Prevalence, incidence, and natural history of HPV infection in adult women ages 24 to 45 participating in a vaccine trial

Objectives

The natural history of human papillomavirus (HPV) infection has been studied extensively in young women; this study investigated HPV infection in adult women.

Methods

Data from 3817 women aged 24–45 years in a global trial of the 4-valent HPV (6/11/16/18) vaccine were used to calculate prevalence of anogenital infections containing 9-valent (9v) HPV vaccine types (6/11/16/18/31/33/45/52/58) and five non-vaccine types (35/39/51/56/59). Incidence of infections and persistent infections was estimated for 989 placebo recipients naive to all 14 HPV types at baseline. Age-adjusted hazard ratios were calculated for various sociodemographic factors.

Results

Prevalence of anogenital infection was highest in France at 29.2% (9vHPV types) and 21.7% (non-vaccine types) and lowest in the Philippines at 7.6% (9vHPV types) and 5.1% (non-vaccine types). Overall, HPV incidence (per 100 person-years) was 5.2 (9vHPV types) and 4.7 (non-vaccine types), and incidence of persistent infection was 2.7 (9vHPV types) and 2.1 (non-vaccine types). Factors associated with new HPV infections included younger age, younger age at first intercourse, being single, current use of tobacco, and higher number of past and recent sex partners.

Conclusions

Because mid-adult women acquire new HPV infections, administration of the 9vHPV vaccine could reduce HPV-related morbidity and mortality in this population.

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Prevalence of HPV infection in mid-adult women varies by country for age.

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Mid-adult women still acquire new HPV infections, including persistent infections.

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Risk factors for acquiring new HPV infections are similar in mid-adult and young women.

Better survival is observed in cervical cancer patients positive for specific anti-glycan antibodies and receiving brachytherapy

OBJECTIVE

To measure anti-glycan antibodies (AGA) in cervical cancer (CC) patient sera and assess their effect on therapeutic outcome.

PATIENTS AND METHODS

Serum AGA was measured in 276 stage II and 292 stage III Peruvian CC patients using a high content and throughput Luminex multiplex glycan array (LMGA) containing 177 glycans. Association with disease-specific survival (DSS) and progression free survival (PFS) were analyzed using Cox regression.

RESULTS

AGAs were detected against 50 (28.3%) of the 177 glycans assayed. Of the 568 patients, 84.5% received external beam radiation therapy (EBRT) plus brachytherapy (BT), while 15.5% only received EBRT. For stage-matched patients (Stage III), receiving EBRT alone was significantly associated with worse survival (HR 6.4, p < 0.001). Stage III patients have significantly worse survival than Stage II patients after matching for treatment (HR = 2.8 in EBRT+BT treatment group). Furthermore, better PFS and DSS were observed in patients positive for AGA against multiple glycans belonging to the blood group H, Lewis, Ganglio, Isoglobo, lacto and sialylated tetrarose antigens (best HR = 0.49, best p = 0.0008).

CONCLUSIONS

Better PFS and DSS are observed in cervical cancer patients that are positive for specific antiglycan antibodies and received brachytherapy.

Comparative study of HPV and Cervical Cancer Knowledge and Beliefs between Mexican Immigrant Women in the US and Peruvian Women

Cervical cancer remains one of the major cancers affecting women from developing countries, especially those from socioeconomically disadvantage backgrounds. In the US, Hispanic immigrant women experience restricted access to health care and higher incidence rates of cervical cancer compared to the non-Hispanic white population. Knowledge of cervical cancer risk factors and symptoms is associated with greater interest in participating in regular cervical cancer screening. To explore knowledge and beliefs about cervical cancer, survey questionnaires were administered to Mexican immigrant women in southeast Georgia, US and to mestizo women - primarily Quechua language dominant speakers - in Cusco, Peru. As part of these survey studies, there was a list of 32 items asking participants to agree or disagree with whether certain symptoms or risk factors could cause cervical cancer and a pile sort of 15 of the most salient items. Cultural consensus analysis was used to calculate overall agreement with a cultural model of cervical cancer risk factor knowledge in each sample independently. For the Georgia sample, there was marginal consensus, but for the Peru sample, there was no consensus. Analysis of cultural competence values and residual agreement show significant differences across education in the Georgia study, with a positive correlation between education and cultural competence (r=0.50, p=0.001), but not in the Peru study. Likewise, the results of the pile sort data exhibited consensus for the Georgia sample for the cervical cancer risk factors, but not for the Peru sample. The lack of consensus among the Peru sample on either task suggests little widespread knowledge on risk factors of cervical cancer. Additional analyses related to factors associated with screening behaviors from the cultural cancer screening scale indicated more pronounced fatalistic beliefs and catastrophic disease expectations about cervical cancer among the Peruvian women compared to the Mexican immigrant women.

