Current global status & impact of human papillomavirus vaccination: Implications for India

A phase-I, open label clinical trial to assess the safety & tolerability of qHPV vaccine manufactured by Serum Institute of India Pvt. Ltd. in adults

Background

This first in human study was designed as an open label clinical trial to assess safety and tolerability of Serum Institute of India Pvt. Ltd. (SIIPL) quadrivalent HPV (qHPV) vaccine.

Methods

A total of 48 healthy male and female (24 each) adult volunteers were administered a 0.5 ml single dose of SIIPL qHPV vaccine intramuscularly, and were followed for one month for safety outcomes viz., immediate, solicited, unsolicited and serious adverse events.

Results

47 subjects completed the study in compliance with protocol. One subject had pain immediately after immunization which was recovered without treatment. None of the participants experienced any other local or systemic solicited AEs and serious AE.

Conclusion

qHPV vaccine manufactured by SIIPL was found to be safe and well tolerable in adults. Further clinical development should continue to assess safety and immunogenicity, in the target population following recommended 2 and 3-dose schedule.Clinical Trial Registration - CTRI/2017/02/007785.

Human Papilloma Virus: An Unraveled Enigma of Universal Burden of Malignancies

HPV, or Human Papilloma Virus, has been the primary causative agent of genital warts and cervical cancer worldwide. It is a sexually transmitted infection mainly affecting women of reproductive age group, also infecting men and high-risk group individuals globally, resulting in high mortality. In recent years, HPV has also been found to be the major culprit behind anogenital cancers in both gender and oropharyngeal and colorectal cancers. Few studies have reported the incidence of HPV in breast cancers as well. For a few decades, the burden of HPV-associated malignancies has been increasing at an alarming rate due to a lack of adequate awareness, famine vaccine coverage and hesitancy. The effectiveness of currently available vaccines has been limited to prophylactic efficacy and does not prevent malignancies associated with post-exposure persistent infection. This review focuses on the current burden of HPV-associated malignancies, their causes and strategies to combat the growing prevalence of the cancers. With the advent of new technologies associated with treatment pertaining to therapeutic interventions and employing effective vaccine coverage, the burden of this disease may be reduced in the population.

Knowledge, Attitudes and HPV Vaccine Intention Among Women in India

In India, cervical cancer associated with human papillomavirus (HPV) infection is a leading cause of cancer-related mortality among women. However, uptake of the vaccine in India is low. We assessed knowledge and attitudes towards HPV, assess participants' willingness to accept the vaccination for themselves and their children, and determine factors associated with intention to receive the HPV vaccine among women in Mangalore, India. This cross-sectional study surveyed a convenient sample of 237 women aged 18-45 years using a semi-structured questionnaire. All respondents reported being aware of HPV infection. However, 22.36% (n = 53) of the respondents have never heard about genital warts and 18.57% (n = 44) have never heard about HPV vaccine. Participants displayed good general knowledge of HPV infection (median score, 1.26; Interquartile Range (IQR): 1.04-1.52) and average knowledge of HPV vaccine (e.g., median score, 1.18; IQR: 0.73-1.45). HPV general knowledge and vaccine knowledge were associated with intention to receive the HPV vaccine and recommend it to children. Participant awareness of the HPV vaccine predicted vaccine intent for themselves. Participants' willingness to recommend the vaccine for their children was associated with older age, married status, having one or more children, and having a college education. Lack of awareness about genital warts was strongly associated with participants' refusal to get the HPV vaccine or recommend it for their own children (Relative Risk Ratio RRR: 12.21; 95% C.I.: 2.33-63.99). Our study validated the questionnaire as a reliable tool for assessing HPV and HPV vaccine knowledge, attitudes, awareness, and vaccine intentions in women aged 18-45 years. Public health education should focus on increasing awareness of genital warts as a sequela of HPV, as well as promote awareness of role and safety of HPV vaccination in -children.

High-risk HPV prevalence among women undergoing cervical cancer screening: Findings a decade after HPV vaccine implementation in British Columbia, Canada

BACKGROUND

British Columbia (BC) introduced a publicly funded, school-based human papillomavirus (HPV) immunization program in 2008 with the quadrivalent vaccine. In 2010/2011, a baseline evaluation of HPV prevalence was conducted among women undergoing cervical cancer screening. After 10 years of publicly funded HPV vaccination, HPV-type prevalence was re-evaluated.

