Declines in Anogenital Warts Among Age Groups Most Likely to Be Impacted by Human Papillomavirus Vaccination, United States, 2006-2014

Sustained Decline in Hospitalisations for Anogenital Warts in Australia: Analysis of National Hospital Morbidity Data 2003-2020

In Australia, school-based human papillomavirus (HPV) vaccination was introduced initially for girls in 2007, and then also for boys in 2013. While studies have shown declines in the incidence of anogenital warts, there is a paucity of recent data analysis assessing the impact of vaccination on more severe disease. The National Hospital Morbidity Database of the Australian Institute of Health and Welfare (AIHW) hospitalisation admission data that included ICD-10-AM code A63.0 ('anogenital warts') as the diagnoses, for the years 2003-2020, were analysed to estimate hospitalisation rates per 100,000 mid-year population. The annual average hospitalisation rates per 100,000 population for anogenital warts in both genders combined in the age groups 10-19 years, 20-29 years, and 30-39 years decreased, respectively, from 16.9, 49.6, and 23.6 in 2003-2007 (pre-vaccine period) to 2.6, 15.2, and 14.6 in 2008-2020 (post-vaccine period), equating to declines of 84.7%, 69.4%, and 38.2%, respectively. Following the introduction of the boy's vaccination, hospitalisation rates decreased further in the respective age bands from 4.3, 22.8, and 18.4 in 2008-2013 (early post-vaccine period) to 1.1, 9.3, and 11.7 in 2014-2020 (late post-vaccine period), equating to respective declines of 73.4%, 59.3%, and 36.4%. This analysis confirms that there is a substantial incremental decline in anogenital warts hospitalisations among Australians aged 10-39 years.

Effect of the human papillomavirus vaccine on the risk of genital warts: a nationwide cohort study of Korean adolescent girls

OBJECTIVES

The purpose of this study was to assess the effectiveness of human papillomavirus (HPV) vaccination administered to adolescent girls through Korea's National Immunization Program.

METHODS

This retrospective cohort study included patients who were 12-13 years old, whether vaccinated or unvaccinated, between July 2016 and December 2017. The incidence of genital warts (GWs) was monitored through 2021. Time-stratified hazard ratios (HRs) were estimated, adjusting for birth year, socioeconomic status, and the level of urbanization of the region, and were presented with 95% confidence intervals (CIs). Data were sourced from the Immunization Registry Integration System, linked with the National Health Information Database.

RESULTS

The study included 332,062 adolescent girls, with an average follow-up period of approximately 4.6 years. Except for the first year, the HRs for the vaccinated group were lower than those for the unvaccinated group. The HRs for specific cut-off years were as follows: year 2, 0.62 (95% CI, 0.31 to 1.13); year 3, 0.58 (95% CI, 0.35 to 0.96); and year 4 and beyond, 0.39 (95% CI, 0.28 to 0.52).

CONCLUSIONS

Our findings indicate that HPV vaccination was associated with a reduction in the risk of GWs among adolescent girls. Notably, this reduction became significant as the incidence of GWs increased with age.

2023 Korean sexually transmitted infections guidelines by the Korean Association of Urogenital Tract Infection and Inflammation: Human papillomavirus vaccination

The Korean Association of Urogenital Tract Infection and Inflammation (KAUTII) and the Korea Disease Control and Prevention Agency updated the guidelines for human papillomavirus (HPV) vaccine against sexually transmitted HPV infections in Korea to respond to changing epidemiologic trends, evolving scientific evidence, and advances in laboratory diagnostics and research. Main purpose and recommendation of vaccination against HPV are as follows: (1) the purpose of HPV vaccine is to reduce the risk of genital warts and HPV-related cancers including cervical and vulvar cancer, head and neck cancer, anal cancer, and penile cancer; (2) in Korea, bivalent (16, 18) vaccines, quadrivalent vaccines (6, 11, 16, 18), and 9-valent vaccines (6, 11, 16, 18, 31, 33, 45, 52, 58) are used depending on the type of HPV; (3) bivalent and quadrivalent vaccines are national immunizations targeting girls aged 11-12 years and low-income young females aged 18-26 years (age and range of inoculation: routinely administered at 11 or 12 years of age, 2 doses at 0 and 6 months for 12-14 years of age; for females aged 15-26 years, 3 doses depending on the type of vaccine; vaccination can be given to those aged up to 45 years through consultation with a clinician); (4) in the case of administering 2 doses, at least 5 months apart; in the case of administering 3 doses, it is recommended to keep 4 weeks between the 1st and 2nd doses, 12 weeks between the 2nd and 3rd doses, and 5 months between the 1st and 3rd doses; (5) immunocompromised patients such as those with HIV, malignant neoplasms, and autoimmune diseases, and those undergoing transplantation or immunosuppressive therapy should receive 3 doses. HPV vaccine is not recommended during pregnancy.

HPV pathogenesis, various types of vaccines, safety concern, prophylactic and therapeutic applications to control cervical cancer, and future perspective

Over 98% of cervical cancers (CC) are caused by regular infections with "high risk" genotype of the human papilloma virus (HPV). However, this is not always the causative factor. Therefore, production of HPV vaccinations represents a significant chance to minimize the risk of CC. Phase III studies for a number of preventative HPV vaccines based on L1-virus-like particle (VLPs) have just been completed and the preliminary results are very convincing. However, there are a lot of practical concerns that need to be resolved before the use of these vaccinations. These vaccines were challenged with obvious queries such as protection time, subject receiving vaccines, time of vaccination, and how to include them into ongoing screening programs. Although these vaccines were 90% effective at preventing HPV infection as these offered only modest advantages for the removal of pre-existing infections. New advancements in the creation of therapeutic vaccinations have been explored for further improvement and post-vaccination surveillance. Therapeutic vaccines attempted to boost cell-mediated immunities and these are detrimental to the infected cell as opposed to neutralizing antibodies (different from prophylactic vaccines).

Updated estimate of the annual direct medical cost of screening and treatment for human papillomavirus associated disease in the United States

The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

Clinical and Public Health Considerations for HPV Vaccination in Midadulthood: A Narrative Review

Human papillomavirus (HPV) is an important cause of anogenital and oropharyngeal cancers, anogenital warts, and recurrent respiratory papillomatosis. Beginning in 2019, US guidelines recommended shared clinical decision-making (SCDM) for HPV vaccination among midadults (27-45 years). We conducted a narrative review of existing literature on HPV vaccination in midadults. The available evidence demonstrates that HPV vaccination in midadults is safe, efficacious, and likely to benefit both HPV-naïve midadults and those with previous infections. However, gaps in knowledge related to HPV vaccination have been identified among clinicians and midadult patients. Universal midadult HPV vaccination in the United States could avert 20 934-37 856 cancer cases over 100 years, costing $141 000-$1 471 000 per quality-adjusted life-year gained. Wide variation in these estimates reflects uncertainties in sexual behavior, HPV natural history, and naturally acquired immunity. Greater awareness among clinicians and midadult patients and broad implementation of SCDM may accelerate progress toward eliminating HPV-associated cancers and other diseases.

Does Vaccination Protect against Human Papillomavirus-Related Cancers? Preliminary Findings from the United States National Health and Nutrition Examination Survey (2011-2018)

Most oropharyngeal and anogenital cancers are caused by human papillomavirus (HPV). Although HPV vaccines showed high efficacy against oropharyngeal and anogenital HPV infections, and cancer precursors in randomized clinical trials, there are limited data on the effectiveness of HPV vaccination against HPV-related cancers. We aimed to evaluate the association of HPV vaccination with HPV-related cancers among a nationally representative sample of United States adults, aged 20-59 years. In a cross-sectional study combining four cycles from the National Health and Nutrition Examination Survey, from 2011 through 2018, we used a survey-weighted logistic regression model, propensity score matching and multiple imputations by chained equations to explore the association of HPV vaccination with HPV-related cancers. Among 9891 participants, we did not find an association of HPV vaccination with HPV-related cancers (adjusted OR = 0.58, 95% CI 0.19; 1.75). Despite no statistically significant association between HPV vaccination and HPV-related cancers, our study findings suggest that HPV-vaccinated adults might have lower odds of developing HPV-related cancers than those who were not vaccinated. Given the importance of determining the impact of vaccination on HPV-related cancers, there is a need to conduct future research by linking cancer registry data with vaccination records, to obtain more robust results.