4-Valent Human Papillomavirus (4vHPV) Vaccine in Preadolescents and Adolescents After 10 Years

OBJECTIVES

We describe the final 10-year data for the long-term follow-up study of the 4-valent human papillomavirus (4vHPV) vaccine in preadolescents and adolescents.

METHODS

In the base study (V501-018), 1661 sexually inactive boys and girls received the 4vHPV vaccine (early vaccination group [EVG], managed for 9.9 years) or a placebo at day 1, month 2, and month 6. Thereafter, at month 30, the placebo group (catch-up vaccination group [CVG], managed for 7.4 years) received the 4vHPV vaccine by using the same dosing schedule. Long-term anti-HPV type 6, 11, 16, and 18 immune responses were assessed. Effectiveness was estimated by calculating the incidence rate of the primary endpoints (HPV types 6, 11, 16, and 18-related disease or persistent infection).

RESULTS

For HPV types 6, 11, and 16, 89% to 96% of subjects remained seropositive through 10-years postvaccination. The preadolescents had 38% to 65% higher geometric mean titers at month 7, which remained 16% to 42% higher at 10 years compared with adolescents. No cases of HPV type 6, 11, 16, and 18-related diseases were observed. Ten subjects had a persistent infection of ≥6 months duration with vaccine-type HPV and 2 subjects had persistent infection for ≥12 months. No new serious adverse events were reported through 10 years.

CONCLUSIONS

A 3-dose regimen of the 4vHPV vaccine was immunogenic, clinically effective, and generally well tolerated in preadolescents and adolescents during 10 years of follow-up. These long-term findings support efforts to vaccinate this population against HPV before exposure.

Salud es Vida: a Cervical Cancer Screening Intervention for Rural Latina Immigrant Women

This study examined the feasibility and efficacy of Salud es Vida-a promotora-led, Spanish language educational group session on cervical cancer screening (Pap tests)-self-efficacy (belief in ability to schedule and complete a Pap test), and knowledge among immigrant Hispanic/Latina women from farmworker backgrounds. These women are disproportionately burdened with cervical cancer, with mortality rates significantly higher than non-Hispanic whites. The two-arm, quasi-experimental study was conducted in four rural counties of Southeast Georgia in 2014-2015. Hispanic/Latina immigrant women aged 21-65 years and overdue for a Pap test were included as intervention (N = 38) and control (N = 52) group participants. The intervention was developed in partnership with a group of promotoras to create the toolkit of materials which includes a curriculum guide, a brochure, a flipchart, a short animated video, and in-class activities. Twelve (32 %) intervention group participants received the Pap test compared to 10 (19 %) control group participants (p = 0.178). The intervention group scored significantly higher on both cervical cancer knowledge recall and retention than the control group (p < 0.001). While there was no statistically significant difference in cervical cancer screening self-efficacy scores between the group participants, both groups scored higher at follow-up, adjusting for the baseline scores. The group intervention approach was associated with increased cervical cancer knowledge but not uptake of Pap test. More intensive interventions using patient navigation approaches or promotoras who actively follow participants or conducting one-on-one rather than group sessions may be needed to achieve improved screening outcomes with this population.

Cultural beliefs and understandings of cervical cancer among Mexican immigrant women in Southeast Georgia

Rural Mexican immigrant women in the U.S. are infrequently screened and experience health disparities from cervical cancer. We explored cancer-related cultural beliefs in this population. We administered a cross-sectional survey to 39 Mexican immigrant women due for screening. We conducted univariate and bivariate analyses of participants' characteristics, