Human Papillomavirus Prevalence and Herd Immunity after Introduction of Vaccination Program, Scotland, 2009-2013

Impacts of travel duration on urban-rural resident free vaccination behavior: Chinese COVID-19 vaccine booster dose evidence

This study aimed to evaluate how the duration of travel affects the behavior of urban and rural residents regarding free COVID-19 vaccination, and provide scientific evidence for promoting free vaccination and building an immune barrier to cope with future epidemics. From August 3, 2022 to February,18,2023, A follow-up survey was conducted in urban and rural adults in four cities in China to collect information on socio-demographic factors, vaccination status and travel time for vaccination. Propensity score matching (PSM) analysis was deployed to measure the net difference of the enhanced vaccination rate between urban and rural residents in different traffic time distribution. A total of 5780 samples were included in the study. The vaccination rate of the booster dose of COVID-19 vaccine among rural residents was higher than that of urban residents with a significant P-value (69.36% VS 64.49%,p < .001). The traffic time had a significant negative impact on the COVID-19 booster vaccination behavior of urban and rural residents. There was a significant interaction between the travel time to the vaccination point and the level of trust in doctors. Travel time had a negative impact on the free vaccination behavior of both urban and rural residents. The government should optimize and expand the number of vaccination sites and enhance residents' trust in the medical system. This is crucial for promoting free vaccination and effective epidemic management in the future.

Assessing real world vaccine effectiveness: A review of Scotland's approach to monitoring human papillomavirus (HPV) vaccine impact on HPV infection and cervical disease

High-risk human papillomavirus (HPV) infections can progress to cervical cancer which is the fourth most common cancer in women globally. In Scotland, the incidence of cervical cancer has a strong socioeconomic deprivation gradient disproportionately affecting women from more deprived areas. An HPV vaccination programme was initiated in Scotland in 2008 targeting girls aged 12-13 years with a catch-up campaign running for the first three years for girls aged up to 18 years. The programme has evolved over the last 16 years with changes in the type of vaccine, dosing schedules and the extension of the programme to boys and gay, bisexual and other men who have sex with men. Vaccine uptake in Scotland has historically been high but has gradually decreased over time and disparities exist in women from more deprived areas of Scotland. The ability to link national immunisation and screening databases in Scotland has allowed direct monitoring of the impact of the HPV vaccine on virological and histological outcomes. Analyses of this linked data have demonstrated real-world evidence of high vaccine effectiveness against HPV infection, cervical disease, and cervical cancer with evidence of herd immunity in unvaccinated women. Continued monitoring is crucial to assess the duration of protection, the impact of vaccine and dosing schedules changes and the emergence of potential type replacement. With the World Health Organisation's aim to eliminate cervical cancer as a public health problem by the next century addressing the inequalities in cervical cancer incidence will be crucial. This will require targeted interventions for women most at risk of cervical cancer to ensure elimination is achieved timely for all women in Scotland.

Effectiveness of a School- and Primary Care-Based HPV Vaccination Intervention: The PrevHPV Cluster Randomized Trial

Importance

The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries.

Objective

To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination.

Design, Setting, and Participants

A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented.

Intervention

The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school.

Main Outcomes and Measures

The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination.

Results

A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction).

Conclusions and Relevance

In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04945655.

Human papillomavirus genotype distribution patterns in Zimbabwe; is the bivalent vaccine sufficient?

BACKGROUND

Vaccination against Human papillomavirus (HPV) is the primary preventative strategy that has been shown to reduce the burden of HPV related diseases. Zimbabwe introduced the bivalent vaccine (HPV 16/18) in the vaccination program targeting prepubescent girls in 2018. This review is an analysis of the distribution of HPV genotypes from various studies conducted in Zimbabwe to ascertain the effectiveness of the bivalent vaccine and make recommendations for future HPV vaccine choices.

SUMMARY

Zimbabwean studies have mostly reported on cervical HPV in the urban areas. The most frequent HPV genotypes from cervical sites were 16, 18, 33, 35, 45, 56 and 58. These were identified from samples with normal cytology, pre-cancer and invasive cervical cancer. The few studies that have been done in rural areas reported HPV 35 as the most frequent cervicovaginal genotype. From the anal region of individuals reporting for routine screening, HPV 16, 18, 35 52 and 58 were the most frequent. A study on genital warts identified HPV 6, 11, 16, 40, 51and 54. In a study on children with recurrent respiratory papillomatosis (RRP), HPV 6 and 11 were the most common and HPV 35 was also identified in these children. There is no available published data on HPV distribution in head and neck cancers in Zimbabwe.

KEY MESSAGES

Given that 83% of cervical cancers in Zimbabwe are caused by HPV 16/18, the bivalent vaccine could cover a significant proportion of HPV related cervical cancer. The current limitation of the bivalent vaccine is its failure to prevent benign lesions such as genital warts and RRP or all cervical cancer cases in Zimbabwe. For the prevention of most HPV related conditions, the nonavalent vaccine would be the most appropriate option for the Zimbabwean population. Currently there is no vaccine that includes HPV 35, yet this genotype was frequently identified in HPV related diseases. Vaccine developers may need to consider HPV 35 when manufacturing the next generation HPV vaccines. Furthermore, boys should also be included in HPV vaccination programs to improve herd immunity, as well as prevent RRP and HPV-related head and neck cancers.

Trust in Physicians in the Context of HPV Vaccination of Children from the Perspective of Social Exchange Theory: A Representative Study of Polish Parents

The vaccination of children against human papillomavirus (HPV) effectively prevents HPV infection and HPV-related cancers in women and men. However, HPV vaccination programs are met with vaccine hesitancy, which varies between countries. The coverage in Poland is low, although introducing nationally funded HPV vaccination for girls aged 12-13 in mid-2023 may increase it. The uptake of the HPV vaccine in adolescents is highly affected by parental decisions, which in turn can be influenced by interactions with the physician. The present representative study aimed to analyze the acceptance of the HPV vaccine among Polish parents (n = 360) and the level of trust in HPV vaccination in the pediatrician/general practitioner who takes care of their children aged 9-15 years. The data were gathered in September 2022 using computer-assisted telephone interviews. Most surveyed parents reported trusting their child's physician regarding vaccine recommendations (89.2%) and vaccinated their child with all or most of the vaccines recommended by a national vaccination guideline (94.7%). However, 13.3% declared themselves as moderate or strong vaccine opponents, a group characterized by high (83.4%) distrust in physicians. There was no difference in the awareness of HPV in groups varying in trusting the physicians, but parents who trusted them were more frequently aware of the HPV vaccine. Parental willingness to vaccinate their child against HPV was highly differentiated by the level of trust in the child's physician. The results highlight that trust in physicians is a critical factor shaping decisions for children's vaccination, stressing a continuous need to improve strategies to communicate with patients.

Inequities in Screening and HPV Vaccination Programs and Their Impact on Cervical Cancer Statistics in Romania

(1) Introduction: A Romanian woman is diagnosed with cervical cancer every two hours; the country ranks second in Europe in terms of the mortality and incidence rate of this disease. This paper aims to identify the main reasons that have led to this situation, focusing on the measures taken by the Romanian Ministry of Health for the prevention of this type of cancer-national programs for cervical cancer screening and HPV vaccination. (2) Materials and methods: We performed a study based on the available secondary data from the National Statistics Institute, World Health Organization and Bucharest Institute of Oncology in order to assess the burden associated with cervical cancer and place it in the context of known global and European incidence and mortality rates, thus evaluating the importance of this health issue in Romania. The second component of our study was a cross-sectional study. Here, we used a 14-question questionnaire applied to the women participating in the National Screening Program for Cervical Cancer and aimed to evaluate the women's level of knowledge about screening and HPV vaccination and their access cervical-cancer-specific healthcare services. (3) Results: The results of this research show that a high percentage of women postpone routine checks due to a lack of time and financial resources and indicate that a low level of knowledge about the disease and the specific preventive methods determines the low participation in screening and HPV vaccination programs implemented in Romania, contributing to the country's cervical cancer situation. (4) Conclusions: The national programs have complicated procedures, are underfunded and do not motivate healthcare workers enough. This, combined with the lack of information for the eligible population, adds up to an extremely low number of women screened and vaccinated. Our conclusion is that the Romanian Ministry of Health must take immediate action by conducting major awareness campaigns, implementing measures to make the programs functional and ensuring coherent funding.