Real-world impact and effectiveness of the quadrivalent HPV vaccine: an updated systematic literature review

INTRODUCTION

Human papillomavirus (HPV) infection, which poses significant disease burden, is decreasing following implementation of vaccination programs. Synthesized evidence on HPV vaccine real-world benefit was published in 2016. However, long-term impact of vaccination, and how vaccination programs influence infection rates and disease outcomes, requires further examination.

AREAS COVERED

We systematically reviewed observational studies on HPV vaccination within MEDLINE, EMBASE, and Google Scholar from 2016 to 2020, involving 14 years of follow-up data. We identified 138 peer-reviewed publications reporting HPV vaccine impact or effectiveness. Outcomes of interest included rates of infection at different anatomical sites and incidence of several HPV-related disease endpoints.

EXPERT OPINION

The expansion of HPV vaccination programs worldwide has led to a reduction in genital infection and significant decreases in incidence of HPV-related disease outcomes. Therefore, the WHO has set goals for the elimination of cervical cancer as a public health concern. To track progress toward this requires an understanding of the effectiveness of different vaccination initiatives. However, the impact on males, and potential benefit of gender-neutral vaccination programs have not been fully explored. To present an accurate commentary on the current outlook of vaccination and to help shape policy therefore requires a systematic review of available data.

Safety and immunogenicity of an Escherichia coli-produced bivalent human papillomavirus type 6/11 vaccine: A dose-escalation, randomized, double-blind, placebo-controlled phase 1 trial

A dose-escalation, randomized, double-blind, placebo-controlled phase 1 clinical trial enrolled 145 eligible participants aged 18-55 years in March 2015 in Liuzhou, China. Stratified by age and sex, the participants were randomly assigned to receive either 30, 60, or 90 μg of the HPV-6/11 vaccine (n = 41/40/40) or the parallel placebo vaccine (n = 8/8/8) with a 0/1/6-month dose-escalation schedule. Participants were actively followed-up to record local and systemic AEs occurring within 30 days after each vaccination, and SAEs occurred in 7 months. Blood and urine samples of each participant were collected before and 2 days after the first and third vaccination to determine changes in routine blood, serum biochemical, and urine indexes. Serum HPV-6/11-specific IgG and neutralizing antibody levels at month 7 were analyzed. A total of 79 adverse events were reported, and no SAEs occurred. The incidences of total adverse reactions in the 30 μg, 60 μg, and 90 μg HPV vaccine groups and the control group were 31.7%, 50.0%, 42.5%, and 62.5%, respectively. All but one of the adverse reactions was mild or moderate with grade 1 or 2. No vaccine-related changes with clinical significance were found in paired blood and urine indexes before and after vaccinations. All the participants in the per-protocol set seroconverted at month 7 for both IgG and neutralizing antibodies. The candidate novel Escherichia-coli-produced bivalent HPV-6/11 vaccine has been preliminarily proven to be well tolerated and with robust immunogenicity in a phase 1 clinical study, supporting further trials with larger sample size. The study has been registered at ClinicalTrials.gov (NCT02405520).

Papillomaviral skin diseases of humans, dogs, cats and horses: A comparative review. Part 1: Papillomavirus biology and hyperplastic lesions

Papillomaviruses (PVs) cause disease in humans, dogs, cats, and horses. While there are some differences, many aspects of the pathogenesis, presentation, and treatment of these diseases are similar between the four species. In this review, the PV-induced diseases of humans are compared to the similar diseases that develop in the companion animal species. By comparing with the human diseases, it is possible to make assumptions about some of the less common and less well-studied diseases in the veterinary species. In the first part of this review, the PV lifecycle is discussed along with the classification of PVs and the immune response to PV infection. The hyperplastic diseases caused by PVs are then discussed; including PV-induced cutaneous, anogenital, and oral warts within the four species.

HPV type-specific trends in cervical precancers in the United States, 2008-2016

Declines in cervical intraepithelial neoplasia grades 2-3 and adenocarcinoma in situ (CIN2+) observed among young women suggest impact from human papillomavirus (HPV) vaccination. To further evaluate vaccine impact including cross-protection and type replacement, we described high-risk (HR)-HPV type-specific cervical precancer incidence rates among women aged 20-39 years, 2008-2016. We analyzed cross-sectional population-based data on 18,344 cases of CIN2+ from a 5-site surveillance system. Diagnostic specimens were tested for individual HPV types, including 14 HR-HPV types (HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68). We estimated age-specific annual HR-HPV type-specific CIN2+ incidence per 100,000 screened women for individual types, vaccine HR-HPV types (HPV16/18) and non-vaccine HR-HPV types (non-HPV16/18). We evaluated trends using average annual percent changes (AAPC) and 95% confidence intervals (CI), and estimated total declines by comparing 2015-2016 to 2008-2009 using incidence rate ratios. Among 20-24-year-olds, HPV16/18-CIN2+ declined from 2008 through 2016 (AAPC: -21.3%, 95% CI: -28.1%, -13.8%), whereas no trend was observed for non-HPV16/18-CIN2+ (AAPC: -1.8%, 95% CI: -8.1%, 4.9%). After 2010, CIN2+ among 20-24-year-olds was more often caused by non-vaccine versus vaccine HR-HPV types. No significant declining trends were observed in older age groups. In 2015-2016 compared to 2008-2009, HPV16-CIN2+ declined 78%, HPV18-CIN2+ 72%, and HPV31-CIN2+ 51% among 20-24-year-olds; no increases were observed in type-specific CIN2+ incidence. Among 25-29-year-olds, HPV16-CIN2+ declined 18%; CIN2+ attributed to seven nonvaccine types increased significantly. No significant declines were observed in older groups. Significant declines in HPV16/18-CIN2+ in 20-24-year-olds and HPV16-CIN2+ in 25-29-year-olds corroborate impact of HPV vaccination. A declining trend in HPV31-CIN2+ is consistent with cross-protection from vaccination.

Human Papillomavirus Vaccine Impact and Effectiveness Through 12 Years After Vaccine Introduction in the United States, 2003 to 2018

BACKGROUND

Human papillomavirus (HPV) vaccination was introduced in 2006 for females and in 2011 for males.

OBJECTIVE

To estimate vaccine impact and effectiveness against quadrivalent HPV vaccine (4vHPV)-type prevalent infection among sexually experienced U.S. females and vaccine effectiveness for sexually experienced U.S. males.

DESIGN

NHANES (National Health and Nutrition Examination Survey) conducted in 2003 to 2006 (prevaccine era) and in 2007 to 2010, 2011 to 2014, and 2015 to 2018 (vaccine eras).

SETTING

Nationally representative U.S. surveys.

PARTICIPANTS

Sexually experienced participants aged 14 to 24 years.

INTERVENTION

U.S. HPV vaccination program.

MEASUREMENTS

Participant-collected cervicovaginal and penile specimens were tested for HPV DNA. The prevalences of 4vHPV and non-4vHPV types were estimated in each era for females and in 2013 to 2016 for males. Prevalences among the female population overall, vaccinated females, and unvaccinated females were compared in vaccine eras versus the prevaccine era (vaccine impact). Within each vaccine era, prevalence among vaccinated females was compared with that among unvaccinated females (vaccine effectiveness). Vaccine impact and effectiveness were estimated as (1 - prevalence ratio) · 100.

RESULTS

Among sexually experienced females aged 14 to 24 years, the impact on 4vHPV-type prevalence in 2015 to 2018 was 85% overall, 90% among vaccinated females, and 74% among unvaccinated females. No significant declines were found in non-4vHPV-type prevalence. Vaccine effectiveness ranged from 60% to 84% during vaccine eras for females and was 51% during 2013 to 2016 for males.

