are previously unvaccinated, obstetrician-gynecologists and other health care professionals may use shared clinical decision making regarding HPV vaccination, considering the patient's risk for acquisition of a new HPV infection and whether the HPV vaccine may provide benefit.

The science of vaccine safety: Summary of meeting at Wellcome Trust

Vaccines are everywhere hugely successful but are also under attack. The reason for the latter is the perception by some people that vaccines are unsafe. However that may be, vaccine safety, life any other scientific subject, must be constantly studied. It was from this point of view that a meeting was organized at the Wellcome Trust in London in May 2019 to assess some aspects of vaccine safety as subjects for scientific study. The objective of the meeting was to assess what is known beyond reasonable doubt and conversely what areas need additional studies. Although the meeting could not cover all aspects of vaccine safety science, many of the most important issues were addressed by a group of about 30 experts to determine what is already known and what additional studies are merited to assess the safety of the vaccines currently in use. The meeting began with reviews of the current situation in different parts of the world, followed by reviews of specific controversial areas, including the incidence of certain conditions after vaccination and the safety of certain vaccine components. Lastly, information about the human papillomavirus vaccine was considered because its safety has been particularly challenged by vaccine opponents. The following is a summary of the meeting findings. In addition to this summary, the meeting organizers will explore opportunities to perform studies that would enlarge knowledge of vaccine safety.