Human papillomavirus vaccine effectiveness by age at vaccination: A systematic review

Human papillomavirus (HPV) vaccines work by preventing infections prior to natural exposure. Thus, it is likely more effective at younger ages, and it is important to understand how effectiveness might be diminished when administered at older ages. We conducted a systematic review of HPV vaccine effectiveness studies published between 2007 and 2022 that included an analysis of effectiveness against vaccine-type HPV infections, anogenital warts, cervical abnormalities and cervical cancer by age at vaccine initiation or completion. Searching multiple databases, 21 studies were included and results were summarized descriptively. Seventeen studies found the highest vaccine effectiveness in the youngest age group. Vaccine effectiveness estimates for younger adolescents ages 9-14 years ranged from approximately 74% to 93% and from 12% to 90% for adolescents ages 15-18 years. These results demonstrate that the HPV vaccine is most effective against HPV-related disease outcomes when given at younger ages, emphasizing the importance of on-time vaccination.

Post Treatment Sexual Function and Quality of Life of Patients Affected by Cervical Cancer: A Systematic Review

Introduction: The aim of this study is to analyze the available scientific evidence regarding the quality of life (QoL) and sexual function (SF) in patients affected by cervical cancer (CC) after surgical and adjuvant treatments. Materials and Methods: Preliminary research was conducted via electronic database (MEDLINE, PubMed and Cochrane Library) with the use of a combination of the following keywords: SF, QoL, and CC. The principal findings considered in the present review were the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered, and the principal findings concerning SF and QoL. Results: All studies were published between 2003–2022. The studies selected consisted of one randomized control study, seven observational studies (three prospective series), and nine case control studies. The scores used were focused on SF, QOL, fatigue, and psychological aspects. All studies reported a decreased SF and QOL. The most developed questionnaires were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression scale (HADS), and the Female Sexual Distress Scale (FSDS). Discussion: All studies reported a decreased SF and QOL. In addition to the perception of body image, several factors coexist in influencing the outcomes such as the physical, hormonal, psychological. Conclusions: Sexual dysfunction after CC treatment has a multifactorial aetiology which negatively affects the quality of life. For these reasons, it is important to follow and support patients with a multidisciplinary team (doctors, nurses, psychologists, dieticians) before and after therapy. This type of tailored therapeutic approach should become a standard. Women should be informed about possible vaginal changes and menopausal symptoms after surgery and on the positive effects of psychological therapy.

HPV vaccine intention among university students during suspension of active recommendation in Japan

In Japan, active recommendation of the human papillomavirus vaccine was withheld between 2013 and 2021 due to adverse reaction reports. This resulted in low vaccine coverage with reports from less than 1%. This study aimed to investigate if knowledge and health-belief related factors associated with vaccine intention among young adolescents with the hope that our findings may be helpful in promotion campaigns. We recruited students in four colleges and universities in Akita Prefecture from 2020 to 2021 who had never been vaccinated. A total of 318 students (male 54%, mean age 21 years) responded to a self-administered questionnaire; only 6% reported immediate vaccine intention, and 61% reported no such intention or "do not know." The correct percentages of 20-item knowledge about HPV vaccine-related morbidity, mortality, and prevention were very low regardless of gender (average males 41.4% vs. females 39.6%). Multivariable logistic regression models demonstrated that in males, higher levels of literacy, perceived susceptibility, and place for vaccination (logistical barrier) were associated with HPV vaccine intention, whereas "no need now" was associated with less intention. In females, a higher level of knowledge was significantly associated with vaccine intention, whereas "concerns of adverse effects" were associated with less intention.

Cervical cancer in sub-Saharan Africa: an urgent call for improving accessibility and use of preventive services

Sub-Saharan Africa has the highest rates of cervical cancer in the world, largely attributed to low cervical cancer screening coverage. Cervical cancer is the most common cause of death among women in 21 of the 48 countries in sub-Saharan Africa. Close to 100% of all cases of cervical cancer are attributable to Human papillomavirus (HPV). HPV types 16 and 18 cause at least 70% of all cervical cancers globally, while types 31, 33, 45, 52, and 58 cause a further 20% of the cases. Women living with HIV are six times more likely to develop cervical cancer than those without HIV. Considering that sub-Saharan Africa carries the greatest burden of cervical cancer, ways to increase accessibility and use of preventive services are urgently required. With this review, we discuss the preventive measures required to reduce the burden of cervical cancer in sub-Saharan Africa, the challenges to improving accessibility and use of the preventive services, and the recommendations to address these challenges.

Factors Affecting the Cervical Cancer Screening Behaviors of Japanese Women in Their 20s and 30s Using a Health Belief Model: A Cross-Sectional Study

In recent years, the incidence and mortality rates of cervical cancer (CC) have increased among young women. Cervical cancer screening (CCS) is crucial to reducing the incidence and mortality of CC in a country such as Japan, where it is challenging to raise HPV vaccination rates. The purpose of this study was to identify psychological and personal characteristics relating to CCS participation among young people by using the Health Belief Model (HBM). For this cross-sectional study, an internet survey was conducted between February–March 2018. Based on HBM and personal characteristics, χ2 tests and logistic analyses were used to identify factors influencing CCS. Responses obtained from 816 women in their 20s and 30s were used in the analysis. For HBM-based psychological characteristics, the odds ratios were significantly higher for “cues to participation in screening” and “barriers to participation at the time of cancer screening”, while “barriers to participation before cancer screening” showed significantly lower odds ratios. On the other hand, it was found that the presence of children and having regular health checkups affected the attributes of screening that were significant for decision-making. Therefore, it is important to create proactive measures to encourage younger women to undergo medical examinations.

The impact of catch-up bivalent human papillomavirus vaccination on cervical screening outcomes: an observational study from the English HPV primary screening pilot

BACKGROUND

In England, bivalent vaccination (Cervarix) against high-risk human papillomavirus (HR-HPV) genotypes 16/18 was offered in a population-based catch-up campaign in 2008-2010 to girls aged 14-17 years. These women are now entering the national cervical screening programme. We determined the impact of catch-up bivalent vaccination on their screening outcomes.

METHODS

We studied the overall and genotype-specific screening outcomes in 108,138 women aged 24-25 (offered vaccination) and 26-29 years (not offered vaccination) included in the English HPV screening pilot between 2013 and 2018.

RESULTS

At 24-25 years, the detection of high-grade cervical intraepithelial neoplasia (CIN2+) associated with HPV16/18 decreased from 3 to 1% (p < 0.001), with estimated vaccine effectiveness of 87% (95% CI: 82-91%). The detection of any CIN2+ halved from 6 to 3% (p < 0.001), with an estimated vaccine effectiveness of 72% (95% CI: 66-77%). The positive predictive value of a colposcopy for CIN2+ decreased for both low-grade (p < 0.001) and high-grade (p = 0.02) abnormalities on triage cytology. The decreases in screen-detected abnormalities at age 26-29 were of a substantially smaller magnitude.

CONCLUSIONS

These data confirm high effectiveness of bivalent HPV vaccination delivered through a population-based catch-up campaign in England. These findings add to the rationale for extending screening intervals for vaccinated cohorts.

Cytology interpretation after a change to HPV testing in primary cervical screening: Observational study from the English pilot

BACKGROUND

Overcalling of abnormalities has been a concern for using cytology triage after positive high-risk human papillomavirus (HPV) tests in cervical screening.

METHODS

The authors studied the detection of cytological and histological abnormalities at age 24 to 64 years, using data from the English HPV pilot. The pilot compared routine implementation of primary cervical screening based on cytology (N = 931,539), where HPV test results were not available before cytology reporting, with that based on HPV testing (N = 403,269), where cytology was only required after positive HPV tests.

RESULTS

Revealed HPV positivity was associated with a higher direct referral to colposcopy after any abnormality (adjusted odds ratio [ORadj ], 1.16; 95% confidence interval [CI], 1.14-1.18). Laboratories with higher direct referral referred fewer persistently HPV-positive women after early recall. The detection of high-grade cervical intraepithelial neoplasia (CIN2+) after direct referral increased with an ORadj of 1.17 (95% CI, 1.13-1.20) for informed versus uninformed cytology. Generally, the positive predictive value (PPV) of colposcopy for CIN2+ remained comparable under both conditions of interpreting cytology. In women 50 to 64 years old with high-grade dyskaryosis, however, the PPV increased from 71% to 83% after revealing HPV positivity (ORadj , 2.05; 95% CI, 1.43-2.93).

CONCLUSIONS

Quality-controlled cervical screening programs can avoid inappropriate overgrading of HPV-positive cytology.

Age-specific outcomes from the first round of HPV screening in unvaccinated women: Observational study from the English cervical screening pilot

OBJECTIVE

To report detailed age-specific outcomes from the first round of an English pilot studying the implementation of high-risk human papillomavirus (HR-HPV) testing in primary cervical screening.

DESIGN

Observational study with screening in 2013-2016, followed by two early recalls and/or colposcopy until the end of 2019.