LIMITATION

Self- or parent-reported vaccination history and small numbers in certain subgroups limited precision.

CONCLUSION

Nationally representative data show increasing impact of the vaccination program and herd protection. Vaccine effectiveness estimates will be increasingly affected by herd effects.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Incidence of anogenital warts after the introduction of the quadrivalent HPV vaccine program in Manitoba, Canada

Background

The incidence of anogenital warts (AGW) decreased after the introduction of the quadrivalent human papillomavirus (qHPV) vaccine in multiple jurisdictions. We studied how comparing AGW incidence rates with different outcomes affects the interpretation of the qHPV vaccination program. To do this, we replicated multiple study designs within a single jurisdiction (Manitoba).

Methods

We measured the incidence rates of AGW, AGW-related prescriptions, chlamydia, and gonorrhea (the latter two as sham outcomes) between 2001 and 2017 using several clinical and administrative health databases from Manitoba. We then used incidence rate ratios (IRRs) to compare, for each outcome, the rate for the 1997–1998 birth cohort (the first cohorts eligible for the publicly funded qHPV vaccination program) and the older 1995–1996 birth cohort.

Results

AGW incidence in Manitoba dropped 72% (95% confidence interval 54–83%) among 16–18 year-old girls and 51% (14–72%) among boys after the introduction of the female-only qHPV vaccination program. Trends in AGW-related prescriptions were different from trends in AGW diagnoses as these prescriptions peaked shortly after the introduction of the publicly funded qHPV vaccine program. Chlamydia and gonorrhea incidence rates also decreased 12% (5–18%) and 16% (-1-30%), respectively, for 16–18 year-old girls.

Conclusions

The publicly funded school-based qHPV vaccine program reduced AGW incidence in Manitoba by three-quarters in young females. AGW-related prescriptions are a poor proxy for medically attended AGW after the introduction of the publicly funded qHPV vaccination program. Different sexual habits in adolescents are, at most, responsible for a small portion of the reduction in AGW incidence.

Changes in Cervical Cytology Results and Human Papillomavirus Types Among Persons Screened for Cervical Cancer, 2007 and 2015-2017

OBJECTIVES

Since 2006, the US human papillomavirus (HPV) vaccination program has led to decreases in HPV infections caused by high-risk vaccine-targeted HPV types (HPV 16/18). We assessed differences in high-risk HPV prevalence by cervical cytology result among 20- to 24-year-old persons participating in routine cervical cancer screening in 2015-2017 compared with 2007.

MATERIALS AND METHODS

Residual routine cervical cancer screening specimens were collected from 20- to 24-year-old members of 2 integrated healthcare delivery systems as part of a cross-sectional study and were tested for 37 HPV types. Cytology results and vaccination status (≥1 dose) were extracted from medical records. Cytology categories were normal, atypical squamous cells of undefined significance, low-grade squamous intraepithelial lesions (SIL), or high-grade SIL/atypical squamous cells cannot exclude high-grade SIL. Prevalences of HPV categories (HPV 16/18, HPV 31/33/45/52/58, HPV 35/39/51/56/59/66/68) were estimated by cytology result for 2007 and 2015-2017.

RESULTS

Specimens from 2007 (n = 4046) were from unvaccinated participants; 4574 of 8442 specimens (54.2%) from 2015-2017 were from vaccinated participants. Overall, HPV 16/18 positivity was lower in 2015-2017 compared with 2007 in all groups: high-grade SIL/atypical squamous cells cannot exclude high-grade SIL, 16.0% vs 69.2%; low-grade SIL, 5.4% vs 40.1%; atypical squamous cells of undefined significance, 5.0% vs 25.6%; and normal, 1.3% vs 8.1%. Human papillomavirus 31/33/45/52/58 prevalence was stable for all cytology groups; HPV 35/39/51/56/59/66/68 prevalence increased among low-grade SIL specimens (53.9% to 65.2%) but remained stable in other groups.

CONCLUSIONS

Prevalence of vaccine-targeted high-risk HPV types 16/18 was dramatically lower in 2015-2017 than 2007 across all cytology result groups while prevalence of other high-risk HPV types was mainly stable, supporting vaccine impact with no evidence of type replacement.

Asian guidelines for condyloma acuminatum

The present guidelines aim to provide comprehensive information on genital condyloma acuminata, including the epidemiology, clinical features, diagnosis and management. The guidelines provide evidence-based recommendations on the diagnosis, prevention and treatment of genital condyloma acuminata in adults in Asia, including patients with HIV co-infection.

METHODOLOGY

A PubMed search was performed, using the keywords "condyloma acuminata", "anal wart", "anogenital wart", "genital wart" and "genital HPV". A total of 3031 results were found in publications during last six years. A careful review of the titles and abstracts was done to find all the studies pertaining to epidemiology, clinical features, diagnosis, treatment and prevention of condyloma acuminata.

DIAGNOSIS

Various diagnostic procedures described are: 1. PCR (LE: 2b). 2. Serology (LE: 2b). 3. In-situ hybridization (LE: 3).

PREVENTION

1. Vaccination (LE: 1a): Quadrivalent vaccine reduced the frequency of anogenital warts in both vaccinated and unvaccinated contacts. According to the update Advisory Committee on Immunization Practices (ACIP) recommendations, the following protocol is recommended: (a). HPV vaccination at age 11 or 12 years for both males and females. (b). Catch-up vaccination for all persons through age 26 years. (c). Shared clinical decision-making regarding potential HPV vaccination for persons aged 27-45 years, who are at risk of new HPV infection. 2. Male circumcision (LE: 2a): conflicting evidence.

HIV AND CONDYLOMA ACUMINATA

In HIV-affected individuals, the course of HPV is more aggressive, with a greater risk of treatment resistance, increased chances of intraepithelial neoplasia as well as cancers.

TREATMENT

Physician administered. 1. Photodynamic therapy (LE: 1a). 2. Laser (LE: 2b). 3. Surgery (LE: 1a). 4. Electrosurgery (LE: 2c). 5. Cryotherapy (LE: 1b). 6. Immunotherapy (LE: 1b). 7. Podophyllin (LE: 1b). Provider administered. 1. Imiquimod 5%(LE: 1a). 2. Podophyllotoxin (LE: 1b). 3. Sinecatechins (LE: 1a). 4. Cidofovir (LE: 3). 5. 5- Fluorouracil (LE: 1a). 6. Interferon (LE: 1a).

High-Grade Vulvar, Vaginal, and Anal Precancers Among U.S. Adolescents and Young Adults After Human Papillomavirus Vaccine Introduction

INTRODUCTION

Since human papillomavirus vaccine introduction, incidence rates of cervical precancers have decreased; however, the vaccine's impact on noncervical anogenital precancers has not been shown. These precancers are identified opportunistically and are not collected routinely by most cancer registries.

METHODS

This study examined the incidence rates of high-grade (intraepithelial lesions grade 3) vulvar, vaginal, and anal precancers among persons aged 15-39 years using 2000-2017 data from select cancer registries covering 27.8% of the U.S. population that required reporting of these precancers. Trends in incidence rates were evaluated with Joinpoint regression. Analyses were conducted in 2020.

RESULTS

High-grade vulvar precancer rates declined by 21.0% per year after human papillomavirus vaccine introduction among females aged 15-19 years. In addition, high-grade vaginal precancer rates declined by 19.1% per year among females aged 15-29 years after human papillomavirus vaccine introduction. Compared with that in the prevaccine period when high-grade anal precancer rates were increasing, anal precancer rates after human papillomavirus vaccine introduction were stable among females aged 15-29 years and among males aged 30-39 years. Among males aged 15-29 years, the rates increased over the entire period but less so after human papillomavirus vaccine introduction.

CONCLUSIONS

Opportunistically-detected high-grade vulvar and vaginal precancers among females aged 15-29 years decreased and anal precancers stabilized in years after the introduction of the human papillomavirus vaccine, which is suggestive of the impact of the vaccine on noncervical human papillomavirus cancers.

Real-world impact and effectiveness assessment of the quadrivalent HPV vaccine: a systematic review of study designs and data sources

INTRODUCTION

Vaccine effectiveness and impact studies are typically observational, generating evidence after vaccine launch in a real-world setting. For human papillomavirus (HPV) vaccination studies, the variety of data sources and methods used is pronounced. Careful selection of study design, data capture and analytical methods can mitigate potential bias in such studies.

AREAS COVERED

We systematically reviewed the different study designs, methods, and data sources in published evidence (1/2007-3/2020), which assessed the quadrivalent HPV vaccine effectiveness and impact on cervical/cervicovaginal, anal, and oral HPV infections, anogenital warts, lesions in anus, cervix, oropharynx, penis, vagina or vulva, and recurrent respiratory papillomatosis.

EXPERT OPINION

The rapid growth in access to real-world data allows global monitoring of effects of different public health interventions, including HPV vaccination programs. But the use of data which are not collected or organized to support research also underscore a need to develop robust methodology that provides insight of vaccine effects and consequences of different health policy decisions. To achieve the WHO elimination goal, we foresee a growing need to evaluate HPV vaccination programs globally. A critical appraisal summary of methodology used will provide timely guidance to researchers who want to initiate research activities in various settings.

Human papillomavirus vaccines effectiveness to prevent genital warts: A population-based study using health system integrated databases, 2009-2017

OBJECTIVES

To assess the effectiveness of the HPV vaccines in preventing genital warts (GW) in women aged 14-23 years and to estimate the incidence of GW in the whole population aged from 14 to 65.

DESIGN

Population-based retrospective cohort study using real-world data from the Valencia health system Integrated Databases (VID).

STUDY POPULATION

All subjects aged 14-65 years residing in the Valencia Region during 2009-2017 (n = 4,492,724), including a cohort of 563,240 females aged 14-23 years followed-up for the vaccine effectiveness (VE) estimations.

MAIN OUTCOME MEASURES

Incident cases of GW defined as the first activation of GW-related codes (ICD-9-CM 078.11 or ICD-10-CM A63.0) in hospital, primary and specialized care during the study period. Adjusted VE was estimated as (1-Relative Risk (RR)) × 100 by a negative binomial Bayesian model.

RESULTS

There were 23,049 cases of GW in the overall population and 2,565 in the females' cohort 14-23 years old. The incidence rate (IR) (in 100,000 persons-year) was 69.1 (95% CI 68.21-69.99) in the population overall, being higher in men (72.73; 95% CI 71.45-74.04). The IR of GW was 104.08 (95% CI 100.79-108.94) in the cohort of young women. The RR of GW increased with age from 14 to 21 years, reaching a plateau from 21 to 23. The VE of a complete schedule was 74% (95% CrI 68-79) for quadrivalent HPV vaccine (HPV4v). No effectiveness was seen with a full vaccination course with the bivalent HPV vaccine (HPV2v) in girls up to 21 years old. GW IR tends to be higher in unvaccinated cohorts covered by HPV4v vaccine than in unvaccinated cohorts not covered by HPV4v vaccine.

CONCLUSIONS

A complete HPV4v vaccination schedule was 74% effective in reducing GW in our population. Our results also suggest an indirect protection to unvaccinated and HPV2v vaccinated girls.

Genital Human Papillomavirus Prevalence Over the Lifespan Among Females and Males in a National Cross-Sectional Survey, United States, 2013-2016

BACKGROUND

Patterns of human papillomavirus (HPV) prevalence by age differ by sex. To further the descriptive epidemiology of genital HPV, we analyzed prevalence by age for nonvaccine (non-4vHPV) type and vaccine (4vHPV) type HPV by sex using 2013-2016 National Health and Nutrition Examination Survey data, the first 4 years of national data from both sexes.

METHODS

Penile and cervicovaginal swabs were self-collected from 15- to 59-year-olds and tested for 37 HPV types. The 4vHPV-type (6/11/16/18) and non-4vHPV-type (any of 33 other types) prevalences were estimated by 3-year age group and participant characteristics. Average percent changes (APCs) in prevalence were estimated using segmented log-binomial regression.

RESULTS

Among females, a positive relationship between non-4vHPV-type prevalence and age was seen from 15-17 to 21-23 years (APC, 56.5), followed by a negative relationship through 30-32 years (APC, -13.2); thereafter, prevalence was not related to age. The 4vHPV-type prevalence was positively related to age through 24-26 years (APC, 56.9), then negatively related through 57-59 years (APC, -6.0). Among males, non-4vHPV-type prevalence had a positive relationship with age through 21-23 years (APC, 102.4) with a smaller positive relationship through 57-59 years (APC, 1.4). For both sexes, modeled joinpoints for 4vHPV-type prevalence occurred at older ages compared with joinpoints for non-4vHPV-type prevalence.

CONCLUSIONS

Sex differences in age-specific non-vaccine-type HPV prevalence may reflect natural history and sexual behavior. Differences in vaccine-type and non-vaccine-type modeling results suggest vaccine impact as joinpoints occur in mid-late 20s for vaccine-type HPV but early 20s for nonvaccine types. These data can assist in refining HPV vaccination models and inform HPV vaccination practices and policy.

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.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Public health impact and cost-effectiveness of catch-up 9-valent HPV vaccination of individuals through age 45 years in the United States

The Advisory Committee on Immunization Practices (ACIP) recommended catch-up 9-valent Human Papillomavirus (HPV) vaccination through age 26 years, and shared clinical decision-making for adults aged 27-45 years, compared with catch-up through age 26 years and 21 years for females and males, respectively (status quo; pre-June-2019 recommendations). This study assessed the public health impact and cost-effectiveness of expanded catch-up vaccination through age 45 years (expanded catch-up) compared with status quo. We used an HPV dynamic transmission infection and disease model to assess disease outcomes and incremental cost-effectiveness ratio (ICER) of expanded catch-up compared with status quo. Costs (2018 USD), calculated from a healthcare sector perspective, and quality-adjusted life years (QALY) were discounted at 3% annually. Historical vaccination coverage was estimated using NIS-TEEN survey data (NHANES data for sensitivity analysis). Alternative scenario analyses included restricting upper age of expanded catch-up through 26 years (June-2019 ACIP recommendation), 29 years, and further 5-year increments. Our results show expanded catch-up vaccination would prevent additional 37,856 cancers, 314,468 cervical intraepithelial neoplasia-2/3s, 1,743,461 genital warts, and 10,698 deaths compared with status quo over 100 years at cost of $141,000/QALY. With NHANES coverage, the ICER was $96,000/QALY. The June-2019 ACIP recommendation also provided public health benefits with an ICER of $117,000/QALY, compared with status quo. The ICER for expanded vaccination through age 34 years was $107,000/QALY. Expanding catch-up vaccination program through age 45 years-old in the US is expected to provide public health benefits, and cost-effectiveness improves with expanding catch-up through age 34.

Viral Venereal Diseases of the Skin

Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.

The Estimated Lifetime Medical Cost of Diseases Attributable to Human Papillomavirus Infections Acquired in 2018

INTRODUCTION

We estimated the lifetime medical costs of diagnosed cases of diseases attributable to human papillomavirus (HPV) infections acquired in 2018.

METHODS

We adapted an existing mathematical model of HPV transmission and associated diseases to estimate the lifetime number of diagnosed cases of disease (genital warts; cervical intraepithelial neoplasia; and cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers) attributable to HPV infections that were acquired in 2018. For each of these outcomes, we multiplied the estimated number of cases by the estimated lifetime medical cost per case obtained from previous studies. We estimated the costs of recurrent respiratory papillomatosis in a separate calculation. Future costs were discounted at 3% annually.

RESULTS

The estimated discounted lifetime medical cost of diseases attributable to HPV infections acquired in 2018 among people aged 15 to 59 years was $774 million (in 2019 US dollars), of which approximately half was accounted for by infections in those aged 15 to 24 years. Human papillomavirus infections in women accounted for approximately 90% of the lifetime number of diagnosed cases of disease and 70% of the lifetime cost attributable to HPV infections acquired in 2018 among those aged 15 to 59 years.

CONCLUSIONS

We estimated the lifetime medical costs of diseases attributable to HPV infections acquired in 2018 to be $774 million. This estimate is lower than previous estimates, likely due to the impact of HPV vaccination. The lifetime cost of disease attributable to incident HPV infections is expected to decrease further over time as HPV vaccination coverage increases.

Temporal Trends in the Incidence of Anogenital Warts: Impact of Human Papillomavirus Vaccination

BACKGROUND

Studies in countries with high human papillomavirus (HPV) vaccination coverage have demonstrated marked reductions in anogenital wart (AGW) incidence. Our goal was to assess the impact of HPV vaccination in a population with suboptimal coverage by comparing AGW incidence trends in the years before and after vaccine introduction.

METHODS

We conducted a retrospective analysis of AGW incidence trends using an ecologic study design among 11- through 39-year-olds enrolled at Kaiser Permanente Northwest. We defined incidence as the proportion of persons who had a new AGW diagnosis for each calendar year in the prevaccine periods (2000 through 2006 for female individuals, 2000 through 2010 for male individuals) and the postvaccine periods (2007 through 2016 for female individuals, 2011 through 2016 for male individuals). We also described cumulative HPV vaccination coverage.

RESULTS

The average annual AGW incidence rates in the prevaccine periods were 27.8 per 10,000 in female individuals and 26.9 per 10,000 in male individuals. In the postvaccine periods, AGW incidence rates decreased by 31% (P < 0.001) in female individuals and 10% (P = 0.006) in male individuals; the largest reductions were observed in 15- to 19-year-old female individuals (67%, P < 0.001) and male individuals (45%, P < 0.001). Three dose HPV coverage rates were less than 50% in all age groups and both sexes.

CONCLUSIONS

In a population of young adults with moderate HPV vaccination coverage, we observed declines in AGW incidence among both female and male year after the introduction of HPV vaccination. The largest incidence reductions were observed in 15- to 19-year-olds who were most likely to have been vaccinated.

Sexually transmitted coinfections in patients with anogenital warts - a retrospective analysis of 196 patients

BACKGROUND AND OBJECTIVES

Anogenital warts (AGWs) are most commonly caused by low-risk human papillomavirus (HPV) types, and although they are the most frequent viral sexually transmitted infections (STIs), little is known about STI coinfections in affected patients. We therefore sought to assess STI coinfection rates in patients with AGW, specify STI coinfections and calculate the number needed to screen (NNS) for each STI.

METHODS

A retrospective cross-sectional study analyzing data sets from AGW patients treated in our clinic between 2008-2016.

RESULTS

142/196 (72 %) patients had been variably screened for infections with HIV, HBV and HCV, Treponema pallidum, Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and HSV. The STI coinfection rate in all tested patients was 24.6 %, yielding an NNS of 4.1 to detect any STI. Of note, the coinfection rate did not differ significantly between heterosexual men, homosexual men and women, respectively. The NNS for syphilis was 8.4, for HIV 14.0, for HCV 28.5 and for HBV 39.0. The NNS for asymptomatic patients tested for HSV, Chlamydia trachomatis and Mycoplasma genitalium were 1.4, 5.3 and 12.0, respectively.

CONCLUSION

Due to the high prevalence of STI coinfections, AGW patients should be screened for other STIs.

Impact of a single-age cohort human papillomavirus vaccination strategy in Catalonia, Spain: Population-based analysis of anogenital warts in men and women

Extensive multiple-age cohort human papillomavirus (HPV) vaccination has proved to be highly effective. We aimed to determine the 8-year population impact of a female single-age cohort HPV vaccination programme on the incidence of anogenital warts (AGW). In 2008, Catalonia initiated a school-based quadrivalent HPV vaccination programme targeting 11-year-old girls, achieving coverage over 80%. Data on diagnoses of AGW and genital herpes were obtained from a population-based database of electronic health records covering 74% of the population. The annual incidence rates from 2009 to 2016 were calculated, stratified by age and sex using Joinpoint regression to estimate trends and annual percentage changes (APC). Among women aged 16-19 years, the AGW incidence decreased by 61% from 2012 to 2016 (APC -19.4%; 95% CI: -30.0 to -7.3). In contrast, the incidence of genital herpes in same-aged women increased throughout the study period (APC 11.1%; 95% CI: 7.2-15.2). Among men aged 20-22 years, the increasing incidence of AGW shifted to a downward trend in 2013 (APC 2009-2013: 17.0%; 95% CI: 8.2-26.5; and APC 2013-2016: -4.5%; 95% CI: -14.6 to 6.9). A similar pattern was observed among men aged 23-25 years (APC 2009-2014: 16.0%; 95% CI: 12.0-20.2; and APC 2014-2016: -6.0%; 95% CI: -18.4 to 8.3). In contrast to AGW, among men aged 20-25 years, the incidence of genital herpes increased over this period. Our study strongly suggests that a single-cohort HPV vaccination strategy with high vaccine uptake not only provides direct benefit in the vaccinated cohorts but also extends protection through a herd effect to unvaccinated men.

Sexually Transmitted Infections: Part I: Genital Bumps and Genital Ulcers

Sexually transmitted infections (STIs) affect young people in a disproportionate way, with more than half of the infections occurring in 15- to 25-year-olds, although as an age group they constitute only 25% of the sexually active population. Pediatricians should be familiar with the social, behavioral, and biological factors that predispose adolescents to STIs. Preventive visits for teens and pre-teens should incorporate education and counseling about sexuality, safe sexual behavior, and STIs. Pediatricians should be able to identify, diagnose, and manage STIs presenting as genital "bumps" and genital "ulcers." Pediatricians should also offer human immunodeficiency virus testing and expedited partner treatment to all adolescents who are diagnosed as having an STI.

Geographical disparities in human papillomavirus herd protection

BACKGROUND

Human papillomavirus (HPV) vaccination has occurred unequally across the United States, potentially contributing to uneven vaccine-type HPV prevalence between regions. We examined whether emerging vaccine-related herd protection exhibits regional differences among unvaccinated girls and women.

METHODS

We evaluated the prevalence of vaginal HPV among women 14-59 years of age from 2003 to 2014 using repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES). Women who provided an adequate vaginal swab sample were included. Vaginal prevalence of vaccine-type HPV (types 6, 11, 16, 18) were examined in four regions of the United States between 2003 and 2014. We examined vaccine-type HPV prevalence in 2007-2014 in each US census region among younger participants (14-34 years old) stratified by vaccination status to determine whether one or both groups contributed to uneven HPV prevalence.

RESULTS

A total of 12 175 participants 14-59 years of age met inclusion criteria. Vaccine-type HPV prevalence decreased in all regions. Vaccine-type HPV varied by region only among unvaccinated 14-34 year olds, with a higher prevalence in the Midwest (13.8%, 95% confidence interval (CI): 10.7-17.0) and South (12.5%, 95% CI: 10.2-14.8) compared to the Northeast (8.9%, 95% CI: 6.5-11.2). No regional variation in vaccine-type HPV prevalence was observed among vaccinated participants.

CONCLUSIONS

Higher prevalence of vaccine-type HPV among unvaccinated women in the South and Midwest may contribute to regional disparities in HPV-related cancer incidence, as emerging herd immunity may not be as strong in those regions.

Human Papillomavirus Vaccination and Anogenital Warts: A Systematic Review of Impact and Effectiveness in the United States

BACKGROUND

Assessing the impact and effectiveness of HPV vaccines on anogenital warts in the United States can provide early indication of the success of vaccination programs as well as identify potential areas for improvement.

METHODS

Articles were identified from the PubMed, Medline, and Embase databases. Exclusion criteria were applied, and remaining studies were then classified as impact or effectiveness studies.

RESULTS

Eight eligible studies published through March 2018 were included. Population-based impact studies examining trends in diagnoses reported consistent declines in females ages 25 years and younger after 2006 when routine female vaccination began in the United States. Declines in males ages 25 years and younger were also seen; however, these declines were lower than those in females and more evident after routine male vaccination began in 2011. Among females and males older than 25 years, little to no change has been seen in the trends of anogenital warts since 2006. Studies that included the pre-vaccine era (before 2006) reported increasing trends during this period. After vaccine introduction, a reversal in these trends was observed. Effectiveness studies that included individual-level vaccination histories consistently demonstrated a lower risk of anogenital warts for those receiving at least one dose of the vaccine compared to those unvaccinated.

CONCLUSIONS

These findings suggest that the degree of HPV vaccine impact has varied substantially by age and sex. Achieving the full prevention potential of HPV vaccines will likely require greater coverage among both females and males. Post-licensure estimates of effectiveness demonstrate the real-world benefit of the vaccine.

Estimating nationwide cases of sexually transmitted diseases in 2015 from sentinel surveillance data in Japan

Background

The rates of newly diagnosed cases of sexually transmitted diseases, including genital chlamydial infection and gonorrhea, are important for prevention and control of these diseases. However, nationwide rates are not reported in Japan.

Methods

We used the number of cases of sexually transmitted diseases reported by nationwide sentinel surveillance in 2015, together with the number of all disease outpatients in September 2014 at all medical institutions, drawn from the Survey of Medical Institutions of Japan. The number of cases of sexually transmitted diseases in the total population was estimated using the ratio estimation method with the number of all disease outpatients as auxiliary information. This method is currently used for estimating influenza cases from sentinel surveillance data in Japan.

Results

The estimated number of newly diagnosed cases per 100,000 population in 2015 in Japan was 244 (95% confidence interval 211–277) for genital chlamydial infection, 87 (95% confidence interval 74–100) for genital herpes, 61 (95% confidence interval 29–93) for condyloma acuminatum, and 89 (95% confidence interval 64–113) for gonorrhea.

Conclusion

We estimated the nationwide number of newly diagnosed cases of sexually transmitted diseases in Japan from sentinel surveillance data. This provides useful information for public health policy-making.

Assessing sociodemographic differences in human papillomavirus vaccine impact studies in the United States: a systematic review using narrative synthesis

OBJECTIVES

Sociodemographic disparities in the incidence and mortality of human papillomavirus (HPV)-associated conditions have been well documented in the pre-HPV vaccine era. It is still unknown if the introduction of routine vaccination has been effective in reducing these prevaccine era inequalities. The purpose of this review was to determine the utilization of sociodemographic variables to assess for disparities in population-level HPV vaccine impact research and to evaluate the current evidence for disparities in the reduction of HPV-associated conditions after vaccine introduction in the United States (US).

STUDY DESIGN

A systematic review of the literature from January 2007 through March 2018 was carried out to identify studies evaluating the impact HPV vaccines have had on the rates of HPV infection, genital warts, and cervical dysplasia (cervical intraepithelial neoplasia grades 1+) in the US. An in-depth review was then performed to synthesize these data and to assess the way prior studies have reported and evaluated for potential disparities in the vaccine's impact within various racial, ethnic, and/or socio-economic subgroups of the population.

METHODS

Vaccine impact studies measure the change in the population-level burden of disease prelicensure versus postlicensure of the vaccine. We systematically searched PubMed/Medline and Embase, combining search terms related to the HPV vaccine, sentinel surveillance, and HPV-associated conditions. Eligible studies were those with population-level, postvaccine introduction data that were conducted in the US. Finally, a cited reference search was conducted for all included articles using the Web of Science platform that accesses three major citation indexes: Science Citation Index, Social Sciences Citation Index, and Arts and Humanities Citation Index. This allowed us to screen not only the articles that were cited by our final collection of studies but also the articles that used our selected studies as one of their references. The study protocol is registered in PROSPERO (#CRD42018107579).

RESULTS

Overall, 23 of the 4139 references retrieved assessed the population-level impact of HPV vaccines between January 1, 2007, and March 29, 2018. Among these, 13 (57%) reported sociodemographic data. Only two articles reported stratified results by sociodemographic factors, thereby allowing assessment for potential disparate impact. One of these studies described differences in the impact of the vaccine by race, ethnicity, and income.

CONCLUSION

Although approximately half of the studies that assessed the impact of the HPV vaccine measured sociodemographic characteristics, few presented results in a way that allowed for the identification of potential differences in impact between the relevant subgroups of the population. Determining to what extent, if any, vaccines are reducing known sociodemographic disparities is an important public health priority and an essential step in developing immunization strategies that are beneficial for all.

Human papillomavirus genotype distribution in genital warts among women in Harare-Zimbabwe

This study aimed to determine the prevalence of HPV genotypes in genital warts among women in Harare, Zimbabwe. Women aged 18-45 years attending gynaecology and genitourinary clinics with a clinical diagnosis of genital-warts were recruited. HPV-DNA was extracted from tissue biopsies. HPV-DNA testing and typing was done by Southern Dot Blot Hybridisation. A hundred samples from 100 women were analysed. Median age of participants was 30.3 years (range 18-45 years). Seventy-eight percent of participants were HIV infected. HPV prevalence was 98%. Low risk genotypes predominated at 86% prevalence. The most prevalent genotypes were 11 (47%), 6 (42%) and 16 (14%). This is the first study on HPV genotype distribution among women with genital warts in Zimbabwe. The high prevalence of HR-HPV 16 in clinically benign lesions shows that warts should have histological analysis to exclude pre-malignancy and malignancy.Impact statementWhat is already known on this subject? Genital warts (GWs), also known as condylomata acuminata (EAC), are a clinical manifestation of persistent infection with 'low risk' or non-oncogenic HPV genotypes. HPV 6 and 11 are examples of low risk genotypes, and both are associated with 90% of GWs. Data on HPV genotypes causing genital warts in the population under study are scarce.What do the results of this study add? A high prevalence (98%) of HPV DNA in genital warts, confirms that the biopsied lesions were HPV related. Over and above the high prevalence of low risk HPV 11 (47%) and HPV 6 (42%), the women had 14% prevalence of HPV 16, an oncogenic genotype, in genital warts. Seventy-eight percent of the participants were HIV infected. The HIV infected women had a 33.3% prevalence of HR-HPV as compared to the 15.8% prevalence in the HIV uninfected women.What are the implications of these findings for clinical practice and/or further research? The population under study will benefit more if an HPV vaccine that includes anti-HPV 6 and 11 is used. The high prevalence of the HR-HPV in apparently benign lesions shows that warts should have histological analysis to exclude vulvar cancer and vulvar intraepithelial neoplasia. All women presenting with genital warts should be offered an HIV test.

Comparison of different human papillomavirus (HPV) vaccine types and dose schedules for prevention of HPV-related disease in females and males

BACKGROUND

Uptake of human papillomavirus (HPV) vaccine remains low in many countries, although the bivalent and quadrivalent HPV vaccines given as a three-dose schedule are effective in the prevention of precancerous lesions of the cervix in women. Simpler immunisation schedules, such as those with fewer doses, might reduce barriers to vaccination, as may programmes that include males.

OBJECTIVES

To evaluate the efficacy, immunogenicity, and harms of different dose schedules and different types of HPV vaccines in females and males.

SEARCH METHODS

We conducted electronic searches on 27 September 2018 in Ovid MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library), and Ovid Embase. We also searched the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov (both 27 September 2018), vaccine manufacturer websites, and checked reference lists from an index of HPV studies and other relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with no language restriction. We considered studies if they enrolled HIV-negative males or females aged 9 to 26 years, or HIV-positive males or females of any age.

DATA COLLECTION AND ANALYSIS

We used methods recommended by Cochrane. We use the term 'control' to refer to comparator products containing an adjuvant or active vaccine and 'placebo' to refer to products that contain no adjuvant or active vaccine. Most primary outcomes in this review were clinical outcomes. However, for comparisons comparing dose schedules, the included RCTs were designed to measure antibody responses (i.e. immunogenicity) as the primary outcome, rather than clinical outcomes, since it is unethical to collect cervical samples from girls under 16 years of age. We analysed immunogenicity outcomes (i.e. geometric mean titres) with ratios of means, clinical outcomes (e.g. cancer and intraepithelial neoplasia) with risk ratios or rate ratios and, for serious adverse events and deaths, we calculated odds ratios. We rated the certainty of evidence with GRADE.

MAIN RESULTS

We included 20 RCTs with 31,940 participants. The length of follow-up in the included studies ranged from seven months to five years. Two doses versus three doses of HPV vaccine in 9- to 15-year-old females Antibody responses after two-dose and three-dose HPV vaccine schedules were similar after up to five years of follow-up (4 RCTs, moderate- to high-certainty evidence). No RCTs collected clinical outcome data. Evidence about serious adverse events in studies comparing dose schedules was of very low-certainty owing to imprecision and indirectness (three doses 35/1159; two doses 36/1158; 4 RCTs). One death was reported in the three-dose group (1/898) and none in the two-dose group (0/899) (low-certainty evidence). Interval between doses of HPV vaccine in 9- to 14-year-old females and males Antibody responses were stronger with a longer interval (6 or 12 months) between the first two doses of HPV vaccine than a shorter interval (2 or 6 months) at up to three years of follow-up (4 RCTs, moderate- to high-certainty evidence). No RCTs collected data about clinical outcomes. Evidence about serious adverse events in studies comparing intervals was of very low-certainty, owing to imprecision and indirectness. No deaths were reported in any of the studies (0/1898, 3 RCTs, low-certainty evidence). HPV vaccination of 10- to 26-year-old males In one RCT there was moderate-certainty evidence that quadrivalent HPV vaccine, compared with control, reduced the incidence of external genital lesions (control 36 per 3081 person-years; quadrivalent 6 per 3173 person-years; rate ratio 0.16, 95% CI 0.07 to 0.38; 6254 person-years) and anogenital warts (control 28 per 2814 person-years; quadrivalent 3 per 2831 person-years; rate ratio 0.11, 95% CI 0.03 to 0.38; 5645 person-years). The quadrivalent vaccine resulted in more injection-site adverse events, such as pain or redness, than control (537 versus 601 per 1000; risk ratio (RR) 1.12, 95% CI 1.06 to 1.18, 3895 participants, high-certainty evidence). There was very low-certainty evidence from two RCTs about serious adverse events with quadrivalent vaccine (control 12/2588; quadrivalent 8/2574), and about deaths (control 11/2591; quadrivalent 3/2582), owing to imprecision and indirectness. Nonavalent versus quadrivalent vaccine in 9- to 26-year-old females and males Three RCTs were included; one in females aged 9- to 15-years (n = 600), one in females aged 16- to 26-years (n = 14,215), and one in males aged 16- to 26-years (n = 500). The RCT in 16- to 26-year-old females reported clinical outcomes. There was little to no difference in the incidence of the combined outcome of high-grade cervical epithelial neoplasia, adenocarcinoma in situ, or cervical cancer between the HPV vaccines (quadrivalent 325/6882, nonavalent 326/6871; OR 1.00, 95% CI 0.85 to 1.16; 13,753 participants; high-certainty evidence). The other two RCTs did not collect data about clinical outcomes. There were slightly more local adverse events with the nonavalent vaccine (905 per 1000) than the quadrivalent vaccine (846 per 1000) (RR 1.07, 95% CI 1.05 to 1.08; 3 RCTs, 15,863 participants; high-certainty evidence). Comparative evidence about serious adverse events in the three RCTs (nonavalent 243/8234, quadrivalent 192/7629; OR 0.60, 95% CI 0.14 to 2.61) was of low certainty, owing to imprecision and indirectness. HPV vaccination for people living with HIV Seven RCTs reported on HPV vaccines in people with HIV, with two small trials that collected data about clinical outcomes. Antibody responses were higher following vaccination with either bivalent or quadrivalent HPV vaccine than with control, and these responses could be demonstrated to have been maintained for up to 24 months in children living with HIV (low-certainty evidence). The evidence about clinical outcomes and harms for HPV vaccines in people with HIV is very uncertain (low- to very low-certainty evidence), owing to imprecision and indirectness.

AUTHORS' CONCLUSIONS

The immunogenicity of two-dose and three-dose HPV vaccine schedules, measured using antibody responses in young females, is comparable. The quadrivalent vaccine probably reduces external genital lesions and anogenital warts in males compared with control. The nonavalent and quadrivalent vaccines offer similar protection against a combined outcome of cervical, vaginal, and vulval precancer lesions or cancer. In people living with HIV, both the bivalent and quadrivalent HPV vaccines result in high antibody responses. For all comparisons of alternative HPV vaccine schedules, the certainty of the body of evidence about serious adverse events reported during the study periods was low or very low, either because the number of events was low, or the evidence was indirect, or both. Post-marketing surveillance is needed to continue monitoring harms that might be associated with HPV vaccines in the population, and this evidence will be incorporated in future updates of this review. Long-term observational studies are needed to determine the effectiveness of reduced-dose schedules against HPV-related cancer endpoints, and whether adopting these schedules improves vaccine coverage rates.

Condylomata Acuminata (Anogenital Warts) Contain Accumulations of HIV-1 Target Cells That May Provide Portals for HIV Transmission

Background

Condylomata acuminata (anogenital warts [AGWs]) are prevalent in human immunodeficiency virus (HIV)-infected individuals and sexually active populations at risk for HIV acquisition and have been associated with HIV transmission. We compared AGW specimens to control tissue specimens for abundance, types, and location of HIV target cells and for susceptibility to HIV infection in vitro, to provide biologic evidence that AGWs facilitate HIV transmission.

Methods

We used immunohistologic staining to identify HIV target cells in AGW and control specimens. We also inoculated HIV in vitro into AGW and control specimens from HIV-negative men and assessed infection by means of TZM-bl and p24 assays.

Results

CD1a+ dendritic cells, CD4+ T cells, and macrophages were significantly more abundant in the epidermis of AGW specimens than control specimens. These HIV target cells also often appeared in large focal accumulations in the dermis of AGW specimens. Two of 8 AGW specimens versus 0 of 8 control specimens showed robust infection with HIV in vitro.

Conclusions

Compared with normal skin, AGWs contain significantly higher concentrations of HIV target cells that may be susceptible to HIV infection. Condylomata may thus promote HIV transmission, especially in the setting of typical lesion vascularity and friability. Prevention or treatment of AGWs may decrease the sexual transmission of HIV.

Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis

BACKGROUND

More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination.

METHODS

In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks.

FINDINGS

We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5-8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11-0·25) among girls aged 13-19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23-0·49) among women aged 20-24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33-0·66) among girls aged 13-19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24-0·46) among girls aged 15-19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36-0.60) among women aged 20-24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53-0·89) among women aged 25-29 years. Among boys aged 15-19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37-0·75) and among men aged 20-24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47-0·98). After 5-9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42-0·58) among screened girls aged 15-19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57-0·84) among women aged 20-24 years.

INTERPRETATION

This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects.

FUNDING

WHO, Canadian Institutes of Health Research, Fonds de recherche du Québec - Santé.

Trends in the Prevalence of Anogenital Warts Among Patients at Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, United States, 2010-2016

BACKGROUND

Approximately 90% of genital warts are caused by human papillomavirus (HPV) types 6 and 11. In the United States, HPV vaccination has been recommended for girls and women aged ≤26 years, and since 2011, for boys and men aged ≤21 years and for gay, bisexual, and other men who have sex with men (MSM) aged ≤26 years.

METHODS

Data were obtained from 27 clinics participating in the STD Surveillance Network. Trends in the annual prevalence of anogenital warts (AGW) from 2010-2016 were described by sex and by the sex of sex partners.

RESULTS

During 2010-2016, significant declines in the prevalence of AGW were observed in women aged <40 years, men who have sex with women only (MSW) aged <40 years, and MSM of all age categories. An inflection in trend in 2012 was noted for MSW aged 20-24 or 25-29 years and for MSM aged 20-24 years.

CONCLUSIONS

The observed declines in the prevalence of AGW suggest that HPV morbidity is declining among populations attending STD clinics, including MSW, MSM, and women. Declines in younger age groups are consistent with what would be expected following the implementation of HPV vaccination. However, declines were also observed in older age groups and are not likely to be the result of vaccination.

Trends in anogenital wart incidence among Tennessee Medicaid enrollees, 2006-2014: The impact of human papillomavirus vaccination

Introduction

Evidence of human papillomavirus (HPV) vaccine impact on anogenital warts (AGWs) by race or urbanicity in the US is lacking. We evaluated HPV vaccine impact in Tennessee by assessing AGW trends among Tennessee Medicaid (TennCare) enrollees aged 15–39 years from 2006-2014.

Methods

Persons with incident AGWs were identified using diagnosis/pharmacy codes from TennCare billing claims. We calculated sex-specific annual AGW incidence by age group, race, and urbanicity; estimated annual percent changes (APCs) using log-linear models; and performed pairwise comparisons by race and urbanicity.

Results

AGW incidence decreased among females aged 15–19 (APC = −10.6; P < 0.01) and 20–24 years (APC = −3.9; P = 0.02). Overall trends were similar between Whites and Blacks, and between those living in metropolitan statistical areas (MSAs) and non-MSAs. Rates among males aged 15–19 years began decreasing after 2010. Among enrollees aged 25–39 years, rates increased or were stable.

Conclusions

Following introduction of the HPV vaccine in 2006, AGWs decreased among age groups most likely to be vaccinated. The change in trend among young males after 2010 suggests early herd effects. Our findings indicate vaccine effects and support the importance of improving adherence to current vaccination recommendations for preventing AGWs and other HPV-related diseases.

Penile warts: an update on their evaluation and management

Background

Penile warts are the most common sexually transmitted disease in males. Clinicians should be familiar with the proper evaluation and management of this common condition.

Objective

To provide an update on the current understanding, evaluation, and management of penile warts.

Methods

A PubMed search was completed in Clinical Queries using the key terms 'penile warts' and 'genital warts'. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.

Results

Penile warts are caused by human papillomavirus (HPV), notably HPV-6 and HPV-11. Penile warts typically present as asymptomatic papules or plaques. Lesions may be filiform, exophytic, papillomatous, verrucous, hyperkeratotic, cerebriform, fungating, or cauliflower-like. Approximately one-third of penile warts regress without treatment and the average duration prior to resolution is approximately 9 months. Active treatment is preferable to watchful observation to speed up clearance of the lesions and to assuage fears of transmission and autoinoculation. Patient-administered therapies include podofilox (0.5%) solution or gel, imiquimod 3.75 or 5% cream, and sinecatechins (polypheron E) 15% ointment. Clinician-administered therapies include podophyllin, cryotherapy, bichloroacetic or trichloroacetic acid, oral cimetidine, surgical excision, electrocautery, and carbon dioxide laser therapy. Patients who do not respond to first-line treatments may respond to other therapies or a combination of treatment modalities. Second-line therapies include topical/intralesional/intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutate.

Conclusion

No single treatment has been shown to be consistently superior to other treatment modalities. The choice of the treatment method should depend on the physician's comfort level with the various treatment options, the patient's preference and tolerability of treatment, and the number and severity of lesions. The comparative efficacy, ease of administration, adverse effects, cost, and availability of the treatment modality should also be taken into consideration.

Cost-effectiveness of nonavalent HPV vaccination among males aged 22 through 26 years in the United States

INTRODUCTION

In the United States, routine human papillomavirus (HPV) vaccination is recommended for females and males at age 11 or 12 years; the series can be started at age 9 years. Vaccination is also recommended for females through age 26 years and males through age 21 years. The objective of this study was to assess the health impact and cost-effectiveness of harmonizing female and male vaccination recommendations by increasing the upper recommended catch-up age of HPV vaccination for males from age 21 to age 26 years.

METHODS

We updated a published model of the health impact and cost-effectiveness of 9-valent human papillomavirus vaccine (9vHPV). We examined the cost-effectiveness of (1) 9vHPV for females aged 12 through 26 years and males aged 12 through 21 years, and (2) an expanded program including males through age 26 years.

RESULTS

Compared to no vaccination, providing 9vHPV for females aged 12 through 26 years and males aged 12 through 21 years cost an estimated $16,600 (in 2016 U.S. dollars) per quality-adjusted life year (QALY) gained. The estimated cost per QALY gained by expanding male vaccination through age 26 years was $228,800 and ranged from $137,900 to $367,300 in multi-way sensitivity analyses.

CONCLUSIONS

The cost-effectiveness ratios we estimated are not so favorable as to make a strong economic case for recommending expanding male vaccination, yet are not so unfavorable as to preclude consideration of expanding male vaccination. The wide range of plausible results we obtained may underestimate the true degree of uncertainty, due to model limitations. For example, the cost per QALY might be less than our lower bound estimate of $137,900 had our model allowed for vaccine protection against re-infection. Models that specifically incorporate men who have sex with men (MSM) are needed to provide a more comprehensive assessment of male HPV vaccination strategies.

Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review

INTRODUCTION

Vaccine herd effects are the indirect protection that vaccinated persons provide to those who remain susceptible to infection, due to the reduced transmission of infections. Herd effects have been an important part of the discourse on how to best implement human papillomavirus (HPV) vaccines and prevent HPV-related diseases.

AREAS COVERED

In this paper, we review the theory of HPV vaccine herd effects derived from mathematical models, give an account of observed HPV vaccine herd effects worldwide, and examine the implications of vaccine herd effects for future cervical cancer screening efforts.

EXPERT COMMENTARY

HPV vaccine herd effects improve the cost-effectiveness of vaccinating preadolescent girls, but contribute to making gender-neutral vaccination less economically efficient. Vaccination coverage and sexual mixing patterns by age are strong determinants of herd effects. Many countries worldwide are starting to observe reductions in HPV-related outcomes likely attributable to herd effects, most notably declining anogenital warts in young men, and declining HPV-16/18 infection prevalence in young unvaccinated women. Policy makers making recommendations for cervical cancer screening will have to consider HPV vaccination coverage and herd effects, as these will affect the positive predictive value of screening and the risk of cervical cancer in unvaccinated women.

Assessment of trends in cervical cancer screening rates using healthcare claims data: United States, 2003-2014

Improved understanding of the natural history of cervical cancer has led to changes in screening recommendations, including the addition of the human papillomavirus (HPV) testing as an option in routine screening. Most studies of screening trends have used national self-reported survey data. To better understand recent trends in cervical cancer screening, including cytology (Papanicolaou, or Pap, tests) and human papillomavirus co-tests (HPV + Pap test), we used healthcare claims data to examine screening practices and trends. We analyzed screening among commercially-insured females ages 18-65 during 2005-2014 who were continuously enrolled during three or more contiguous calendar years, to identify those who received cervical cancer screening with a Pap test or co-test. We examined screening prevalence by age group and year. During the latter years of our study period, screening prevalence (regardless of screening method) declined significantly for women in all age groups examined. Despite declines in overall screening, the prevalence of co-testing increased in all age groups except those aged 18-20. In 2014, women aged 30-39 had the highest overall screening uptake (77.5%) and the highest use of co-testing (44.4%); this group also had the lowest overall declines in screening over the time period (-4.5%). These screening measures from healthcare claims were lower than self-reported screening from national surveys of the general population. More research to explore the reasons for these differences is needed to ensure that women are receiving appropriate screening, and to better understand why screening prevalence is declining among this population of commercially insured women.