METHODS

From August 2017 to March 2018, 1107 physicians were invited to return cytobrushes used during routine Pap screening to the Cervical Cancer Screening Laboratory for HPV testing. Only age or year of birth was collected. Specimens were screened for high-risk HPV (hrHPV) and positive samples were genotyped. HPV type prevalence was compared for females 15-22 yrs (those eligible for the school-based vaccination) and 23+ yrs (ineligible for school-based vaccination) for the 2010/2011 and the 2017/2018 data.

RESULTS

There were 3309 valid samples received for testing; of these, 3107 were included in the analysis. The overall hrHPV prevalence was 12.2% (95% CI 11.3-13.3) in 2010/11, and 12.0% (95% CI 10.9-13.2) in 2017/18. For the 15-22 age group, the prevalence for any hrHPV was 26.8% (95% CI 23.1-30.8) in 2010/11 and 25.4% (95% CI 15.3-37.9) in 2017/18. For those aged 15-22, HPV16 prevalence in 2010/11 was 8.8% (95% CI 6.5-11.5) and in 2017/18 was 6.3% (95% CI 1.8-15.5), with corresponding figures for HPV18 3.7% (95% CI 2.3-5.7) and 0% (95% CI 0.0-5.7), respectively. For all hrHPV types, there were no statistically significant differences between the 2010/11 and 2017/18 periods.

CONCLUSIONS

This study illustrates the prevalence of hrHPV in BC over time in women undergoing cervical cancer screening, where an indication of a decline in HPV16/18 is seen in vaccine eligible women.

The Immune Microenvironment in Human Papilloma Virus-Induced Cervical Lesions-Evidence for Estrogen as an Immunomodulator

Globally, human papilloma virus (HPV) infection is a common sexually transmitted disease. However, most of the HPV infections eventually resolve aided by the body’s efficient cell-mediated immune responses. In the vast majority of the small group of patients who develop overt disease too, it is the immune response that culminates in regression of lesions. It is therefore a rarity that persistent infection by high-risk genotypes of HPV compounded by other risk factors progresses through precancer (various grades of cervical intraepithelial neoplasia—CIN) to cervical cancer (CxCa). Hence, although CxCa is a rare culmination of HPV infection, the latter is nevertheless causally linked to >90% of cancer. The three ‘Es’ of cancer immunoediting viz. elimination, equilibrium, and escape come into vogue during the gradual evolution of CIN 1 to CxCa. Both cell-intrinsic and extrinsic mechanisms operate to eliminate virally infected cells: cell-extrinsic players are anti-tumor/antiviral effectors like Th1 subset of CD4+ T cells, CD8+ cytotoxic T cells, Natural Killer cells, etc. and pro-tumorigenic/immunosuppressive cells like regulatory T cells (Tregs), Myeloid-Derived Suppressor Cells (MDSCs), type 2 macrophages, etc. And accordingly, when immunosuppressive cells overpower the effectors e.g., in high-grade lesions like CIN 2 or 3, the scale is tilted towards immune escape and the disease progresses to cancer. Estradiol has long been considered as a co-factor in cervical carcinogenesis. In addition to the gonads, the Peyer’s patches in the gut synthesize estradiol. Over and above local production of the hormone in the tissues, estradiol metabolism by the gut microbiome: estrobolome versus tryptophan non-metabolizing microbiome, regulates free estradiol levels in the intestine and extraintestinal mucosal sites. Elevated tissue levels of the hormone serve more than one purpose: besides a direct growth-promoting action on cervical epithelial cells, estradiol acting genomically via Estrogen Receptor-α also boosts the function of the stromal and infiltrating immunosuppressive cells viz. Tregs, MDSCs, and carcinoma-associated fibroblasts. Hence as a corollary, therapeutic repurposing of Selective Estrogen Receptor Disruptors or aromatase inhibitors could be useful for modulating immune function in cervical precancer/cancer. The immunomodulatory role of estradiol in HPV-mediated cervical lesions is reviewed.