SETTING

Six NHS laboratory sites.

POPULATION

A total of 1 341 584 women undergoing screening with HR-HPV testing or liquid-based cytology (LBC).

METHODS

Early recall tests and colposcopies were recommended, depending on the nature of the screening-detected abnormality.

MAIN OUTCOME MEASURES

We reported standard screening process indicators, e.g. proportions with an abnormality, including high-grade cervical intraepithelial neoplasia (CIN2+) or cancer, and the positive predictive value (PPV) of colposcopy for CIN2+, by screening test and age group.

RESULTS

Among unvaccinated women screened with HR-HPV testing at age 24-29 years, 26.9% had a positive test and 10.4% were directly referred to colposcopy following cytology triage, with a PPV for CIN2+ of 47%. At 50-64 years of age, these proportions were much lower: 5.3%, 1.2% and 27%, respectively. The proportions of women testing positive for HR-HPV without cytological abnormalities, whose early recall HR-HPV tests returned negative results, were similar across the age spans: 54% at 24-29 years and 55% at 50-64 years. Two-thirds of infections at any age were linked to non-16/18 genotypes. Among women with CIN2, CIN3 or cervical cancer, however, the proportion of non-16/18 infections increased with age. As expected, the detection of abnormalities was lower following screening with LBC.

CONCLUSIONS

These data provide a reliable reference for future epidemiological studies, including those concerning the effectiveness of HPV vaccination.

TWEETABLE ABSTRACT

Data from the English pilot study provide a comprehensive overview of abnormalities detected through HPV screening.

Effectiveness of HPV vaccine against cervical precancer in Japan: multivariate analyses adjusted for sexual activity

Japanese girls aged 12–16 years are offered free human papillomavirus (HPV) vaccination and cervical cancer screening is conducted with cytology and not HPV testing from the age of 20 years. So far, no study has analyzed the effect of HPV vaccination against cervical precancers considering HPV infection status and sexual activity. We aimed to analyze the vaccine effectiveness (VE) against HPV infection and cytological abnormalities, adjusted for sexual activity. This study comprised women aged 20–26 years who underwent cervical screening in Niigata. We obtained HPV vaccination status from municipal records and a questionnaire along with information concerning sexual activity. Of 5194 women registered for this study, final analyses included 3167 women in the vaccinated group (2821 vaccinated women prior to sexual debut) and 1386 women in the unvaccinated group. HPV 16/18 (0.2% vs 3.5%), 31/45/52 (3.4% vs 6.6%), and 31/33/45/52/58 (5.0% vs 9.3%) positive rates were significantly lower in the vaccinated group (P < 0.001). No women vaccinated before sexual debut had HPV 16/18‐related cytological abnormalities. VE for HPV 16/18 infection and high‐grade cytological abnormalities in women vaccinated prior to sexual debut were 95.8% (95% CI 81.9–99.0%; P < 0.001) and 78.3% (95% CI 11.3–94.7%; P = 0.033), respectively, in multivariate analyses adjusted for age and number of sexual partners. However, analyses of all vaccinated women did not show significant effectiveness against cytological abnormalities. Our results showed the effectiveness of HPV vaccine against high‐grade cervical cytological abnormalities and the importance of the vaccination before sexual debut.

Global burden of oropharyngeal cancer attributable to human papillomavirus by anatomical subsite and geographic region

BACKGROUND

Oropharynx is the anatomical site with the highest human papillomavirus (HPV) infection in head and neck. Many studies on HPV prevalence and p16^INK4a positivity in oropharyngeal cancer have been published in recent years. We aimed to update the global burden estimates of oropharyngeal cancer attributable to HPV with the latest data and estimate global burden of tonsillar cancer and base of tongue cancer attributable to HPV by region and country.

METHODS

We calculated the number of new cancer cases using the Cancer Incidence in Five Continents Volume XI (CI5XI) and country-specific population in 2012 issued by the United Nations. Estimates of HPV prevalence and p16^INK4a positivity were obtained from literature search and pooled analyses where necessary.

RESULTS

Globally the number of oropharyngeal cancer and tonsillar cancer attributable to HPV were 42,000 and 20,000 in 2012, corresponding to AFs of 42.7% and 52.7%. The number of cancer cases attributable to HPV among males was about 4-fold greater than that among females. For both oropharyngeal cancer and tonsillar cancer, AFs were higher in more developed countries. Among HPV positive oropharyngeal cancer cases, 86.7%, 87.8%, and 92.5% could have been prevented by bivalent (2v), quadrivalent (4v), and nonavalent (9v) HPV vaccines.

CONCLUSIONS

It is worth considering the inclusion of HPV immunization in males, especially in the regions where oropharyngeal cancer is highly prevalent.

A nationwide epidemiological survey of adolescent patients with diverse symptoms similar to those following human papillomavirus vaccination: background prevalence and incidence for considering vaccine safety in Japan

BACKGROUND

Since June 2013, Japan has suspended proactive recommendation of human papillomavirus (HPV) vaccination due to self-reported diverse symptoms, including pain and motor dysfunction, as possible serious adverse events following immunization. Although these symptoms may be seen in adolescents without HPV vaccination, their frequency taking into account disease severity has not been examined.

METHODS

A two-stage, descriptive, nationwide epidemiological survey was conducted in 2016 with a 6-month targeted period from July 1 to December 31, 2015 to estimate the prevalence and incidence of diverse symptoms among Japanese adolescents without HPV vaccination. Participants were 11,037 medical departments in hospitals selected nationwide by stratified random sampling. Eligible patients had to satisfy four criteria: (1) aged 12-18 years upon visiting hospital; (2) having at least one of four symptoms/disorders (pain or sensory dysfunction, motor dysfunction, autonomic dysfunction, or cognitive impairment); (3) symptoms/disorders persisting for at least three months; and (4) both criteria (2) and (3) influence attendance at school or work. We further extracted patients with diverse symptoms similar to those after HPV vaccination while considering opinions of doctors in charge.

RESULTS

Estimated 6-month period prevalence of diverse symptoms among girls aged 12-18 years without HPV vaccination was 20.2 per 100,000. Annual incidence was estimated to be 7.3 per 100,000.

CONCLUSION

Adolescent Japanese girls without HPV vaccination also visited hospitals with diverse symptoms similar to those following HPV vaccination. Our findings predicted the medical demands for diverse symptoms that are temporally associated with but not caused by vaccination of Japanese adolescents.

Multistakeholder knowledge levels and perspectives of human papillomavirus and its vaccination: An exploratory qualitative study

OBJECTIVE

This qualitative study was an integral part in the development of a multidisciplinary team-led school-based human papillomavirus vaccination health-promotion programme (MDL-SHPVP) aiming to increase HPV vaccine uptake in Hong Kong. Study findings will inform the design of the MDL-SHPVP by drawing on interview data regarding the expectations and needs of key stakeholders and potential programme users.

METHODS

Eight mother-daughter dyads, four secondary school teachers, two school principals, three social workers and one school nurse were interviewed. All interviews were audio-recorded and transcribed verbatim for thematic analysis.

RESULTS

Most participants had misconceptions about HPV and the vaccine. Alhough there was no immediate perceived need for the vaccination, most participants had favourable attitudes towards HPV inoculation and vaccines in general. Factors affecting vaccine uptake included perceptions about risk of infection, vaccine availability, and cost. Participants were largely open to suggested MDL-SHPVP components (videos, digital game, and group discussions).

CONCLUSION

Findings have highlighted knowledge gaps among potential users and key stakeholders and will be used to inform the design of the MDL-SHPVP to ensure that their needs and expectations are addressed. Study findings may also aid future HPV vaccine promotion efforts and boost HPV vaccine uptake among youth in the city.

Partial Protective Effect of Bivalent Human Papillomavirus 16/18 Vaccination Against Anogenital Warts in a Large Cohort of Dutch Primary Care Patients

Background

There is ongoing debate about the possible protective effect of the bivalent human papillomavirus (2vHPV) vaccine, targeting oncogenic types HPV-16/18, against anogenital warts (AGWs), commonly attributed to HPV-6/11. We performed a retrospective registry-based open cohort study to assess the effect of 2vHPV vaccination on AGWs.

Methods

We linked general practice (ie, primary care) data from women born between 1993 and 2002, who had been eligible for HPV vaccination in the Netherlands, to the Dutch national immunization registry on an individual level. Women were followed until their first AGW diagnosis or end of follow-up. Adjusted incidence rate ratios (aIRRs) were estimated using Poisson regression with vaccination status as a time-dependent exposure.

