The current state of introduction of human papillomavirus vaccination into national immunisation schedules in Europe: first results of the VENICE2 2010 survey

Effect of vaccine hesitancy on female college students' willingness to receive the HPV vaccine in China: a multicenter cross-sectional study

OBJECTIVE

To analyse the influencing factors of vaccine hesitancy on HPV vaccination willingness of female college students in order to promote the promotion of HPV vaccine in female college student population.

METHODS

From September-October 2022, a convenience sampling method was used to conduct a questionnaire survey among freshman female students from four higher vocational colleges in Henan Province, China. The survey comprised a general information questionnaire, as well as inquiries regarding vaccine hesitancy and willingness to receive the human papillomavirus (HPV) vaccine. In PSM analyses, vaccine-hesitant students were matched with non-vaccine-hesitant students at a 1:1 ratio; subsequently, both univariate and multivariatble logistic regression analyses were applied to assess the impact of vaccine hesitancy on female university students' willingness to receive the HPV vaccine.

RESULTS

The results revealed a vaccine hesitancy rate of 44.75% among female university students, with 82.9% expressing willingness to receive the HPV vaccine. The results of the multivariable ordinal logistic regression analysis indicated vaccine hesitancy is a risk factor for HPV vaccination intentions among female university students [OR = 4.38, 95% CI (2.74, 6.99), P < 0.001]. Furthermore, the field of study (P = 0.01) and independently seeking information about the HPV vaccine (P = 0.04) were identified as factors influencing female university students' willingness to receive the HPV vaccine.

CONCLUSIONS

Non-vaccine-hesitant students were more likely to be willing to receive the HPV vaccine than vaccine-hesitant students. Healthcare providers and educators should focus on vaccine attitudes among female college students to reduce vaccine hesitancy and enhance community education on cervical cancer, HPV infection and prevention through multichannel campaigns.

Cost-effectiveness of human papillomavirus (HPV) vaccination in Burkina Faso: a modelling study

BACKGROUND

Africa has some of the highest cervical cancer incidence and mortality rates globally. Burkina Faso launched a human papillomavirus (HPV) vaccination programme for 9-year-old girls in 2022 with support from Gavi, the Vaccine Alliance (Gavi). An economic evaluation of HPV vaccination is required to help sustain investment and inform decisions about optimal HPV vaccine choices.

METHODS

We used a proportionate outcomes static cohort model to evaluate the potential impact and cost-effectiveness of HPV vaccination for 9-year-old girls over a ten-year period (2022-2031) in Burkina Faso. The primary outcome measure was the cost (2022 US$) per disability-adjusted life year (DALY) averted from a limited societal perspective (including all vaccine costs borne by the government and Gavi, radiation therapy costs borne by the government, and all other direct medical costs borne by patients and their families). We evaluated four vaccines (CERVARIX®, CECOLIN®, GARDASIL-4®, GARDASIL-9®), comparing each to no vaccination (and no change in existing cervical cancer screening and treatment strategies) and to each other. We combined local estimates of HPV type distribution, healthcare costs, vaccine coverage and costs with GLOBOCAN 2020 disease burden data and clinical trial efficacy data. We ran deterministic and probabilistic uncertainty analyses.

RESULTS

HPV vaccination could prevent 37-72% of cervical cancer cases and deaths. CECOLIN® had the most favourable cost-effectiveness (cost per DALY averted < 0.27 times the national gross domestic product [GDP] per capita). When cross-protection was included, CECOLIN® remained the most cost-effective (cost per DALY averted < 0.20 times the national GDP per capita), but CERVARIX® provided greater health benefits (66% vs. 48% reduction in cervical cancer cases and deaths) with similar cost-effectiveness (cost per DALY averted < 0.28 times the national GDP per capita, with CECOLIN® as the comparator). We estimated the annual cost of the vaccination programme at US$ 2.9, 4.1, 4.4 and 19.8 million for CECOLIN®, GARDASIL-4®, CERVARIX® and GARDASIL-9®, respectively. A single dose strategy reduced costs and improved cost-effectiveness by more than half.

CONCLUSION

HPV vaccination is cost-effective in Burkina Faso from a limited societal perspective. A single dose strategy and/or alternative Gavi-supported HPV vaccines could further improve cost-effectiveness.

Knowledge on human papillomavirus (HPV), HPV screening and HPV vaccine among sexual health clinic patients in Martinique, French West Indies

OBJECTIVES

To assess the level of knowledge about HPV in a population attending a sexual health clinic in the University Hospital of Martinique.

METHODS

Cross sectional observational study based on a validated questionnaire among 500 young adults between June 2020 and March 2021. First question was "Have you ever heard of HPV?". If the answer was "Yes", the person was invited to answer the next 28 questions.

RESULTS

Overall, 68% of participants had never heard of HPV, rising to 74.6% of women. Out of 28 questions, the median of correct answers by participants was 15 (IQR 8-19). We did not find any difference related to age. Women had more correct answers than men on most of the items related to screening and vaccine.

CONCLUSION

In Martinique, knowledge about HPV is poor. New communication methods are required to reach young boys and girls.

Prophylactic Human Papillomavirus Vaccination: From the Origin to the Current State

Immunization is the most successful method in preventing and controlling infectious diseases, which has helped saving millions of lives worldwide. The discovery of the human papillomavirus (HPV) infection being associated with a variety of benign conditions and cancers has driven the development of prophylactic HPV vaccines. Currently, four HPV vaccines are available on the pharmaceutical market: Cervarix, Gardasil, Gardasil-9, and the recently developed Cecolin. Multiple studies have proven the HPV vaccines' safety and efficacy in preventing HPV-related diseases. Since 2006, when the first HPV vaccine was approved, more than 100 World Health Organization member countries reported the implementation of HPV immunization. However, HPV vaccination dread, concerns about its safety, and associated adverse outcomes have a significant impact on the HPV vaccine implementation campaigns all over the world. Many developed countries have successfully implemented HPV immunization and achieved tremendous progress in preventing HPV-related conditions. However, there are still many countries worldwide which have not created, or have not yet implemented, HPV vaccination campaigns, or have failed due to deficient realization plans associated with establishing successful HPV vaccination programs. Lack of proper HPV information campaigns, negative media reflection, and numerous myths and fake information have led to HPV vaccine rejection in many states. Thus, context-specific health educational interventions on HPV vaccination safety, effectiveness, and benefits are important to increase the vaccines' acceptance for efficacious prevention of HPV-associated conditions.

Knowledge and Awareness of Polish Parents on Vaccination against Human Papillomavirus

Background: Human papillomavirus (HPV) vaccinations are rare among Polish children, and the reasons are scant. The objective was to evaluate the knowledge, attitude and awareness of parents about HPV vaccination to investigate reasons for low HPV vaccination coverage. Methods: 387 parents of children hospitalized at the Children’s Hospital were asked to participate in an anonymous and voluntary survey study. Three hundred and two surveys were returned. Results: Only 54% of participants have heard about HPV, while 26% know that it is a sexually transmitted disease. According to 71% of responders, vaccines are generally effective, and 63% claim that they are safe. However, only 5% of daughters and 4% of sons are vaccinated against HPV. A total of 25% of parents spoke with their doctor about HPV-related diseases and prevention methods. A higher level of education (p = 0.01), knowledge of sexually transmitted diseases (p < 0.0001), perceiving vaccination as an effective and safe prophylactic method (p < 0.0001), and conversations with a doctor (p < 0.0001) are strong motivators to vaccinate children against HPV. This decision is free of religious beliefs, origin, age, gender and the number of children. Conclusions: Polish parents have a positive attitude towards vaccination. They recognize the limitations of their knowledge and express a desire to further it. Educational activity is an important element of physicians’ work.

The Effect of Health Education on Adolescents' Awareness of HPV Infections and Attitudes towards HPV Vaccination in Greece

Background: The purpose of this paper is to evaluate the role of health education among young adolescents, regarding their level of knowledge about the HPV and the acceptance of the HPV vaccination, with the aim of increasing vaccination coverage, in Trikala city, mainland of Greece. Methods: This study included high school students from all public and private schools of Trikala city. Questionnaires related to knowledge regarding the HPV infection and HPV vaccination were administered in three phases. In the first phase of the study, the questionnaires were completed by the entire study population. During the second and third phases, the completion of the questionnaires concerned only the population that received the intervention (interactive seminars). The second and third phase questionnaires were completed immediately after the interactive seminar and three months later, respectively. The statistical analysis of the results was performed using IBM SPSS 20.0 statistical program. Results: A total of 434 female students completed the questionnaire (response rate 76.26%). Most participants (66.6%) were females. The questionnaires evaluated the respondents’ awareness of the HPV infection. The results show that the percentage of the participants who stated that they “do not know” what HPV is decreased from 44.4% (first phase), to 1.6% (second phase), and 8.1% (third phase). Similarly, the willingness to accept the HPV vaccine increased from 71% (first phase), to 89.1% (second phase), and 83.5% (third phase). Conclusions: The present study shows that targeted interactive informational interventions in the school environment leads to a statistically significant increase in both the level of knowledge about HPV and the willingness of young adolescent students to be vaccinated against cervical cancer.

The status of human papillomavirus vaccination recommendation, funding, and coverage in WHO Europe countries (2018-2019)

Background: There is a need to better understand HPV vaccination (HPVv) implementation in WHO Europe Region (WHO/ER), including recommendations, funding, and vaccination coverage rates (VCR). Methods: A targeted literature review (up to 31 January 2020) was conducted using national health ministry websites, WHO database, and published studies from WHO/ER countries (n = 53). HPVv recommendations and funding data (target age, gender, schedule, setting, target and monitored VCR) for primary and catch-up cohorts were collected. Results: National recommendations for HPVv exist in 46/53 (87%) countries, of which 38 (83%), 2 (4%), and 6 (13%) countries provided full, partial, or no funding, respectively, for the primary cohort. Fully or partially funded HPVv was provided for girls only in 25/53 (47%) countries and for both boys and girls in 15/53 (28%) countries. HPVv catch-up was fully or partially funded in 14/53 (26%) countries. Among 40 countries with a national immunization program (NIP), monitored VCRs ranged from 4.3% to 99% (n = 30). Of the 10 countries reporting VCR targets, only Portugal exceeded its target. Conclusion: Of the 53 WHO/ER countries, 40 have funded HPVv NIPs, among which 30 report VCRs. Additional efforts are required to ensure HPVv NIPs are fully funded and high VCRs maintained.

Awareness of Human Papillomavirus and Its Oncogenic Potential in Head and Neck Cancer among Students: Still More Questions than Answers

In the past years, human papilloma virus (HPV) has been proved to be an important risk factor for head and neck squamous cell carcinomas (HNSCCs), especially in the oropharynx (OPCCS). The aim of this study was to assess the level of knowledge about HPV among students and to raise their awareness on the issue. A 22-question questionnaire was uploaded to an online service. Information about the project was sent out to students from three Universities in Lodz, Poland. All data were collected via questionnaire website tools. A total of 1710 students participated in this study. The group was divided into medical (MS) and non-medical (non-MS) students. Merely 59.38% of the non-MS had ever heard about HPV. Only 44.74% of the non-MS knew about vaccines against HPV. The oncogenic potential of HPV was evident for 81.17% of the MS and only 55.92% of the non-MS. Very similar numbers of respondents from both groups (39.21% vs. 36.47%) knew that HPV may cause cancers other than cervical. Nearly half of the respondents from both groups (46.28% vs. 48.32%) did not know about the risk of developing oral or oropharyngeal cancer. The level of knowledge about the consequences of HPV infection in head and neck cancers in young adults remains insufficient.

Italian Health Care Workers' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Infection and Prevention

Objective: To assess healthcare workers’ knowledge and attitudes about human papillomavirus (HPV) infection, related diseases, and prevention. Methods: A cross-sectional multicenter survey about HPV and its prevention, targeted to healthcare workers involved in HPV vaccine counseling, was performed from May 2017 to December 2018. Results: The overall median knowledge and attitude scores were 69.2% (25–75, p = 61.5–84.6) and 5 (25–75, p = 4–5), respectively. Both knowledge and attitudes statistically significantly differ between physicians and healthcare professions. The median propensity score before and after the educational intervention was stable and high, at 10 (25–75, p = 9–10). The predictors of statistically significantly high knowledge scores are to be a physician, general practitioner, or pediatrician, attending courses/congresses, and consulting technical product characteristics and scientific literature to obtain information about the HPV vaccine. Being a physician and consulting scientific literature to obtain information about the HPV vaccine were found also as predictors of statistically significantly different attitude scores among study participants. Conclusions: Although healthcare workers showed overall positive attitudes towards the relevance of HPV burden and prevention tools, demonstrated knowledge was largely suboptimal, particularly that shown by healthcare professions. Obtained results allow highlighting knowledge gaps, and thus improving counselling to HPV vaccine targets.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effectiveness of vaccination to prevent the papillomavirus infection: a systematic review and meta-analysis

Our purpose was to determine the effectiveness and harms of vaccination in patients with any sexual history to prevent the prevalence of papillomavirus infection. A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE and LILACS databases. Searches were also conducted in other databases and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration's tool. Analysis of fixed effects was conducted. The primary outcome was the infection by any and each human papillomavirus (HPV) genotype, serious adverse effects and short-term adverse effects. The measure of the effect was the risk difference (RD) with a 95% confidence interval (CI). The planned interventions were bivalent vaccine/tetravalent/nonavalent vs. placebo/no intervention/other vaccines. We included 29 studies described in 35 publications. Bivalent HPV vaccine offers protection against HPV16 (RD −0.05, 95% CI −0.098 to −0.0032), HPV18 (RD −0.03, 95% CI −0.062 to −0.0004) and HPV16/18 genotypes (RD of −0.1, 95% CI −0.16 to −0.04). On the other side, tetravalent HPV vaccine offered protection against HPV6 (RD of −0.0500, 95% CI −0.0963 to −0.0230), HPV11 (RD −0.0198, 95% CI −0.0310 to −0.0085). Also, against HPV16 (RD of −0.0608, 95% CI −0.1126 to −0.0091) and HPV18 (RD of −0.0200, 95% CI −0.0408 to −0.0123). There was a reduction in the prevalence of HPV16, 18 and 16/18 genotypes when applying the bivalent vaccine, with no increase in adverse effects. Regarding the tetravalent vaccine, we found a reduction in the prevalence of HPV6, 11, 16 and 18 genotypes, with no increase in adverse effects.

Human papillomavirus vaccination coverage, policies, and practical implementation across Europe

BACKGROUND

Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland.

METHODS

Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information.

RESULTS

Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9-15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51-70% in seven, 31-50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used.

CONCLUSION

According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.

Social and cultural construction processes involved in HPV vaccine hesitancy among Chinese women: a qualitative study

Background

HPV vaccine is a prophylactic vaccine to prevent HPV infections. Recommended by the World Health Organization, this vaccine is clinically proven to be one of the most effective preventive measures against the prevalence of cervical cancer and other HPV-associated cancers and chronic genital conditions. However, its uptake rate among women in Hong Kong is insignificant—only approximately 2.9% adolescent girls and 9.7% female university students received HPV vaccination in 2014. With the notion of Critical Medical Anthropology, we aimed to identify if different influential factors, ranging from individual, societal, and cultural, are involved in the decision-making process of whether to receive HPV vaccination.

Methods

We adopted a qualitative approach and conducted in-depth individual semistructured interviews with 40 women in Hong Kong between May and August 2017.

Results

We noted that the following factors intertwined to influence the decision-making process: perceptions of HPV and HPV vaccine; perceived worthiness of HPV vaccines, which was in turn influenced by vaccine cost, marriage plans, and experiences of sexual activities; history of experiencing gynecological conditions, stigma associated with HPV vaccination, acquisition of information on HPV vaccines, distrust on HPV vaccines, and absence of preventive care in the healthcare practice.

Conclusions

HPV vaccination is promoted in a manner that is “feminized” and “moralized” under the patriarchal value system, further imposing the burden of disease on women, and leading to health inequality of women in pursuing the vaccination as a preventive health behaviour as a result. We believe that this ultimately results in an incomplete understanding of HPV, consequently influencing the decision-making process. The “mixed-economy” medical system adopting capitalist logic also molds a weak doctor–patient relationship, leading to distrust in private practice medical system, which affects the accessibility of information regarding HPV vaccination for participants to make the decision.

Reaching 80% human papillomavirus vaccination prevalence by 2026: How many adolescents need to be vaccinated and what are their characteristics?

BACKGROUND

Human papillomavirus vaccination (HPVV) prevents several types of cancer. The American Cancer Society recently established a goal that by 2026, 80% of adolescents will be up to date (UTD) before their 13th birthday. However, the number in need of vaccination to reach this goal is unknown. This study estimated the number of additional adolescents (11-12 years old) who need HPVV for 80% prevalence to be reached by 2026.

METHODS

The study used de-identified and publicly available data and exempt from institutional review board approval and informed consent. The 2016 National Immunization Survey for Teens was used to estimate the baseline HPVV prevalence. Linear growth to 80% HPVV prevalence by 2026 was applied to set intermediate targets. US Census Bureau data were used for population projections. This study estimated the cumulative number of additional adolescents 11 to 12 years old who would need to become UTD (ie, receive 2 doses) by first subtracting the number who would need to be vaccinated to achieve an intermediate target prevalence from the estimated number currently compliant and then summing these numbers between 2018 and 2026.

RESULTS

Nationwide, an additional 7.62 million males (95% confidence interval [CI], 6.78 million to 8.40 million) and an additional 6.77 million females (95% CI, 5.95 million to 7.55 million), aged 11 to 12 years, would need to receive 2 doses of the vaccine between 2018 and 2026 for 80% prevalence to be achieved. Most adolescents not UTD (80%) also needed to initiate vaccination, and more than 90% recently visited a health care provider.

CONCLUSIONS

It is estimated that at least 14.39 million additional adolescents aged 11 to 12 years in the United States will need to receive 2 doses of HPVV for a UTD HPVV prevalence of 80% to be achieved by 2026. To reach this goal, improvements in facilitators of HPVV initiation, including physician recommendations and parental acceptability, are needed.

Awareness and Knowledge About HPV and HPV Vaccine Among Romanian Women

Cervical cancer is one of the most prevalent gynecological malignancies worldwide. Romania has the highest incidence of this type of cancer in Europe. A successful prevention strategy has to consider the primary prevention measures (including health education on human papilloma virus (HPV) infection but also vaccination). The aim of this study was to assess the knowledge and attitudes of Romanian women about HPV and HPV vaccine. We conducted a cross-sectional study survey of 454 women using an anonymously completed questionnaire covering the awareness and knowledge of HPV infection and attitudes to vaccination. We also analyzed the discussions and conclusion from a focus group of healthcare professionals regarding (1) HPV and HPV awareness and attitude, and (2) suggestions for improving HPV vaccine knowledge and acceptance. 69.2% of women were aware about HPV but their knowledge was minimal and incomplete. While 62.3% had heard about HPV vaccine, only 50.7% had a positive attitude toward it. The main barriers to vaccination were the fear of side effects, the perception that is risky, and the financial concerns. Deficiencies in knowledge were noted for vaccine, genital warts, or risks factors for HPV infection like the early onset of sexual life. The information regarding HPV and vaccine is not always accurate and complete, and only 50.7% of women have a positive attitude toward the vaccine. More educational programs and clearer communication are needed to raise awareness and knowledge regarding HPV and HPV vaccine.

Policies and processes for human papillomavirus vaccination in Latin America and the Caribbean

OBJECTIVES

Three highly effective vaccines are available to prevent human papillomavirus (HPV) infection, and they have been introduced in many countries around the world. This article describes advances and challenges in introducing HPV vaccines in the Expanded Program of Immunization (EPI) of countries in Latin America and the Caribbean (LAC).

METHODS

We reviewed national and regional sources of information to identify LAC countries with and without universal HPV vaccination, along with the year of introduction, type of HPV vaccine, vaccination scheme, age groups targeted, and coverage level reached. Incidence rates of cervical cancer were compared across countries with and without an HPV vaccination program, in order to identify inequities in access to HPV vaccines.

RESULTS

So far, 10 LAC countries have supplied data on their vaccination policies and vaccination coverage rates to the Pan America Health Organization. The majority of those 10 started their vaccination programs using quadrivalent vaccine. Only Chile, Ecuador, and Mexico started their programs using a two-dose scheme. However, by the end of 2016, most of the other countries had switched from a three-dose to a two-dose scheme. Different age groups are targeted in the various programs. Some countries vaccinate one-year birth cohorts, while others vaccinate multiple-year birth cohorts. By the end of 2014, coverage with at least two doses ranged from a low of 2% to a high of 86%. With the exception of Venezuela, the LAC countries with the largest populations introduced universal HPV vaccination between 2010 and 2014. Despite the progress that has occurred in some LAC countries, there are still 10 LAC nations with cervical cancer rates above the LAC average (21.2 cases per 100 000) that have not introduced an HPV vaccine in their EPI.

CONCLUSIONS

With several key adjustments, HPV vaccination programs across Latin America and the Caribbean could be substantially strengthened. Ongoing monitoring of HPV infection outcomes is needed in order to assess the impact of different vaccination policies.

Adoption of the HPV vaccine: a case study of three emerging countries

Background: The human papillomavirus (HPV) vaccine has recently attracted considerable attention in emerging countries, due to its potential to reduce the impact of HPV-related diseases. This case study sheds new light about the variety of HTA arrangements, methods and processes involved in the adoption and use of HPV vaccines in a selected sample of central, eastern and southern Europe and Latin America and the Caribbean, all of them emerging in the use of HTA. Materials & Methods: A multi-country case study was designed. Mixed methods, document review, semi-structured surveys and personal communication with experts, were used for data collection and triangulation. Results: This study shows that common elements of good practice exist in the processes and methods used, with all countries arriving at the same appraisal recommendations. However, the influence of socio-politico-economic factors appears to be determinant on the final decisions and restrictions to access made. Conclusion: This case study intends to draw useful lessons for policymakers in emerging settings interested in the adoption of the HPV vaccine supported by evidence-informed processes, such as those offered by institutionalized HTA. Future studies are also recommended to elucidate the specific roles that social values and uncertainties play in vaccine decision-making across different societies.

Challenges in Cost-Effectiveness Analysis Modelling of HPV Vaccines in Low- and Middle-Income Countries: A Systematic Review and Practice Recommendations

BACKGROUND

Low- and middle-income countries (LMICs) face a number of challenges in implementing cervical cancer prevention programmes that do not apply in high-income countries.

OBJECTIVE

This review assessed how context-specific challenges of implementing cervical cancer prevention strategies in LMICs were accounted for in existing cost-effectiveness analysis (CEA) models of human papillomavirus (HPV) vaccination.

METHODS

The databases of MEDLINE, EMBASE, NHS Economic Evaluation Database, EconLit, Web of Science, and the Center for the Evaluation of Value and Risk in Health (CEA) Registry were searched for studies published from 2006 to 2015. A descriptive, narrative, and interpretative synthesis of data was undertaken.

RESULTS

Of the 33 studies included in the review, the majority acknowledged cost per vaccinated girl (CVG) (26 studies) and vaccine coverage rate (21 studies) as particular challenges for LMICs, while nine studies identified screening coverage rate as a challenge. Most of the studies estimated CVG as a composite of different cost items. However, the basis for the items within this composite cost was unclear. The majority used an assumption rather than an observed rate to represent screening and vaccination coverage rates. CVG, vaccine coverage and screening coverage were shown by some studies through sensitivity analyses to reverse the conclusions regarding cost-effectiveness, thereby significantly affecting policy recommendations.

CONCLUSIONS

While many studies recognized aspects of the particular challenges of HPV vaccination in LMICs, greater efforts need to be made in adapting models to account for these challenges. These include adapting costings of HPV vaccine delivery from other countries, learning from the outcomes of cervical cancer screening programmes in the same geographical region, and taking into account the country's previous experience with other vaccination programmes.

ADVICE for a healthier life: Adult Vaccination Campaign in Europe

Immunization is one of the most effective public health measures to prevent disease. Despite relatively good vaccination rates in childhood in many parts of the world, vaccines to prevent diseases are underused in the adult population and adult vaccination rates are still far below the target. The European Federation of Internal Medicine (EFIM), declared that 'internal medicine must focus on better care for individuals, better health care for populations and lower costs'. Adult vaccination is a good example of a public health initiative aimed at reducing morbidity and mortality, but awareness of the need for adult vaccination and uptake of the programs across Europe is variable. The Adult Vaccination Campaign in Europe (ADVICE) was developed with an aim to raise awareness for adult vaccination and to understand the dynamics of the vaccination practices and the possible barriers against achieving targeted vaccination rates in Europe. In order to reach vaccination targets, we need evidence based, up to date guidelines; recommendations at national and international levels; surveillance for vaccination rates; and opportunities to provide vaccines more readily. Leadership at a European level and a firm research and action agenda are crucial. The European Federation of Internal Medicine can take the lead as it declared its interest on 'better care for individuals, better health care for populations'. Hence, we consider ADVICE a very timely and very valuable initiative to draw a roadmap to improve adult vaccination rates in Europe.

Ethnic background and human papillomavirus vaccine uptake in Denmark: A countrywide retrospective cohort study including 274,154 women aged 19-28 years

AIM

We examined ethnicity-related differences in the uptake of a temporary free-of-charge HPV vaccine (HPVV) catch-up programme offered in Denmark from August 2012 to December 2013 to women born from 1985-1992 and compared it with the previous self-payment system in place.

METHODS

We conducted a nationwide retrospective cohort study. We performed logistic regression analyses to examine the relationship between ethnic background and HPV vaccine (HPVV) programme initiation.

RESULTS

The free programme increased the vaccination uptake from 16% to 75%. Descendants (Denmark-born women with both parents of foreign origin) and immigrants in Denmark for more than 5 years were less likely to initiate the free HPVV programme than Denmark-born women ((aOR=0.56; 95% CI: 0.54-0.59) and (aOR=0.39; 95% CI: 0.38-0.40), respectively). The likelihood of HPVV programme initiation among immigrants increased with time in Denmark ((aOR=2.28; 95% CI: 2.11-2.48) for immigrants living in Denmark for 16-20 years compared to 6-10 years)).

CONCLUSION

The initiation of the free-of-charge HPVV programme was satisfactory. However, large differences in uptake were demonstrated, indicating that some target groups are harder to reach than others. The integration process (as related to use of health services) occurs over many years where differences between the different population groups seem to vanish.

American Society of Clinical Oncology Statement: Human Papillomavirus Vaccination for Cancer Prevention

American Society of Clinical Oncology (ASCO), the leading medical professional oncology society, is committed to lessening the burden of cancer and as such will promote underused interventions that have the potential to save millions of lives through cancer prevention. As the main providers of cancer care worldwide, our patients, their families, and our communities look to us for guidance regarding all things cancer related, including cancer prevention. Through this statement and accompanying recommendations, ASCO hopes to increase awareness of the tremendous global impact of human papillomavirus (HPV) -caused cancers, refocus the discussion of HPV vaccination on its likely ability to prevent millions of cancer deaths, and increase HPV vaccination uptake via greater involvement of oncology professionals in ensuring accurate public discourse about HPV vaccination and calling for the implementation of concrete strategies to address barriers to vaccine access and acceptance.

[Practices and attitudes regarding HPV vaccination among general practitioners from Besançon]

OBJECTIVES

To assess opinions, practices and difficulties of general practitioners (GP) of Besançon concerning human papillomavirus (HPV) vaccination.

MATERIALS AND METHODS

A survey among the 140 GP of Besançon, France, was conducted in 2015.

RESULTS

A percentage of 77.1 reported being favourable to HPV vaccination and 72.9% practices HPV vaccination. The 2 main concerns about HPV vaccination for GP are the fear of side effects (for 40.6% of GP) and the doubt on efficacy. According to GP, the hepatitis B vaccination controversy, the fear of side effects, the limited clinical efficacy experience and the lack of confidence in health authorities are concerns about HPV vaccination for 77.1%, 76%, 74% and 49% of patients, respectively.

CONCLUSION

Courses for GP on HPV vaccination must be pursued and reinforced. A school-based program could be developed to facilitate communication between GP and patients to improve HPV vaccination coverage.

Vaccination coverage in French 17-year-old young adults: an assessment of mandatory and recommended vaccination statuses

We aimed to assess vaccination coverage (VC) in 17-year-old French young adults (YAs) participating in one mandatory Day of Defence and Citizenship (DDC). Between June 2010 and May 2011, YAs participating in 43 randomly selected mandatory sessions of the DDC programme in Poitou-Charentes (France) were asked to provide their personal vaccination record. Tetanus, diphtheria, polio, hepatitis B, Haemophilus influenzae b, pertussis, measles, mumps and rubella vaccination status were assessed at ages 2, 6, 13 and 17 years. Of 2610 participants, 2111 (81%) supplied documents for evaluation. Of these, 1838 (87%, M:F sex ratio 0·96) were aged 17 years (9% of the global population of this age in the area). The assessment of the 17-year-olds demonstrated the following rates of complete vaccination: diphtheria-tetanus-polio 83%; measles, mumps and rubella 83%; pertussis 69%; H. influenzae b 61%; human papillomavirus 47%; and hepatitis B 40%. At age 6 years, only 46% had received two doses of the vaccine against measles. The YAs were not aware of their status but were in favour of vaccination. VC in YAs is insufficient, particularly for hepatitis B, pertussis and measles. Combined vaccines and the simplification of vaccination schedules should improve VC. Preventive messages should focus on YAs.

Determinants in the Uptake of the Human Papillomavirus Vaccine: A Systematic Review Based on European Studies

Background

Cervical cancer is the fourth most common cancer affecting women worldwide. Since 2006, two human papillomavirus vaccines (HPVV) have been licensed to protect women against the virus that causes cervical cancer. However, worldwide coverage remains unequal. Studies from the USA found strong evidence for differences in HPVV uptake by ethnicity and healthcare coverage. As the profile of ethnic groups and the healthcare system in the USA differ from countries in Europe where HPVV is free in most of the countries, we conducted a systematic review in order to analyze the determinants of HPVV uptake in Europe.

Methods

We performed a systematic Pubmed, Scopus, and Science Direct search to find articles published from HPVV availability in European countries until April 2014. No age restriction was applied. We included all studies assessing factors associated with HPVV uptake. Uptake refers to either initiation and/or completion of the three dose vaccination program.

Results

Out of the 23 eligible studies, 14 were retrospective reviews of data, six were cross-sectional surveys, and three were prospective cohort studies. Higher HPVV uptake was associated with ethnic majority populations, higher socio-economic status, regular cervical screening participation by the mother, and having received previous childhood vaccinations.

Conclusion

Since the vaccine is offered for free in most of the European countries, the findings suggest that ethno-cultural and educational factors play an important role when it comes to HPVV uptake. Girls who were undervaccinated had also a lower uptake of standard childhood vaccines and mothers who were less likely to attend cervical cancer screening. This may indicate that only few parents have specific concerns with HPVV, and that preventive health care should seek ways to target these vulnerable groups.

Gavi HPV Programs: Application to Implementation

Developing countries disproportionately suffer from the burden of cervical cancer yet lack the resources to establish systematic screening programs that have resulted in significant reductions in morbidity and mortality in developed countries. Human Papillomavirus (HPV) vaccination provides an opportunity for primary prevention of cervical cancer in low-resource settings through vaccine provision by Gavi The Vaccine Alliance. In addition to the traditional national introduction, countries can apply for a demonstration program to help them make informed decisions for subsequent national introduction. This article summarizes information from approved Gavi HPV demonstration program proposals and preliminary implementation findings. After two rounds of applications, 23 countries have been approved targeting approximately 400,000 girls for vaccination. All countries are proposing primarily school-based strategies with mixed strategies to locate and vaccinate girls not enrolled in school. Experiences to date include: Reaching marginalized girls has been challenging; Strong coordination with the education sector is key and overall acceptance has been high. Initial coverage reports are encouraging but will have to be confirmed in population based coverage surveys that will take place later this year. Experiences from these countries are consistent with existing literature describing other HPV vaccine pilots in low-income settings.

A cost-effectiveness analysis of human papillomavirus vaccination of boys for the prevention of oropharyngeal cancer

BACKGROUND

Many western countries have established female human papillomavirus (HPV) vaccination programs for the prevention of cervical cancer. The quadrivalent HPV vaccine (HPV4) has proven efficacy against additional HPV-related disease in both sexes, but the cost effectiveness of male HPV vaccination remains controversial. To assess the cost effectiveness of male HPV vaccination in Canada with respect to oropharyngeal cancer (OPC), the authors performed a preliminary cost-effectiveness analysis.

METHODS

After an extensive literature review regarding HPV-related OPC in Canadian males, health care costs and clinical effectiveness estimates were obtained. A Markov model was used to compare the potential costs and effectiveness of HPV4 versus no vaccination among boys aged 12 years. A theoretical cohort based on a Canadian population of 192,940 boys aged 12 years in 2012 was assumed to apply the model. A 3-month cycle length was used with a "lifetime" time horizon. The outcome of the analysis was the incremental cost per quality-adjusted life-year (QALY). Sensitivity analyses were conducted on variables, including the vaccine uptake rate and vaccine efficacy.

RESULTS

Assuming 99% vaccine efficacy and 70% uptake, HPV4 produced 0.05 more QALYs and saved $145 Canadian dollars (CAD) per individual compared with no vaccine (QALYs and costs were discounted at 5% per year). Assuming 50% vaccine efficacy and 50% uptake, HPV4 produced 0.023 more QALYs and saved $42 CAD. The results indicated that HPV4 in males may potentially save between $8 and $28 million CAD for the theoretical cohort of 192,940 over its lifetime.

CONCLUSIONS

On the basis of this model, HPV vaccination for boys aged 12 years may be a cost-effective strategy for the prevention of OPC in Canada.

Female students receiving post-secondary education in Greece: the results of a collaborative human papillomavirus knowledge survey

OBJECTIVES

Contrary to the optimistic forecasts, existing until 2008 and despite the incorporation of the vaccine into the Greek National Immunization Program, six years later, the percentage of HPV vaccination coverage in Greece remains disappointingly low. The aim of this extended study was to investigate the knowledge, behaviour and attitude of a representative sample of the initial target group; young female students of Greek higher education institutions to Pap cervical screening, biology of HPV infection and principles of HPV vaccination.

STUDY DESIGN

Cross-sectional study.

METHODS

One thousand two hundred ten (1210) questionnaires were completed by young female students aged 17-24 years. The survey questionnaire sought data relating to sociodemographic characteristics, health behaviour and knowledge about HPV, as well as vaccination status.

RESULTS

79.6% of the sample reported at least one annual gynaecologic examination and 92.6% were familiar with the rationale of cervical screening; however only 52.9% had undergone a Pap smear. 69.7% reported adequate knowledge about HPV and 89.3% were aware of the possible course of HPV infection. Despite most (95.9%) were aware of vaccine availability, vaccinated students represented only 33.1%. According to the multivariate analysis, vaccination status was associated with university studies (OR 1.96; 95% CI: 1.19-3.20), parental area of expertise (OR 2.77; 95% CI: 1.18-6.53, OR 2.03; 95% CI: 1.05-3.94), and adequate knowledge of the reasons for which women should undergo regular cervical screening (OR 4.23; 85% CI: 1.55-11.55). Fear of side-effects and equivocal information were the main reasons of non-vaccination (52.2% and 33.1% respectively). Finally, the majority of unvaccinated individuals showed a positive attitude towards prospective HPV vaccination, providing they received well-documented advising.

CONCLUSIONS

Young women attending Greek higher education exhibit a good level of knowledge about HPV and its correlation with cervical cancer. These data highlight the need for further sensitization of the general population.

Development of a quality framework for models of cervical screening and its application to evaluations of the cost-effectiveness of HPV vaccination in developed countries

BACKGROUND

HPV vaccination has now been introduced in most developed countries, but this has occurred in the context of established cervical cancer screening mechanisms which provide population-level protection against the most common HPV-related cancer. Therefore, estimating the cost-effectiveness of HPV vaccination to further reduce HPV-related disease depends in large part on the estimation of the effectiveness of the cervical screening 'background'. The aim of this study was to systematically review and assess methods for simulating cervical screening in decision analytic models used for evaluation of HPV vaccination.

METHODS

Existing quality frameworks for economic models were extended to develop a specific quality framework for models of cervical screening. This involved domains for model structure, parameterisation (data sources) and validation (consistency). A systematic review of economic evaluations of HPV vaccination was then conducted, and assessment of cervical screening model components was then performed via application of the new quality framework.

RESULTS

Generally, models took into account population-level cervical screening participation, but were inconsistent in their approach to modelling abnormal smear management, diagnostic evaluation and treatment of precancerous disease. There was also considerable variability in the accuracy of modelling clinical pathways and the scope of validation performed for screening-related outcomes, with focus directed towards cervical cancer targets. Only a few models comprehensively validated against observed pre-cancerous abnormalities.

CONCLUSION

Models of HPV vaccination in developed countries can be improved by further attention to the 'background' modelling of secondary protection via cervical screening. The quality framework developed for this review can be used to inform future HPV vaccination evaluations, including evaluations of the cost-effectiveness of male vaccination and next generation HPV vaccines, and to assess models used to evaluate new cervical screening technologies and recommendations.

Human papillomavirus prevalence and type-distribution, cervical cancer screening practices and current status of vaccination implementation in Central and Eastern Europe

We present a review of current cervical cancer screening practices, the implementation status of vaccination against human papillomaviruses (HPV) and available data concerning the burden of HPV infection and HPV type-specific distribution in 16 Central and Eastern European countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and the Former Yugoslav Republic (FYR) of Macedonia. Since published data were relatively scarce, two detailed surveys were conducted during August-October 2011 and in January 2013 to obtain relevant and updated information. The mean prevalence of HPV infection in 8610 women with normal cervical cytology from the region was 12.6%, with HPV16 being the most frequent HPV type. The overall HPV DNA prevalence in women with high-grade cervical lesions was 78.1%. HPV DNA was found in 86.6% of cervical cancers; the combined prevalence of HPV16/18 among HPV positive cases was 87.5%. The overall HPV DNA prevalence in genital warts and laryngeal papillomas was 94.8% and 95.2%, respectively, with HPV6 and HPV11 being the most frequent types. Opportunistic and organized cervical screening, mainly based on conventional cytology, is performed in nine and seven countries in the region, respectively, with the proposed age of the start of screening ranging from 20 to 30 years and the estimated coverage ranging from a few percent to over 70%. At least one of the current HPV prophylactic vaccines is registered in all Central and Eastern European countries except Montenegro. Only Bulgaria, Czech Republic, FYR Macedonia, Latvia, Romania and Slovenia have actually integrated HPV vaccination into their national immunization programme and currently provide routine vaccination free of charge to the primary target population. The key reasons for lack of implementation of HPV vaccination into the national immunization programme are high vaccine cost and negative public perception. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Central and Eastern Europe and Central Asia Region" Vaccine Volume 31, Supplement 7, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Factors impacting HPV vaccination: lessons for health care professionals

HPV infection leads to significant morbidity and mortality worldwide. The HPV vaccine is currently licensed and recommended for adolescents and young adults in many countries. Nonetheless, coverage levels remain low, especially in settings using a clinic-based rather than school-based delivery model. Health care professionals (HCPs) have the potential to strongly impact HPV vaccine acceptability and uptake, yet often fail to discuss and/or strongly recommend HPV vaccination. This article reviews the myriad factors that influence HPV vaccination, focusing, in particular, on those relevant to HCP communication with patients and families. It also provides a historical framework and highlights recent evidence related to HPV vaccination that may be valuable for these conversations. Lastly, it discusses strategies targeting HCPs and their practices that may increase HPV vaccination initiation and completion rates globally.

Cost-effectiveness of female human papillomavirus vaccination in 179 countries: a PRIME modelling study

BACKGROUND

Introduction of human papillomavirus (HPV) vaccination in settings with the highest burden of HPV is not universal, partly because of the absence of quantitative estimates of country-specific effects on health and economic costs. We aimed to develop and validate a simple generic model of such effects that could be used and understood in a range of settings with little external support.

METHODS

We developed the Papillomavirus Rapid Interface for Modelling and Economics (PRIME) model to assess cost-effectiveness and health effects of vaccination of girls against HPV before sexual debut in terms of burden of cervical cancer and mortality. PRIME models incidence according to proposed vaccine efficacy against HPV 16/18, vaccine coverage, cervical cancer incidence and mortality, and HPV type distribution. It assumes lifelong vaccine protection and no changes to other screening programmes or vaccine uptake. We validated PRIME against existing reports of HPV vaccination cost-effectiveness, projected outcomes for 179 countries (assuming full vaccination of 12-year-old girls), and outcomes for 71 phase 2 GAVI-eligible countries (using vaccine uptake data from the GAVI Alliance). We assessed differences between countries in terms of cost-effectiveness and health effects.

FINDINGS

In validation, PRIME reproduced cost-effectiveness conclusions for 24 of 26 countries from 17 published studies, and for all 72 countries in a published study of GAVI-eligible countries. Vaccination of a cohort of 58 million 12-year-old girls in 179 countries prevented 690,000 cases of cervical cancer and 420,000 deaths during their lifetime (mostly in low-income or middle-income countries), at a net cost of US$4 billion. HPV vaccination was very cost effective (with every disability-adjusted life-year averted costing less than the gross domestic product per head) in 156 (87%) of 179 countries. Introduction of the vaccine in countries without national HPV vaccination at present would prevent substantially more cases of cervical cancer than in countries with such programmes, although the disparity has narrowed since 2012. If 71 phase 2 GAVI-eligible countries adopt vaccination according to forecasts, then in 2070 GAVI Alliance-funded vaccination could prevent 200,000 cases of cervical cancer and 100,000 deaths in some of the highest-burden countries.

INTERPRETATION

Large between-country disparities exist for HPV vaccination, with countries with the most to gain yet to introduce national HPV vaccination. Support from the GAVI Alliance could help to reduce such disparities, but a substantial burden will remain even after presently projected vaccine introductions.

FUNDING

WHO.

Practices and opinions regarding HPV vaccination among French general practitioners: evaluation through two cross-sectional studies in 2007 and 2010

OBJECTIVES

To use both quantitative and qualitative methods to investigate the evolution of practices and opinions regarding human papillomavirus (HPV) vaccination among French general practitioners.

METHODS

A cross-sectional study (self-questionnaires) was performed in 2007 and repeated in 2010 among 271 general practitioners. Semi-structured interviews were conducted on 27 voluntary participants by a sociologist and analyzed according to content analysis.

RESULTS

Acceptability of HPV vaccination had increased from 2007 to 2010 (79.9 vs. 87.1%, respectively), just as the practice of HPV vaccination among 14-year-old girls (19.0 vs. 49.1%, respectively). Though about 60% reported complications associated with HPV vaccination, irrespective of year, the types of difficulties have varied: difficulties related to "questions asked by patients" had decreased, though concerns about side effects had remained stable. During interviews, difficulties related to "the reason for medical consultation" and "the target age" were often associated with addressing the issue of sexuality, especially when the parents were present.

CONCLUSIONS

Although the high level of acceptability of HPV vaccination among general practitioners, which increased from 2007 to 2010, there remain difficulties in addressing this practice.

Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination

Aim

To explore why parents refused to allow their 10- to 12-year-old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school-based vaccination programme.

Methods

Individual interviews with 25 parents who had been offered, but not consented to, their daughters receiving the HPV vaccination.

Results

Five themes emerged through the interviews: 1) she is just a little girl, 2) inadequate information, 3) not compatible with our way of life, 4) scepticism about the vaccination and 5) who can you trust? The parents made their decisions with their child's best interests in mind. This was not considered the right time, and the vaccine was perceived as unnecessary and different from other vaccines. Mistrust in Government recommendations and a lack of evidence or information were other reasons to decline.

Conclusion

The decision-making process was complex. These parents preferred to wait until their daughter was older and believed the information they received from the school health system was insufficient. The results indicate that a more flexible HPV vaccination schedule may improve vaccine uptake. This includes more transparent information about the virus and the vaccine and information about who to contact to get the daughter vaccinated at a later date.

HPV vaccine uptake after introduction of the vaccine in Germany: an analysis of administrative data

In Germany, vaccination against human papilloma virus (HPV) has been recommended by the German Standing Vaccination Committee (STIKO) for girls aged 12-17 years since March 2007. The vaccine is free of charge for this age group. Additionally, some statutory health insurance providers (SHI) offer reimbursement for women aged 18-26 years. Currently available information on the uptake or coverage of HPV vaccination is limited to specific regions, age groups, or study populations. This report describes the HPV vaccine uptake in 2008 for females aged 12-26 years in Germany on a broad regional level based on data from one large SHI. HPV vaccinations were identified by outpatient codes used for reimbursement of vaccine administration. Vaccine uptake was calculated by dividing the number of females, who received at least one HPV vaccine dose by the number of female insurees in the respective age group. The overall study population consisted of 317 234 females, of whom 77 350 received at least one HPV vaccine dose in 2008. Vaccine uptake was 32.2% in the recommended age group, with a peak age at 14-16 years. In the age group of females aged 18-26 years, where HPV vaccination was not officially recommended by the STIKO, uptake was 12.3%. Vaccine uptake in 2008 reflects an early stage after the recommendation of HPV vaccination in 2007. Future changes in vaccine uptake should be further and more promptly monitored.

Post-licensure safety surveillance for human papillomavirus-16/18-AS04-adjuvanted vaccine: more than 4 years of experience

Purpose

To summarise post-licensure safety surveillance over more than 4 years of routine use of the human papillomavirus-16/18-AS04-adjuvanted vaccine (HPV-16/18 vaccine: Cervarix®, GlaxoSmithKline, Belgium).

Methods

We describe global post-licensure passive surveillance data based on routine pharmacovigilance from 18 May 2007 until 17 November 2011 and enhanced surveillance implemented during the 2-year national immunisation programme in the UK (school years 2008–2010).

Results

Spontaneous reports from countries worldwide showed a similar pattern for the most frequently reported adverse events after HPV-16/18 vaccination. No patterns or trends were observed for potential immune-mediated diseases after vaccination. Observed incidences of Bell's palsy and confirmed Guillain–Barré syndrome were within the expected range in the general population. Outcomes of pregnancy in women who were inadvertently exposed to HPV-16/18 vaccine during pregnancy, were in line with published reports for similar populations. Enhanced surveillance of adverse events in the UK triggered a review of cases of anaphylaxis, angioedema and syncope reports, leading to an update to the prescribing information.

Conclusion

Collaborative partnerships between industry and national regulatory agencies facilitated rapid notification and transfer of safety information, allowing for rapid responses in the event of a safety signal of adverse event of concern. More than 4 years of post-licensure experience may provide confidence to providers and the public about the safety profile of HPV-16/18 vaccine in routine use. The safety profile appears to be consistent with pre-licensure data reporting that HPV-16/18 vaccine has an acceptable benefit–risk profile in adolescent girls and women.

Human Papillomavirus prevalence and probable first effects of vaccination in 20 to 25 year-old women in Germany: a population-based cross-sectional study via home-based self-sampling

Background

Estimates of Human Papillomavirus (HPV) prevalence in a population prior to and after HPV vaccine introduction are essential to evaluate the short-term impact of vaccination.

Methods

Between 2010 and 2012 we conducted a population-based cross-sectional study in Germany to determine HPV prevalence, genotype distribution and risk factors for HPV-infection in women aged 20-25 years. Women were recruited by a two-step cluster sampling approach. A home-based self-collection of cervicovaginal lavages was used. Specimens were analysed using a general primer GP5+/GP6+-based polymerase chain reaction and genotyped for 18 high-risk and 6 low-risk HPV- strains by Luminex-based multiplexed genotyping.

Results

Among 787 included women, 512 were not vaccinated against HPV. In the non-vaccinated population, HPV prevalence of any type was 38.1%, with HPV 16 (19.5%) being the most prevalent genotype. Prevalence of any high-risk type was 34.4%, and in 17.4% of all women, more than one genotype was identified. A higher number of lifetime sexual partners and low educational status were independently associated with HPV-infection. In 223 vaccinated women, prevalence of HPV 16/18 was significantly lower compared to non-vaccinated women (13.9% vs. 22.5%, p = 0.007). When stratifying by age groups, this difference was only significant in women aged 20-21 years, who at time of vaccination were on average younger and had less previous sexual contacts than women aged 22-25 years.

Conclusion

We demonstrate a high prevalence of high-risk HPV genotypes in non-vaccinated women living in Germany that can be potentially prevented by vaccination. Probable first vaccination effects on the HPV prevalence were observed in women who were vaccinated at younger age. This finding reinforces the recommendation to vaccinate girls in early adolescence.

Upscaling human papillomavirus vaccination in high-income countries: impact assessment based on transmission model

BACKGROUND

The decrease in human papillomavirus (HPV) vaccine prices may allow upscale already started vaccination programmes but the advantages of different options are unclear.

METHODS

Using a mathematical model of HPV16 and 18 transmission and data on vaccination coverage from Italy, we compared 3 options to upscale an already started programme targeting 11-year old girls (coverage 65%): a) coverage improvement (from 65% to 90%); b) addition of 11-year-old boys (coverage 65%); or c) 1-year catch-up of older girls (coverage 50%).

RESULTS

The reduction of cervical HPV16/18 infection as compared to no vaccination (i.e. effectiveness against HPV16/18) increased from 76% to 98% with coverage improvement in girls and to 90% with the addition of boys. With higher coverage in girls, HPV16/18 infection cumulative probability by age 35 decreased from 25% to 8% with a 38% increase in vaccine number. The addition of boys decreased the cumulative probability to 18% with a 100% increase in the number of vaccinees. For any coverage in girls, the number of vaccinees to prevent 1 woman from being infected by HPV16/18 by age 35 was 1.5, whereas it was 2.7 for the addition of boys. Catch-up of older girls only moved forward the vaccination effectiveness by 2-5 years.

CONCLUSIONS

Increasing vaccination coverage among girls is the most effective option for decreasing HPV16/18. If not achievable, vaccinating boys is justifiable if vaccine cost has at least halved, because this option would almost double the number of vaccinees.

Coverage of the English national human papillomavirus (HPV) immunisation programme among 12 to 17 year-old females by area-level deprivation score, England, 2008 to 2011

The English national human papillomavirus (HPV) immunisation programme has offered vaccination to girls aged 12 years at the start of each school year since September 2008. A catch-up programme has offered vaccination to girls up to 18 years. Delivery is predominantly school-based, with some general practitioner (GP)-based immunisation. The relationship between HPV immunisation coverage and deprivation (index of multiple deprivation, IMD) was assessed by geographical area (N=151) for each school year offered the HPV vaccine between 2008 to 2011 using the Spearman’s rank correlation coefficient, and compared to that for adequate cervical screening of women aged 25 to 49 years. Coverage at age 12 showed no significant association with IMD at the area-level (p=0.12). Within the catch-up years, there was some suggestion of higher deprivation being associated with lower coverage. This was not significant for girls offered immunisation under 16 years (in compulsory education) (p=0.09), but was more marked and statistically significant for older girls (p<0.0001). The proportion of women aged 25 to 49 years with an adequate cervical screen was negatively associated with deprivation (p<0.0001). School-based HPV immunisation delivery appears to be successfully reducing inequalities in cervical cancer control at area-level. However, the catch-up cohorts above the age of compulsory education may face increased inequality. Further investigation is needed into individual-level factors associated with coverage.

Risk of cervical HPV infection and prevalence of vaccine-type and other high-risk HPV types among sexually active teens and young women (13-26 years) enrolled in the VALHIDATE study

HPV vaccination is expected to reduce the incidence of cervical cancer. The greatest and the earliest health gains will be ensured by high vaccine coverage among all susceptible people. The high costs and the risk of a reduced cost/effectiveness ratio in sexually active girls still represent the main obstacles for a more widespread use of HPV vaccination in many countries. Data on the rate, risk factors, and HPV types in sexually active women could provide information for the evaluation of vaccination policies extended to broader age cohorts.

Sexually active women aged 13–26 years enrolled in an Italian cohort study were screened for cervical HPV infections; HPV-DNA positive samples were genotyped by InnoLipa HPV Genotyping Extra or by RFLP genotype analysis.

Among the 796 women meeting the inclusion criteria, 10.80% (95% CI 8.65–12.96) were HPV-DNA infected. Age >18 years, lifetime sexual partners >1, and history of STIs were associated to higher risk of HPV infection in the multivariable models adjusted for age, lifetime sexual partners, and time of sexual exposure. The global prevalence of the four HPV vaccine-types was 3.02% (95% CI 1.83–4.20) and the cumulative probability of infection from at least one vaccine-type was 12.82% in 26-years-old women and 0.78% in 18-years-old women.

Our data confirm most of the previously reported findings on the risk factors for HPV infections. The low prevalence of the HPV vaccine-types found may be useful for the evaluation of the cost/efficacy and the cost/effectiveness of broader immunization programs beyond the 12-years-old cohort.

Prevalence of human papillomavirus in young Italian women with normal cytology: how should we adapt the national vaccination policy?

BACKGROUND

Human Papillomavirus (HPV) is the most common sexually transmitted infection. In Italy, HPV vaccination is now offered free of charge to 12-year-old females. However, some regional health authorities have extended free vaccination to other age-groups, especially to girls under 18 years of age. We conducted a multicentre epidemiological study to ascertain the prevalence of different genotypes of HPV in young Italian women with normal cytology, with the aim of evaluating the possibility of extending vaccination to older females.

METHODS

The study was performed in 2010. Women aged 16-26 years with normal cytology were studied. Cervical samples were analyzed to identify the presence of HPV by PCR amplification of a segment of ORF L1 (450 bp). All positive HPV-DNA samples underwent viral genotype analysis by means of a restriction fragment length polymorphism assay.

RESULTS

Positivity for at least one HPV genotype was found in 18.2% of the 566 women recruited: 48.1% in the 16-17 age-class, 15.4 in the 18-20 age-class, 21.9% in the 21-23 age-class, and 15.5% in the 24-26 age-class; 10.1% of women were infected by at least one high-risk HPV genotype. HPV-16 was the most prevalent genotype. Only 4 (0.7%), 4 (0.7%) and 3 (0.5%) women were infected by HPV-18, HPV-6 and HPV-11, respectively. Of the HPV-DNA-positive women, 64.1% presented only one viral genotype, while 24.3% had multiple infections. The HPV genotypes most often involved in multiple infections were high-risk. A high prevalence was noted in the first years of sexual activity (48.1% of HPV-DNA-positive women aged 16-17 years); HPV prevalence subsequently declined and stabilized.The estimate of cumulative proportions of young women free from any HPV infection at each age was evaluated; 93.3% and 97.1% of 26 year-old women proved free from HPV-16 and/or HPV-18 and from HPV-6 and/or HPV-11, respectively.

CONCLUSIONS

Our findings confirm the crucial importance of conducting studies on women without cytological damage, in order to optimise and up-date preventive interventions against HPV infection, and suggest that vaccinating 26-year-old females at the time of their first pap-test is to be recommend, though this issue should be further explored.

Adult immunization policies in advanced economies: vaccination recommendations, financing, and vaccination coverage

OBJECTIVES

While many countries have robust child immunization programs and high child vaccination coverage, vaccination of adults has received less attention. The objective of this study was to describe the adult vaccination policies in developed countries.

METHODS

From 2010 to 2011, we conducted a survey of 33 advanced economies as defined by the International Monetary Fund. The survey asked about national recommendations for adults for 16 vaccines or vaccine components, funding mechanisms for recommended adult vaccines, and the availability of adult vaccination coverage estimates.

RESULTS

Thirty-one of 33 (93.9 %) advanced economies responded to the survey. Twelve of 31 (38.7 %) reported having a comprehensive adult immunization schedule. The total number of vaccines or vaccine components recommended for adults ranged from one to 15 with a median of 10. Seasonal influenza (n = 30), tetanus (n = 28), pneumococcal polysaccharide (n = 27), and hepatitis B (n = 27) were the most frequently recommended vaccines or components.

CONCLUSIONS

Approximately two-thirds of survey respondents do not have a comprehensive adult vaccine schedule, and most do not measure vaccination coverage. We found that a funding mechanism is available for most recommended adult vaccines.

National Advisory Groups and their role in immunization policy-making processes in European countries

During the twenty-first century, the development of national immunization programmes (NIP) has matured into robust processes where evidence-based methodologies and frameworks have increasingly been adopted. A key role in the decision-making and recommending processes is played by National Immunization Technical Advisory Groups (NITAGs). In a survey performed among European Union member states, Norway and Iceland, in February 2013, 85% of the 27 responding countries reported having established a NITAG, and of these, 45% have formal frameworks in place for the systematic development of vaccination recommendations. Independent of whether a formal framework is in place, common key factors are addressed by all NITAGs and also in countries without NITAGs. The four main factors addressed by all were: disease burden in the country, severity of the disease, vaccine effectiveness or efficacy, and vaccine safety at population level. Mathematical modelling and cost-effectiveness analyses are still not common tools. Differences in the relative weighting of these key factors, differences in data or assumptions on country-specific key factors, and differences in existing vaccination systems and financing, are likely to be reasons for differences in NITAG recommendations, and eventually NIPs, across Europe. Even if harmonization of NIPs is presently not a reasonable aim, systematic reviews and the development of mathematical/economic models could be performed at supranational level, thus sharing resources and easing the present work-load of NITAGs. Nevertheless, it has been argued that harmonization would ease central purchase of vaccines, thus reducing the price and increasing access to new vaccines.

Towards the eradication of HPV infection through universal specific vaccination

BACKGROUND

The Human Papillomavirus (HPV) is generally recognized to be the direct cause of cervical cancer. The development of effective anti-HPV vaccines, included in the portfolio of recommended vaccinations for any given community, led to the consolidation in many countries of immunization programs to prevent HPV-related cervical cancers. In recent years, increasing evidence in epidemiology and molecular biology have supported the oncogenic role of HPV in the development of other neoplasm including condylomas and penile, anal, vulvar, vaginal, and oro-pharyngeal cancers. Men play a key role in the paradigm of HPV infection: both as patients and as part of the mechanisms of transmission. Data show they are affected almost as often as women. Moreover, no screening procedures for HPV-related disease prevention are applied in men, who fail to undergo routine medical testing by any medical specialist at all. They also do not benefit from government prevention strategies.

DISCUSSION

A panel of experts convened to focus on scientific, medical, and economic studies, and on the achievements from health organizations' intervention programs on the matter. One of the goals was to discuss on the critical issues emerging from the ongoing global implementation of HPV vaccination. A second goal was to identify contributions which could overcome the barriers that impede or delay effective vaccination programs whose purpose is to eradicate the HPV infection both in women and men.

SUMMARY

The reviewed studies on the natural history of HPV infection and related diseases in women and men, the increasing experience of HPV vaccination in women, the analysis of clinical effectiveness vs economic efficacy of HPV vaccination, are even more supportive of the economic sustainability of vaccination programs both in women and men. Those achievements address increasing and needed attention to the issue of social equity in healthcare for both genders.

Cost-effectiveness of human papillomavirus vaccination in low and middle income countries: a systematic review

The World Health Organization recommends establishing that human papillomavirus vaccination is cost-effective before vaccine introduction. We searched Pubmed, Embase and the Cochrane Library to 1 April 2012 for economic evaluations of human papillomavirus vaccination in low and middle income countries. We found 25 articles, but almost all low income countries and many middle income countries lacked country-specific studies. Methods, assumptions and consequently results varied widely, even for studies conducted for the same country. Despite the heterogeneity, most studies conclude that vaccination is likely to be cost-effective and possibly even cost saving, particularly in settings without organized cervical screening programmes. However, study uncertainty could be reduced by clarity about vaccine prices and vaccine delivery costs. The review supports extending vaccination to low income settings where vaccine prices are competitive, donor funding is available, cervical cancer burden is high and screening options are limited.