Experience of Human Papillomavirus Vaccination Project in a Community Set Up-An Indian Study

Background:

Initial introduction of HPV vaccination from 2006 to 2008 was largely confined to high-income countries (HIC), such as Australia, the United States, and Europe, where cervical cancer incidence is lowest. Much of the post-introduction literature has come from HICs, with a focus on coverage levels achieved, provider acceptability and early impact of vaccination on disease endpoints. However, there are a few literature evaluating the mechanics of delivery, feasibility of the health system and acceptability from low and middle income countries (LMICs). The primary objective was to evaluate the feasibility, acceptability and safety of two dose HPV vaccination in adolescent girls between 9-14 years.

Methods:

After an orientation camp followed by filling up of prevaccine questionnaires by parents on HPV related diseases and its vaccines and informed consent, girls between9-14years were vaccinated. They were asked to report any side effects in the next 24 hours after each dose. Parents were contacted on Day 7 and Day 30 to enquire about any side effects . Total 3 visits were required i.e two for the vaccination and one visit at 7th month post completion of second dose. To estimate the acceptability, successful completion of two doses by at least 80% of the girls were measured. For measurement of acceptability, either of the parents were recalled along with their daughter at 7th month and were asked to fill up a pre-set questionnaire.

Results:

After institutional ethical clearance, 555 girls were recruited in the study from rural parts of West Bengal, India between July, 2017 to November, 2017. Out of which, 544 girls (98%) received their 2^nd dose between January, 2018 and May, 2018 without any serious adverse effects. No serious adverse effect was reported on follow up till December, 2019.

Conclusion:

The introduction of HPV vaccination is feasible in large scale and the vaccine is well accepted and safe.

Impact of indirect education on knowledge and perception on cervical cancer and its prevention among the parents of adolescent girls: an interventional school-based study

BACKGROUND

India has almost 225 million adolescent girls and they seem to be at a disadvantage, both economically and by their lack of knowledge on human papilloma virus (HPV) vaccine, when compared to adolescent girls of other Asian countries.

AIM

To assess the prevalence of HPV vaccination and to identify the impact of education in improving the knowledge and perception about the HPV infection and vaccination among the parents of adolescent girls.

METHODOLOGY

The prospective interventional study was conducted in four schools within a South Indian City, Mysuru. The informed consent form and the questionnaire were sent home with the identified adolescent girls during the pre-interventional phase. Educational sessions were conducted for the students in their school and an education leaflet was distributed to their parents. Three weeks later, questionnaires were re-administered to the parents via the enrolled girls and their responses were collected.

RESULTS

The prevalence of HPV vaccination in the study population was 4.4%. There was a statistically significant improvement in knowledge in the post-interventional phase of the study (p = 0.001), but could not identify a significant change in their perception (p = 0.479). Parents belonging to the socioeconomic class of upper middle and upper lower showed better improvement at the end of the study, with a percentage improvement of 58.93% and 48.44%, respectively.

CONCLUSION

The study proved that the healt care professional can target school children to communicate effectively to their parents on the importance of HPV vaccine as the study clearly observed a positive behavioral change among the study population.

Human Papillomavirus (HPV): unawareness of the causal role of HPV infection in cervical cancer, HPV vaccine availability, and HPV vaccine uptake among female schoolteachers in a Middle Eastern country

BACKGROUND

Human papillomavirus (HPV) is the most common viral infection of the reproductive tract. This cross-sectional study among female schoolteachers assessed the prevalence of i) unawareness of HPV infection's causal role in cervical cancer; ii) unawareness of HPV vaccine availability and iii) examined the sociodemographic variables associated both the outcome variables.

METHODS

This cross-sectional study was conducted among female schoolteachers employed in public and private sectors schools in Kuwait using a structured questionnaire for data collection. Prevalence of each of the outcome variables was computed. Multivariable logistic regression analyses were used to evaluate independent predictors of two dependent variables.

RESULTS

A total 1341 female schoolteachers were enrolled. Of the participants, 60% were unaware of HPV causal role in cervical cancer and 88% were unaware of HPV vaccine availability. Among those who were aware of HPV vaccine availability, 83.8% were unvaccinated. Multivariable logistic regression (MLR) model showed that 20-29 years old participants or those with low family income (< 500 KD/month) were significantly (p < 0.05) more likely to be unaware of HPV causal role in cervical cancer. Moreover, participants with family/ personal history of cervical cancer were significantly (p < 0.05) less likely to be unaware of HPV role in causation of cervical cancer. A separate MLR model revealed that the participants were significantly more likely to be unaware of HPV vaccine availability if they were Kuwaiti nationals or non-Kuwaiti Arabs (p < 0.05), employed in public schools (p = 0.003) or less likely to be unaware if they had personal or family history of cervical cancer (p < 0.001).