Results

We linked data of 96 468 women with a total of 328 019 years observation time and 613 AGW diagnoses (incidence: 1.87/1000 person-years). At the end of follow-up, 61% were 2vHPV vaccinated (≥ 1 dose) of whom 91% were fully vaccinated. The AGW incidence was lower among those with ≥ 1 dose vs 0 doses (aIRR, 0.75 [95% confidence interval {CI}, .64–.88]). The effect of vaccination was stronger after full vaccination (aIRR, 0.72 [95% CI, .61–.86]) and for women who were offered vaccination at 12–13 years of age (aIRR, 0.69 [95% CI, .51–.93]) vs those at 13–16 years of age (aIRR, 0.77 [95% CI, .64–.93]).

Conclusions

This is the largest population-based study so far to examine the effect of 2vHPV vaccination on AGWs, with reliable individual information on AGW diagnoses and vaccination status. The results indicate that 2vHPV vaccination partially protects against AGWs, especially when administered in early adolescence.

Human Papillomavirus Distribution in Women with Abnormal Pap Smear and/or Cervical Intraepithelial Neoplasia in Vaccination Era. A Single-Center Study in the North Italian Population

Time trends prevalence of human papillomavirus (HPV) genotypes including negative and untypable infections were analyzed during a 15-year period (2005–2019) among 5807 subjects with abnormal pap-smears and/or cervical intraepithelial neoplasia (CIN). The rates of HPV16 dropped by 13% every 3 years (Prevalence Ratio, PR = 0.87, 95% CI = 0.82–0.93) in the CIN1 biopsy, while HPV16 status was unchanged over time in the CIN2+ biopsy. In CIN1 lesions, there was a corresponding increase of HR-HPV types unrelated to nonavalent vaccine. The rates of HPV 18, 31, and 52, decreased by 35% (PR = 0.65, 95% CI = 0.54–0.79), 19% (PR = 0.81, 95% CI = 0.73–0.91), and 21% (PR = 0.79, 95% CI = 0.73–0.86) every 3-year interval in CIN2+, respectively. Overall, the prevalence of negative/untypable HPV specimens in the entire database increased from 9.6% (129/1349) in the period 2011–2013 to 17.6% (161/913) and 28.4% (224/790) in the 2014–2016 period and in the 2017–2019 period, respectively (PR = 1.69, 95% CI = 1.52–1.88). HPV 16 prevalence decreased significantly among subjects with low-grade cervical squamous lesions. A significant increase of both HPV types unrelated to nonavalent vaccination and negative/untypable HPV infections was reported. The prevalence of HPV types among subjects with abnormal pap smears in Northern Italy is changing. Many variables including demographic factors and possibly vaccination could be responsible for this modification.

Systematic literature review of cross-protective effect of HPV vaccines based on data from randomized clinical trials and real-world evidence

BACKGROUND

The extent of cross-protection provided by currently licensed bivalent and quadrivalent HPV vaccines versus direct protection against HPV 31-, 33-, 45-, 52-, and 58-related disease is debated. A systematic literature review was conducted to establish the duration and magnitude of cross-protection in interventional and observational studies.

METHODS

PubMed and Embase databases were searched to identify randomized controlled trials (RCT) and observational studies published between 2008 and 2019 reporting on efficacy and effectiveness of HPV vaccines in women against non-vaccine types 31, 33, 45, 52, 58, and 6 and 11 (non-bivalent types). Key outcomes of interest were vaccine efficacy against 6- and 12-month persistent infection or genital lesions, and type-specific genital HPV prevalence or incidence. RCT data were analyzed for the according-to-protocol (bivalent vaccine) or negative-for-14-HPV-types (quadrivalent vaccine) efficacy cohorts.

RESULTS

Data from 23 RCTs and 33 observational studies evaluating cross-protection were extracted. RCTs assessed cross-protection in post-hoc analyses of small size subgroups. Among fully vaccinated, baseline HPV-naïve women, the bivalent vaccine showed statistically significant cross-protective efficacy, although with wide confidence intervals, against 6-month and 12-month persistent cervical infections and CIN2+ only consistently for HPV 31 and 45, with the highest effect observed for HPV 31 (range 64.6% [95% CI: 27.6 to 83.9] to 79.1% [97.7% CI: 27.6 to 95.9] for 6-month persistent infection; maximal follow-up 4.7 years). No cross-protection was shown in extended follow-up. The quadrivalent vaccine efficacy reached statistical significance for HPV 31 (46.2% [15.3-66.4]; follow-up: 3.6 years). Similarly, observational studies found consistently significant effectiveness only against HPV 31 and 45 with both vaccines.

CONCLUSIONS

RCTs and observational studies show that cross-protection is inconsistent across non-vaccine HPV types and is largely driven by HPV 31 and 45. Furthermore, existing data suggest that it wanes over time; its long-term durability has not been established.

Universal Human Papillomavirus Vaccination and its Impact on the Southern Italian Region

HPV is still the most common sexually transmitted infection, leading to the onset of many disorders while causing an increase in direct and indirect health costs. High Risk (HR) HPV is the primary cause of invasive cervical cancer and contributes significantly to the development of anogenital and oropharyngeal cancers. The introduction of universal HPV vaccination has led to a significant reduction in vaccine-targeted HPV infections, cross-protective genotypes, precancerous lesions and anogenital warts. Despite the several limitations of HPV vaccination programs, including vaccine type specificity, different schedules, target age-groups and poor communication, the impact has become increasingly evident, especially in countries with high vaccine uptake. We carried out a review of the most recent literature to evaluate the effects of HPV vaccination on vaccinetargeted HPV genotypes and to assess the level of cross-protection provided against non-vaccine HPV types. Subsequently, to assess the rates of HPV infection in a southeast Italian region, we performed an epidemiological investigation on the impact of vaccination on genotypes and on the prevalence and distribution of HPV infection during the twelve-year period 2006-2017 in the Local Health Unit (LHU) of Lecce. The vaccination coverage of about 70% among girls in the LHU led to an initial reduction in vaccine-targeted HPV types and cross-protective genotypes. However, the results on this population should be interpreted cautiously because the period since the start of vaccination is too short and the coverage rate is not yet optimal to evaluate the efficacy of vaccination in lowering the prevalence of non-vaccine HR HPV types in the vaccinated cohort and in older subjects. Nevertheless, it is expected that direct effects will increase further and that herd immunity will begin to emerge as vaccination coverage increases.

How to Understand "Herd Immunity" in COVID-19 Pandemic

The COVID-19 pandemic has been a global threat. Through rapid and effective surveillance and control, the newly confirmed patients have been fluctuated at a very low level and imported case explained most of them through March, 2020 to the present, indicating China's response has achieved a stage victory. By contrast, the epidemic of COVID-19 in other countries out of China is bursting. Different countries are adopting varied response strategy in terms of their public health system to prevent the spread. Herd immunity has been a hot topic since the outbreak of COVID-19 pandemic. Can it be a possible strategy to combat COVID-19? To fully interpret the knowledge regarding the term upon the background of COVID-19-related health crisis, we aim to systematically review the definition, describe the effective measures of acquiring herd immunity, and discuss its feasibility in COVID-19 prevention. Findings from this review would promote and strengthen the international cooperation and joint efforts when confronting with COVID-19.

How to Understand "Herd Immunity" in COVID-19 Pandemic

The COVID-19 pandemic has been a global threat. Through rapid and effective surveillance and control, the newly confirmed patients have been fluctuated at a very low level and imported case explained most of them through March, 2020 to the present, indicating China’s response has achieved a stage victory. By contrast, the epidemic of COVID-19 in other countries out of China is bursting. Different countries are adopting varied response strategy in terms of their public health system to prevent the spread. Herd immunity has been a hot topic since the outbreak of COVID-19 pandemic. Can it be a possible strategy to combat COVID-19? To fully interpret the knowledge regarding the term upon the background of COVID-19-related health crisis, we aim to systematically review the definition, describe the effective measures of acquiring herd immunity, and discuss its feasibility in COVID-19 prevention. Findings from this review would promote and strengthen the international cooperation and joint efforts when confronting with COVID-19.

Human Papillomavirus (HPV) Vaccine Effectiveness and Potential Herd Immunity for Reducing Oncogenic Oropharyngeal HPV-16 Prevalence in the United Kingdom: A Cross-sectional Study

Background

Oropharyngeal cancer incidence is rapidly rising due to human papillomavirus (HPV) type 16 infection. The dearth of data on effectiveness of national female-only vaccination programs in preventing oral HPV infection and potential herd immunity in unvaccinated males has resulted in considerable controversy regarding the need to vaccinate males, especially in countries with high female vaccination coverage.

Methods

Subjects aged 0–65 years undergoing tonsillectomy for nonmalignant indications were recruited in 6 hospitals in the United Kingdom. Oral samples were collected as follows: oral rinse, tongue base, and pharyngeal wall brushes, then tonsil tissue (tonsillectomy). Vaccination data were obtained from regional health authorities. All samples were centrally tested for HPV DNA by polymerase chain reaction.

Results

Of 940 subjects, 243 females and 69 males were aged 12–24 years (median age, 18.6 years), with 189 (78%) females and no males vaccinated against HPV. Overall, oropharyngeal HPV-16 prevalence was significantly lower in vaccinated versus unvaccinated females (0.5% vs 5.6%, P = .04). In contrast, prevalence of any oropharyngeal HPV type was similar in vaccinated and unvaccinated females (19% vs 20%, P = .76). Oropharyngeal HPV-16 prevalence in unvaccinated males was similar to vaccinated females (0% vs 0.5%, P > .99), and lower than unvaccinated females (0% vs 5.6%, P = .08).

Conclusions

Our findings indicate that the UK female-only vaccination program is associated with significant reductions in oropharyngeal HPV-16 infections. These are also the first data to suggest potential herd immunity from female-only vaccination against oropharyngeal HPV infection in contemporaneously aged males.

Progress in Vaccination of Prophylactic Human Papillomavirus Vaccine

The human papillomavirus (HPV) vaccine plays an important role in preventing a series of diseases caused by HPV. Recent studies have shown that as a primary prevention measure, it can considerably prevent HPV infection and HPV-associated cervical cancer. However, studies on the safety, efficacy, and coverage of the HPV vaccine remain insufficient, especially in developing countries. Therefore, in this review, we outlined the recent studies of the HPV vaccine in terms of immunogenicity, safety, efficacy, latest vaccination concepts, and strategies. This review may provide a theoretical basis for use of the HPV vaccine.

B. Hanley S, Hara M, Adachi S, Ueda Y, Miyagi E, Ikeda S, Yagi A, Enomoto T. Epidemiologic Profile of Type-Specific Human Papillomavirus Infection after Initiation of HPV Vaccination

Organized human papillomavirus vaccination (OHPV) in Japan was introduced in 2010 for girls aged 12–16 years who were born in 1994 or later. The rate of OHPV coverage was 70–80%. However, after suspension of the government vaccination recommendation, the coverage dramatically decreased. We aim to investigate the change in prevalence of HPV infection after the initiation of HPV vaccination. We recruited females aged 20–21 years attending public cervical cancer screening from 2014 to 2017 fiscal years (April 2014 to March 2018). Residual Pap test specimens were collected for HPV testing. We compared the prevalence of HPV type-specific infection between women registered in 2014 (born in 1993–1994, including the pre-OHPV generation) and registered in 2015–2017 (born in 1994–1997, the OHPV generation). We collected 2379 specimens. The vaccination coverage figures were 30.7%, 86.6%, 88.4% and 93.7% (p < 0.01) from 2014 to 2017, respectively. The prevalence of HPV16/18 infection significantly decreased from 1.3% in 2014 to 0% in 2017 (p = 0.02). The three most prevalent types were HPV52, 16 and 56 in 2014, and HPV52, 58 and 56 in 2015–2017, respectively. HPV16 and 33 infection rates decreased. On the other hand, the HPV58 infection rate was obviously increased after OHPV from 0.3% to 2.1%. Our study demonstrates that the prevalence of HPV16/18 infection dramatically decreased and the profile of type-specific HPV infection was changed after OHPV.

Human papillomavirus infection rates before and after the introduction of prophylactic vaccines in Kunming, Yunnan, China

Purpose

The purpose of this study was to determine the prevalence of human papillomavirus (HPV) in the population in Kunming, Yunnan, China, before and after the introduction of HPV preventive vaccines.

Materials and Methods

In total, 28,959 patients were enrolled in this study between 1 January 2016 and 31 August 2019. HPVs were genotyped using a flow-through hybridisation technique, and differences in HPV infection rates before and after the introduction of an HPV vaccine were determined.

Results

The prevalence of HPV before and after the introduction of HPV vaccines was 17.74% and 17.11%, respectively. This difference was not statistically significant (χ2 = 1.920, P > 0.05). The HPV infection rates showed a bimodal U-shaped curve for all age groups. The most common genotypes of HPV detected were HPV52, HPV16, HPV58 and HPV39.

Conclusion

Although the overall HPV infection rate in Kunming did not change significantly after the introduction of HPV vaccines, differences in HPV infection rates and multi-typic HPV infection rates were evident in certain age groups.

Effectiveness of the AS04-adjuvanted HPV-16/18 vaccine in reducing oropharyngeal HPV infections in young females-Results from a community-randomized trial

We studied effectiveness of the AS04-adjuvanted HPV-16/18 (AS04-HPV-16/18) vaccine against human papillomavirus (HPV) oropharyngeal infections associated with the increase of head/neck cancers in western countries. All 38,631 resident adolescents from 1994 to 1995 birth cohorts of 33 Finnish communities were invited in this community-randomized trial (NCT00534638). During 2008-2009, 11,275 girls and 6,129 boys were enrolled in three arms of 11 communities each. In Arm A, 90% of vaccinated girls/boys, and in Arm B, 90% of vaccinated girls received AS04-HPV-16/18 vaccine. Other Arm A/B and all Arm C vaccinated participants received control vaccine. All Arm A participants and Arm B female participants were blinded to vaccine allocation. Oropharyngeal samples were analyzed from 4,871 18.5-year-old females who attended follow-up visit 3-6 years postvaccination. HPV DNA prevalence was determined by SPF-10 LiPA and Multiplex type-specific PCR. Total vaccine effectiveness (VE) was defined as relative reduction of oropharyngeal HPV prevalence in pooled Arms A/B HPV-vaccinated females vs. all Arm C females. VE against oropharyngeal HPV-16/18, HPV-31/45 and HPV-31/33/45 infections were 82.4% (95% confidence intervals [CI]: 47.3-94.1), 75.3% (95%CI: 12.7-93.0) and 69.9% (95% CI: 29.6-87.1), respectively. In conclusion, the AS04-HPV-16/18 vaccine showed effectiveness against vaccine and nonvaccine HPV-types oropharyngeal infections in adolescent females up to 6 years postvaccination.

Selective Persistence of HPV Cross-Neutralising Antibodies following Reduced-Dose HPV Vaccine Schedules

The duration of cross-neutralising antibody responses (cross-NAb) following HPV immunisation is unknown. We compared cross-NAb responses in cohort of girls who were either unimmunised or had received immunisation with one, two or three doses of 4vHPV (Gardasil^®, Merck Inc., Kenilworth, NJ, USA) six years earlier, before and one month after a booster dose of 2vHPV (Cervarix^®, GSK, Brentford, UK). NAb to potentially cross-reactive HPV genotypes 31, 33, 45, 52 and 58 were measured using a HPV pseudovirion-based neutralisation assay. Girls who had previously received at least one dose of 4vHPV had significantly higher NAb titres for HPV31 when compared with unimmunised girls, whereas no difference in NAb titre was observed for four other genotypes (33, 45, 52 and 58). Following a single further immunisation with 2vHPV, NAb titres to each of the five tested HPV genotypes were comparable for girls who previously received one, two or three doses of 4vHPV, and were significantly higher than for previously unimmunised girls. Immunisation with one, two or three doses of 4vHPV induced NAb to HPV31 that persisted for six years, but there was no persistence of NAb to HPV33, 45, 52 or 58. Our results suggest that one or two doses of 4vHPV may provide long-term protection against HPV31.

Decline in vaccine-type human papillomavirus prevalence in young men from a Midwest metropolitan area of the United States over the six years after vaccine introduction

PURPOSE

The aim of this study was to determine changes in human papillomavirus (HPV) prevalence among young men from a Midwest metropolitan area over the six years after vaccine introduction, including HPV prevalence in men overall, in vaccinated men to examine vaccine impact and in unvaccinated men to examine herd protection. An exploratory aim was to examine associations between number of vaccine doses and HPV prevalence.

METHODS

Men aged 14-26 years reporting male-female and/or male-male sexual contact were recruited from a primary care clinic, sexually transmitted disease clinic, and community setting during two waves of data collection: 2013-2014 (N = 400) and 2016-2017 (N = 347). Participants completed a questionnaire and were tested for penile, scrotal and anal HPV. Changes in prevalence of any (≥1 type) and vaccine-type HPV (HPV6, 11, 16, and/or 18) were examined using propensity score weighted logistic regression. Associations between number of doses and HPV infection were determined using chi-square tests and logistic regression.

RESULTS

The proportion of men with a history of ≥1 HPV vaccine doses increased from 23% to 44% (p < 0.001) from waves 1 to 2. After propensity score weighting, infection with ≥1 vaccine-type HPV significantly decreased among all men (29% to 20%; 31% decrease; odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.44-0.88) and unvaccinated men (32% to 21%; 36% decrease; OR = 0.56, 95%CI = 0.34-0.86); there was a non-significant decrease (21%) among vaccinated men. Associations between number of doses and HPV prevalence were not statistically significant.

CONCLUSIONS

Prevalence of vaccine-type HPV decreased among all, vaccinated, and unvaccinated men six years after HPV vaccine recommendation, supporting vaccine impact and herd protection. Decreases in vaccine-type HPV in all men appear to be due to decreases in unvaccinated men, suggesting that the full impact of vaccination has yet to be realized. Continued monitoring and efforts to vaccinate men prior to sexual initiation are warranted.

HPV vaccination: Are we overlooking additional opportunities to control HPV infection and transmission?

Human papillomavirus virus-like particles (HPV VLPs) have distinctive immunogenic properties that generate a durable antibody response, producing high-quality neutralizing antibodies. By vaccination, i.e., intramuscular injection of these HPV VLPs, the viral survival strategy of avoiding exposure to the systemic immune system is completely overruled, and large amounts of vaccine-induced systemic antibodies are generated. These systemic circulating antibodies are easily transuded to the genital mucosa and are detectable in female genital secretions. It is well accepted that these antibodies interact with the virions presented by an infected partner and inhibit infection. However, much less attention has been paid to the role of anti-HPV vaccine-induced antibodies in an HPV-infected individual where infectious virions are encountered by neutralizing antibodies in mucosal secretions. There is a clear need to further investigate and document this role. Indeed, if HPV vaccination of HPV-infected women has an effect on HPV transmission, auto-inoculation, and relapse after treatment, this may influence how we model, assess, and implement HPV vaccination programmes.

Human papillomavirus (HPV) vaccination: from clinical studies to immunization programs

Cervical cancer incidence and mortality have decreased in high-income countries, but low- and middle-income countries continue to bear a significant burden from the disease. Human papillomavirus (HPV) vaccines are a promising alternative for disease control; however, their introduction is slow in settings with greater need. We conducted a review of HPV vaccine efficacy and effectiveness reported in clinical trials and population-based studies. Efficacy of HPV vaccines is close to 100% when using a three-dose schedule in HPV-negative young women (<25 years old) for protection against persistent infection and HPV vaccine-type associated pre-cancerous lesions. Furthermore, sustained protection for up to 12 years of follow-up has been demonstrated; cross-protection against non-vaccine types is particularly observed for the bivalent vaccine, and preliminary data regarding impact on invasive cancer have emerged. Given its lower efficacy, catch-up vaccination beyond 19 years of age and proposals for vaccinating adult women deserve careful evaluation in accurately designed studies and economic analyses. Despite positive results regarding immunogenicity and post-hoc analysis for cervical intra-epithelial neoplasia in clinical trials, population-based data for prime and booster two-dose schedules are not available. Evaluation of vaccine safety from surveillance systems in immunization programs that have already distributed more than 270 million doses found no association of HPV vaccination with serious side effects. The introduction of HPV vaccination in national immunization programs remains the main challenge in tackling the burden of cervical cancer (up to 2018, only 89 countries have introduced vaccination worldwide, and most of these are high-income countries). Access models and technical capacity require further development to help low- and middle-income countries to increase the pace of vaccine delivery. Alternative approaches such as one-dose schedules and vaccination at younger ages may help reduce the programmatic and economic challenges to adolescent vaccination.

Exploration of the effect of human papillomavirus (HPV) vaccination in a cohort of pregnant women in Montreal, 2010-2016

HPV vaccination efficacy has been shown in clinical trials but it is important to verify population level vaccine effectiveness (VE). We aimed to explore VE and herd effect using HPV infection data from a cohort study of Canadian pregnant women. We analyzed the baseline data of the HERITAGE study, which includes pregnant women recruited in Montreal between 2010-2012 and 2015–2016. Cervicovaginal samples self-collected in the first trimester were tested for 36 HPV types. Vaccination status was self-reported. VE and 95% confidence intervals (CI) were estimated by comparing the prevalence of HPV between vaccinated and unvaccinated women. Herd effect was explored by comparing HPV prevalence in unvaccinated women between the 2 recruitment periods. Adjusted ORs (95%CI) were estimated using exact logistic regression. The proportion of vaccinated women with at least one dose of 4vHPV was 7.5%. Although most of them were vaccinated after the onset of sexual activity, a high VE was found for HPV-16/18 (86.1% (95%CI: 15.0–99.7)). For HPV-6/11/16/18 and for HPV-31/33/45, VE was 61.9% (-23.5–92.6) and 57.0% (-47.7–92.0%), respectively. We also observed a non-statistically significant reduction in the prevalence of HPV-6/11/16/18 and HPV-31/33/45 among unvaccinated women recruited during the second recruitment period (adjusted OR: 0.8 (0.4–1.8) and 0.8 (0.3–1.7), respectively).

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.

Efficacy and safety of glucosaminylmuramyl dipeptide in treatment of human papillomavirus-associated diseases: a systematic review

Introduction. Human papillomavirus infection (HPV-infection) remains one of the most important health problems as it significantly reduces the quality of life and stigmatizes the patients. Also, the prevalence of cervical cancer – the most severe outcome of the HPV-infection is 5 % of the global burden of cancer. Although vaccination against human papillomavirus has been proved efficient, its availability in Russia continues to be limited. Therefore, it is important to review other methods of HPV-infection control. A number of studies have confirmed the efficacy of glucosaminylmuramyl dipeptide (GMDP) in the treatment of diseases associated with HPV-infection, but no systematic evaluation of these studies has been published in the available literature.

Aim: to analyze the data on the efficacy and safety of GMDP in the treatment of diseases and conditions associated with HPVinfection.

Materials and methods. We used the PRISMA approach. The search for the relevant publications was conducted in international scientific databases: the Scientific Electronic Library, the Google Scholar, the ScienceDirect, the Cochrane Community Library, the Pubmed/MEDLINE, and clinical research registries. For this systematic analysis, only full-text publications were used. We evaluated the reliability of evidence and the methodological quality of the studies.

Results. We used the following search queries: "glucosaminyl-muramyl dipeptide", "glucosamine L'muramyl dipeptide", "H-acetylglucosaminyl-H-acetylmuramyl dipeptide", "GMDP", "Licopid" (both in Russian and English transcriptions). Based on the results of the screening, 14 full-text publications were selected. At the final stage, review articles with secondary data were excluded; also excluded were original articles published in doubtful resources and those with an unclear status of peer reviewing. This systematic analysis includes 7 publications of acceptable methodological quality. Here, we summarize the consistent conclusions derived from these reports: the addition of therapy with GMDP to local (surgical) methods increases the efficacy of treatment and the duration of remission; destruction of condylomas is more effective when combined with the course of GMDP as compared to using the local destruction alone; GMDP enhances the production of cytokines that have a direct antiviral and antiproliferative effect in HPV-infection (interleukin-1, tumor necrosis factor alpha, gamma-interferon); GMDP causes normalization of cellular and humoral immunity (T-lymphocytes, T-cytotoxic lymphocytes, B-lymphocytes, CD3+, CD4+, CD8+, CD16+, and CD72+ lymphocytes, as well as the production of serum immunoglobulins IgA, IgG, and IgM). A high safety profile of GMDP is evidenced from the absence of reports on adverse events.

Discussion. The recommendation for the inclusion of GMDP into a comprehensive treatment for HPV-infection in addition to local interventions is a strong recommendation. The differences between the Russian and international approaches can be explained by the difference in the available resources and funding. We propose to test whether using GMDP for reducing the risk of recurrent HPV-infection is beneficial in terms of pharmacoeconomics. Conclusion. The high efficacy and safety of GMDP in the combined therapy of HPV-infection has been confirmed. Further carefully designed studies on GMDP are needed.

Prophylactic human papilloma virus vaccination in head and neck: indications and future perspectives

PURPOSE OF REVIEW

To gain the evidence-based knowledge concerning the efficacy of HPV vaccination for oropharyngeal sites and to highlight the trials and strategies for vaccine administration in HPV-dependent head and neck diseases.

RECENT FINDINGS

Vaccination can be provided in two injections. There is increasing anecdotal evidence that therapeutic vaccination is effective in treatment of recurrent respiratory papillomatosis.

SUMMARY

The availability and broadening spectrum of HPV vaccines make possible the prevention of cervical and other HPV-dependent diseases. Vaccination is now included in the national immunization programs of most industrial countries and will be used, it is hoped, in developing countries within the next few years. In developing countries, few women are screened for cervical precancerous lesions, making immunization even more important. In affluent countries and matured societies, with high coverage of cervical screening, the focus of interest will shift to other HPV-related diseases. The HPV vaccination is effective in preventing oral infection with types targeted by the vaccines.