CONCLUSION

High prevalences of unawareness of causal role of HPV in cervical cancer and unawareness of HPV vaccine availability were recorded. Targeted education among identified sociodemographic groups with high levels of unawareness is warranted. If undertaken, future studies may evaluate the impact of recommended efforts.

Awareness and Knowledge Among Dental and Medical Undergraduate Students Regarding Human Papilloma Virus and Its Available Preventive Measures

Background

India is a major contributor to the global burden of human papilloma virus (HPV) infection and associated diseases like cervical and oropharyngeal cancers. Hence, it is essential to recognize the existing knowledge pool of current healthcare students about HPV and its preventive measures to translate this into benefits for the society in the future.

Objective

To determine the awareness and knowledge among dental and medical undergraduate students regarding HPV and its diagnosis and prevention.

Methods

This cross-sectional study enrolled in 577 dental and undergraduate medical students from a tertiary-care teaching hospital. A questionnaire containing 20 closed-ended multiple-choice questions was used to assess their knowledge regarding HPV and its transmission, cervical cancer and its screening, as well as HPV vaccines and their attitude towards them. Descriptive statistics, Mann Whitney U test, and Chi square test were employed for statistical analysis. p ≤ 0.05 was considered statistically significant.

Results

The study consisted of 52.68% dental and 47.31% medical students, with a mean age of 20.95 ± 1.82 years, M:F ratio of 0.7:1, and a mean overall score of 10.75 ± 5.18 (average). The mean scores for knowledge about HPV, its vaccination, and its diagnosis were 7.98 ± 3.26 (good), 1.61 ± 0.95 (average), and 1.15 ± 1.16 (average), respectively. These scores showed no significant difference between the courses as well as the genders (p > 0.05).

Conclusion

Overall, the dental and medical undergraduate students presented an average level of knowledge and awareness regarding HPV and its prevention. This reflects a greater need for educating healthcare professionals in order to have a ripple effect on society at large.

Assessment of understanding about human papilloma virus vaccination among undergraduate medical students in a developing country: Perspective from India

Background and Aims:

Human papilloma virus (HPV) infection is the most common sexually transmitted infection responsible for cervical cancer in women. There is no cure for HPV but safe and effective vaccinations before sexual debut can definitely decrease the incidence of cervical cancer. This research aims to explore the basic understanding of medical students about cervical cancer, HPV and HPV vaccination.

Methods and Material:

This was a descriptive, questionnaire based cross-sectional study conducted among the undergraduate medical students of All India Institute of Medical Sciences, Jodhpur from April 2018 to May 2018. A total of 238 respondents participated in the study. For statistical analysis, 'Z' score was used for categorical data and student t test was used for normally distributed continuous data.

Results:

Overall, 41% students had good knowledge about HPV infection and HPV vaccination while 44% students had average knowledge and 15% had poor knowledge. The majority of them (>80%) knew that HPV is responsible for cervical cancer and ano-genital warts but their awareness was not of the same order when it came to associating HPV with penile and oropharyngeal cancer (60%). Females had better knowledge as compared to males and this difference was statistically significant (P < 0.05). 88% of the students were willing to accept the vaccination while only 10% of females were previously vaccinated.

Conclusion:

Medical students, who are potential recipients of the HPV vaccine themselves, can play a unique role in promoting awareness about HPV vaccination in the future.

Knowledge, attitudes and factors associated with acceptability of human papillomavirus vaccination among undergraduate medical, dental and nursing students in South India