Age-specific HPV type distribution in high-grade cervical disease in screened and unvaccinated women

BACKGROUND AND AIM

Age-specific type-distribution of high-risk human papillomavirus (hrHPV) in cervical precancerous lesions is subject to change in the HPV vaccination era. Knowing the pre-vaccination type-distribution helps to anticipate changes induced by mass vaccination and optimize screening.

METHODS

We recruited 1279 women referred to colposcopy for abnormal cytology into a population-based study on HPV type distribution in diagnostic cervical samples (ISRCTN10933736). The HPV genotyping findings were grouped as: HPV16/18+, other hrHPV+ (HPV31/33/35/39/45/51/52/56/58/59/66/68), non-vaccine targeted hrHPV+ (HPV35/39/51/56/59/66/68), low-risk HPV, and HPV negative. We estimated the HPV group-specific prevalence rates according to diagnostic histopathological findings in the age groups of <30 (n = 339), 30-44.9 (n = 614), and ≥45 (n = 326).

RESULTS

Altogether 503 cases with high grade squamous intraepithelial lesion or worse (HSIL+) were diagnosed. More than half, 285 (56.7%) of HSIL+ cases were associated with HPV16/18: 64.3% (101/157) in women <30 years (reference group), 58.4% (157/269) in women 30-44.9 years (risk ratio (RR) 0.91, 95% confidence interval (95% CI) 0.78-1.06), and 35.1% (27/77) in women ≥45 years of age (RR 0.55, 95% CI 0.39-0.75). Conversely, other hrHPV's were associated with 191 (38.0%) of HSIL+: 31.9% (50/157) in women <30, 36.8% (99/269) in women 30-44.9 years, 54.6% (42/77) and in women ≥45 (RR 1.71, 95% CI 1.26-2.33). The proportion of non-vaccine targeted hrHPV and HPV negative HSIL+ increased with advancing age.

CONCLUSIONS

Pre-vaccination HPV type distribution in HSIL+ was distinctly polarised by age with HPV16/18 attributed disease being markedly more prevalent in women aged <30. In the older women the other hrHPV types, however, dominated suggesting a need for more age-dependent screening strategies.

Reduction in HPV 16/18 prevalence among young women following HPV vaccine introduction in a highly vaccinated district, Japan, 2008-2017

Objective: Human papillomavirus (HPV) vaccination was introduced in Japan in April 2013, as a national immunization program for girls aged 12–16 years, after an initial introduction in 2010 as a public-aid program for girls aged 13–16 years. The Yuri-Honjo district had the highest vaccine coverage among women aged 17–51 years in 2017, due to the original public-aid program. The aim of this study was to evaluate the differences in the vaccine types of HPV16/18 infections between 2008–2012 (pre-vaccine era) and 2013–2017 (vaccine era).

Materials and Methods: We evaluated whether HPV vaccination was associated with a decrease in the prevalence of HPV16/18 and high-risk HPV and the incidence of HPV-associated cervical lesions. A total of 1,342 women aged 18–49 years, covering both the pre-vaccine and vaccine eras, who visited Yuri Kumiai General Hospital and underwent HPV genotype tests from June 2008 to December 2017 were compared.

Results: Among women aged 18–24 years with higher vaccine coverage (68.2%), the prevalence of HPV16/18 and high-risk HPV decreased from 36.7% and 69.4%, respectively, in the pre-vaccine era to 5.8% and 50.0%, respectively, in the vaccine era (p=0.00013 and p=0.047, respectively). Among those with cervical intraepithelial neoplasia grade 2− and grade 2+, HPV16/18 prevalence decreased from 30.0% to 2.7% (p=0.0018) and from 81.8% to 36.4% (p=0.030), respectively. In this age group, the rate of HPV16/18 positivity decreased significantly. Among age groups with lower vaccine coverage, HPV prevalence did not significantly differ between the two eras.

Conclusion: The prevalence of HPV16/18 and high-risk HPV significantly decreased in women aged 18–24 years, most of whom were vaccinated. HPV vaccination effectively reduced the prevalence of HPV16/18 infections in the Yuri-Honjo district.

Non-Vaccine-Type Human Papillomavirus Prevalence After Vaccine Introduction: No Evidence for Type Replacement but Evidence for Cross-Protection

BACKGROUND

We examined non-vaccine-type human papillomavirus (HPV) prevalence in a community before and during the first 8 years after vaccine introduction, to assess for (1) type replacement with any non-vaccine-type HPV and (2) cross-protection with non-vaccine types genetically related to vaccine-type HPV.

METHODS

Sexually experienced 13- to- 26-year-old women were recruited for 3 cross-sectional studies from 2006 to 2014 (N = 1180). Outcome variables were as follows: (1) prevalence of at least 1 of 32 anogenital non-vaccine-type HPVs and (2) prevalence of at least 1 HPV type genetically related to HPV-16 and HPV-18. We determined changes in proportions of non-vaccine-type HPV prevalence across the study waves using logistic regression with propensity score inverse probability weighting.

RESULTS

Vaccine initiation rates increased from 0% to 71.3%. Logistic regression demonstrated that from 2006 to 2014, there was no increase in non-vaccine-type HPV among vaccinated women (adjusted odds ratio [AOR], 1.02; 95% confidence interval [CI], 0.73-1.42), but an increase among unvaccinated women (AOR, 1.88; 95% CI, 1.16-3.04). Conversely, there was a decrease in types genetically related to HPV-16 among vaccinated (AOR, 0.57; 95% CI, 0.38-0.88) but not unvaccinated women (AOR, 1.33; 95% CI, 0.81-2.17).

CONCLUSIONS

We did not find evidence of type replacement, but did find evidence of cross-protection against types genetically related to HPV-16. These findings have implications for cost-effectiveness analyses, which may impact vaccine-related policies, and provide information to assess the differential risk for cervical cancer in unvaccinated and vaccinated women, which may influence clinical screening recommendations. The findings also have implications for public health programs, such as health messaging for adolescents, parents, and clinicians about HPV vaccination.

Bivalent Vaccine Effectiveness Against Type-Specific HPV Positivity: Evidence for Cross-Protection Against Oncogenic Types Among Dutch STI Clinic Visitors

Background

Observational postmarketing studies are important to assess vaccine effectiveness (VE). We estimated VE from the bivalent human papillomavirus (HPV) vaccine against HPV positivity of vaccine and nonvaccine types in a high-risk population.

Methods

We included all vaccine-eligible women from the PASSYON study, a biennial cross-sectional survey in Dutch sexually transmitted infection clinics. Vaginal swabs were analyzed using a polymerase chain reaction-based assay (SPF10-LiPA25) able to detect the 12 high-risk HPV (hrHPV) types 16/18/31/33/35/39/45/51/52/56/58/59. We compared hrHPV positivity between self-reported vaccinated (≥1 dose) and unvaccinated women, and estimated VE by a logistic mixed model.

Results

We included 1087 women of which 53% were hrHPV positive and 60% reported to be vaccinated. The adjusted pooled VE against HPV-16/18 was 89.9% (81.7%-94.4%). Moreover, we calculated significant VE against nonvaccine types HPV-45 (91%), HPV-35 (57%), HPV-31 (50%), and HPV-52 (37%). Among women who were offered vaccination 5/6 years ago, we estimated similar VE against HPV-16/18 (92%) and all hrHPV types (35%) compared to women who were offered vaccination <5 years ago (83% and 33%, respectively).

Conclusion

We demonstrated high VE of the bivalent vaccine against HPV-16/18 and cross-protection against HPV-45/35/31/52. Protection against HPV-16/18 was sustained up to 6 years postvaccination.

Human Papillomavirus Vaccination Rates of Military and Civilian Male Respondents to the Behavioral Risk Factors Surveillance System Between 2013 and 2015

OBJECTIVE

To evaluate human papillomavirus (HPV) vaccination rates among men in the USA and to compare vaccination rates among men who had served in the military to those reporting no previous military service.

METHODS

We performed a cross-sectional analysis using Behavioral Risk Factor Surveillance System (BRFSS) data from the 2013 to 2015 to analyze HPV vaccination rates for vaccine eligible adult men. The BRFSS is a multistage, cross-sectional telephone survey conducted nationally by state health departments. Univariable and logistic regression analyses were performed to examine the relationship between military service and HPV vaccination status was assessed as well as the number of HPV vaccination doses received.