Purpose: To evaluate knowledge, attitudes and factors associated with acceptability of human papillomavirus (HPV) vaccine among undergraduate medical, dental, and nursing students in South India. Methods: Using a post-test study design, a convenience sample of 988 students (age 18-26 years) were surveyed. The primary outcome was vaccine acceptability (likely to intend to receive the vaccine). Bivariate analysis using Chi-Square test of independence and multivariate binary logistic regression analysis was used to examine factors associated with vaccine acceptability. Results: Out of 988 students surveyed, majority had heard about cervical cancer (95%), HPV (89.3) or genital warts(77.5). Only 59.7% had heard of HPV vaccine prior to the survey; 65.2% intended to receive the vaccine and 68.3% were willing to recommend the vaccine to others. Participants aged <22 years were less likely to accept the vaccine (OR:0.85, CI:0.76-0.96) compared with participants aged older than 22 years. Medical students (OR:1.12, CI:1.03-1.23), students who reported alcohol use (OR:1.15, CI:1.03-1.29) and those with moderate knowledge scores were more likely to intend to receive the vaccine (OR:1.14, CI:1.04-1.24), compared to others. On multivariate analysis, only course (OR 1.366, CI 1.016-1.835) and attitude score (OR 4.17; CI 2.12-8.2) were statistically associated with intention to receive the HPV vaccine. Conclusion: Two-thirds of students intended to receive the HPV vaccine. Although the overall awareness of the HPV-related disease and prevention is good, considerable knowledge gaps exists in many areas suggesting that that more education about HPV disease and benefits of vaccination should be included in the undergraduate medical school curriculum.

Global human papilloma virus vaccine implementation: An update

Human papillomavirus (HPV) infections continue to be one of the most common sexually transmitted infections worldwide. The oncogenic potential of this virus was well established in anogenital malignancies and oropharyngeal cancers. Even though a fall in cervical cancer rates has been reported worldwide, the subsequent rise in HPV-associated head and neck cancers among men and women have been reported from developed countries, necessitating the vaccination of adolescent boys as well. The objective of this narrative review is to provide an update on the current status of HPV vaccination worldwide. This will be helpful for clinicians in counseling parents and guardians as this vaccine mainly targets sexually naïve preadolescents. An electronic search of the databases was carried out to retrieve information concerning HPV vaccine implementation between July 2006 and 2017, with special emphasis on the current viewpoints, controversies and ethical issues. Globally, 74 countries have implemented the HPV vaccine in the national immunization schedule, and this vaccine is listed as an essential medicine by WHO. About 60% of the low- and lower-middle-income countries have implemented the vaccine with financial assistance from Gavi and WHO. The HPV vaccine is a safe vaccine with no serious adverse effects as per the data available from developed nations as well as low/lower middle/upper middle-income countries. However, long-term follow-up is essential to substantiate the impact of the vaccination programs in cancer prevention.

Report on WHO meeting on immunization in older adults: Geneva, Switzerland, 22-23 March 2017

Many industrialized countries have implemented routine immunization policies for older adults, but similar strategies have not been widely implemented in low- and middle-income countries (LMICs). In March 2017, the World Health Organization (WHO) convened a meeting to identify policies and activities to promote access to vaccination of older adults, specifically in LMICs. Participants included academic and industry researchers, funders, civil society organizations, implementers of global health interventions, and stakeholders from developing countries with adult immunization needs. These experts reviewed vaccine performance in older adults, the anticipated impact of adult vaccination programs, and the challenges and opportunities of building or strengthening an adult and older adult immunization platforms. Key conclusions of the meeting were that there is a need for discussion of new opportunities for vaccination of all adults as well as for vaccination of older adults, as reflected in the recent shift by WHO to a life-course approach to immunization; that immunization in adults should be viewed in the context of a much broader model based on an individual's abilities rather than chronological age; and that immunization beyond infancy is a global priority that can be successfully integrated with other interventions to promote healthy ageing. As WHO is looking ahead to a global Decade of Healthy Ageing starting in 2020, it will seek to define a roadmap for interdisciplinary collaborations to integrate immunization with improving access to preventive and other healthcare interventions for adults worldwide.

Management algorithms for cervical cancer screening and precancer treatment for resource-limited settings

Management algorithms for screen-positive women in cervical cancer prevention programs have undergone substantial changes in recent years. The WHO strongly recommends human papillomavirus (HPV) testing for primary screening, if affordable, or if not, then visual inspection with acetic acid (VIA), and promotes treatment directly following screening through the screen-and-treat approach (one or two clinic visits). While VIA-positive women can be offered immediate ablative treatment based on certain eligibility criteria, HPV-positive women need to undergo subsequent VIA to determine their eligibility. Simpler ablative methods of treatment such as cryotherapy and thermal coagulation have been demonstrated to be effective and to have excellent safety profiles, and these have become integral parts of new management algorithms. The challenges faced by low-resource countries are many and include, from the management perspective, identifying an affordable point-of-care HPV detection test, minimizing over-treatment, and installing an effective information system to ensure high compliance to treatment and follow-up.