RESULTS

A total of 5,274 participants were analyzed representing a weighted estimate of 1.5 million HPV vaccine eligible men in the USA. The vaccination rate among veterans was 25.3% (95% confidence interval (CI), 18.8-33.3%) compared to 15.9% (95% CI, 14.3-17.6%) for civilians (p < 0.01). Veterans were more likely to report having received at least one dose of the HPV vaccine compared to civilian men (adjusted odds ratios [aOR] = 2.7, 95% CI, 1.7%-4.1%, p < 0.001).

CONCLUSIONS

Veteran men are more likely to have received HPV vaccination than similarly aged civilian men. However, for both civilians and veterans, the HPV vaccination coverage remains low when compared to their female counterparts.

Trends in Human Papillomavirus Vaccine Types 16 and 18 in Cervical Precancers, 2008-2014

BACKGROUND

The impact of human papillomavirus (HPV) vaccination has been observed in the United States through declining cervical precancer incidence in young women. To further evaluate vaccine impact, we described trends in HPV vaccine types 16/18 in cervical precancers, 2008-2014.

METHODS

We analyzed data from a 5-site, population-based surveillance system. Archived specimens from women age 18-39 years diagnosed with cervical intraepithelial neoplasia grades 2-3 or adenocarcinoma in situ (CIN2+) were tested for 37 HPV types. We described the proportion and estimated number of cases of CIN2+ by HPV-type groups over time. Trends in HPV16/18-positive CIN2+ were examined, overall and by vaccination status, age, histologic grade, and race/ethnicity, using Cochrane-Armitage tests.

RESULTS

In 10,206 cases, the proportion and estimated number of cases of HPV16/18-positive CIN2+ declined from 52.7% (1,235 cases) in 2008 to 44.1% (819 cases) in 2014 (P < 0.001). Declining trends in the proportion of HPV16/18-positive CIN2+ were observed among vaccinated (55.2%-33.3%, P < 0.001) and unvaccinated (51.0%-47.3%, P = 0.03) women; ages 18-20 (48.7%-18.8%, P = 0.02), 21-24 (53.8%-44.0%, P < 0.001), 25-29 (56.9%-42.4%, P < 0.001), and 30-34 (49.8%-45.8%, P = 0.04) years; CIN2 (40.8%-29.9%, P < 0.001) and CIN2/3 (61.8%-46.2%, P < 0.001); non-Hispanic white (59.5%-47.9%, P < 0.001) and non-Hispanic black (40.7%-26.5%, P < 0.001).

CONCLUSIONS

From 2008-2014, the proportion of HPV16/18-positive CIN2+ declined, with the greatest declines in vaccinated women; declines in unvaccinated women suggest herd protection.

IMPACT

The declining proportion of HPV16/18-positive CIN2+ provides additional evidence of vaccine impact in the United States.

Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women

BACKGROUND

Clinical trials of the 4-valent human papillomavirus (HPV) vaccine demonstrate high efficacy, but surveillance studies are essential to examine the long-term impact of vaccine introduction on HPV prevalence in community settings. The aims of this study were to determine during the 11 years after vaccine introduction the prevalence of (1) vaccine-type HPV in adolescent and young adult women who were vaccinated (to assess vaccine effectiveness) and (2) vaccine-type HPV in women who were unvaccinated (to assess herd protection).

METHODS

Young women 13 to 26 years of age were recruited from hospital-based and community health clinics for 4 surveillance studies from 2006 to 2017. We determined the proportion of vaccinated and unvaccinated women who were positive for vaccine-type HPV across the studies, and the odds of positivity for vaccine-type HPV using logistic regression; all analyses were propensity score-adjusted to control for between-wave differences in participant characteristics.

RESULTS

Vaccination rates increased from 0% to 84.3% (97% of study participants received the 4-valent vaccine). Among women who were vaccinated, 4-valent vaccine-type HPV detection decreased from 35% to 6.7% (80.9% decline; odds ratio 0.13, 95% confidence interval 0.08 to 0.22). Among women who were unvaccinated, 4-valent vaccine-type HPV detection decreased from 32.4% to 19.4% (40% decline; odds ratio 0.50, 95% confidence interval 0.26 to 0.97). Estimated vaccine effectiveness was 90.6% in wave 3 and 80.1% in wave 4.

CONCLUSIONS

In this study in which trends in HPV in a US community >10 years after 4-valent HPV vaccine introduction and after 9-valent vaccine introduction were examined, we found evidence of vaccine effectiveness and herd protection. Further research is needed to examine trends in 9-valent vaccine-type HPV after higher rates of vaccination are achieved.

Eradication of human papillomavirus and elimination of HPV-related diseases - scientific basis for global public health policies

INTRODUCTION

Infections with oncogenic human papillomaviruses (HPV) globally cause about 9% of cancers in females and 1% of cancers in males. HPV disease burden can be effectively controlled by prophylactic HPV-vaccination provided it has high impact.

AREAS COVERED

A unique series of biobank-based and health registry-based studies that exploit randomized intervention cohorts has provided data on population-level safety of HPV vaccination, duration of vaccine-induced protection and impact of gender-neutral HPV vaccination, providing a scientific basis for policies to eradicate oncogenic HPV types and associated diseases worldwide.

EXPERT COMMENTARY

The ultimate goal of HPV vaccination is the eradication of high-risk (hr) HPVs. Seventy-five percent coverage gender-neutral vaccination of early adolescents will rapidly eradicate also HPV16 from the general population.

Clinical performance of Anyplex II HPV28 by human papillomavirus type and viral load in a referral population

Anyplex II HPV28 (`Anyplex`) is a semi-quantitative DNA PCR assay divided into set A, comprising 14 high risk (hr)HPV types; and set B, comprising 5 possibly hrHPV types and 9 low risk (lr)HPV types. We compared the ability of Anyplex to that of Hybrid Capture 2 (HC2) and PreTect HPV-Proofer (`Proofer`) to detect cervical intraepithelial neoplasia grade two or worse (CIN2+) by HPV types and viral load. This cross-sectional study included 296 women referred to colposcopy with abnormal cervical cytology and/or persistent HPV infection. CIN2+ was identified in 175/296 women. Liquid based cytology samples were used to perform HPV testing. The sensitivity of Anyplex to detect CIN2+ was 98.9% (95% CI 95.9–99.9) and specificity 43.0% (95% CI 34.0–52.3). Restricting to medium and high viral loads in Anyplex set A, sensitivity and specificity were 97.1% (95% CI 93.5–99.1) and 59.5% (95% CI 50.2–68.3) with positive (PPV) and negative predictive value (NPV) 77.6% and 93.5%, respectively, comparable to HC2. Restricting Anyplex to the hrHPV types in Proofer, HPV16, 18, 31, 33 and 45, sensitivity and specificity for CIN2+ were 85.1% (95% CI 79.0–90.1) and 71.1% (95% CI 62.1–79.0), comparable to Proofer`s. When adding HPV52 and 58, the sensitivity for CIN2+ was 92.6% (95% CI 87.6–96.0) and CIN3+ 96.5% (95% CI 92.0–98.8). No value of Anyplex set B was found in detecting CIN2+. In conclusion, the clinical performance of medium and high viral loads in Anyplex set A was comparable to HC2. Restricting the test to the 7 hrHPV types included in the 9-valent HPV-vaccine, HPV16, 18, 31, 33, 45, 52 and 58, satisfies the international criteria for cervical cancer screening with relative sensitivity compared to HC2 for CIN2+ and CIN3+ of 0.98 and 1.01, respectively. Detecting all 28 Anyplex HPV types adds no benefit in a referral population.

Understanding of risk factors for the human papillomavirus (HPV) infection based on gender and race

This study assessed if race and gender predict known sexual risk factors associated with HPV. Data (n = 301) were from a cross-sectional study conducted at a drag racing event on September 12-13, 2015 in Madison, Illinois. Both multivariable logistic and linear regression models estimated the association between race, gender, and sexual risk factors. About 63% of participants were males, and 65% identified as Blacks. Compared to females, males were more likely to have a higher number of oral sexual partners (OR = 2.10; 95% CI: 1.23, 3.57). Males were also more likely to have earlier oral sexual (b = -2.10; 95% CI: -3.60, -0.60) and vaginal sexual (b = -1.10; 95% CI: -1.69, -0.31) debuts compared to females. Blacks were more likely to have higher number of vaginal sexual partners (OR = 3.38; 95% CI: 1.81, 6.31) and earlier vaginal sex (b = -1.09; 95% CI: -1.78, -0.41) but less likely to have earlier oral sexual debuts compared with Whites (b = 2.67; 95% CI: 1.21, -4.13). Because HPV is associated with several cancers, our findings provide impetus for the development of targeted educational interventions aimed at improving the knowledge of these sexual risk factors, especially among men and across race groups.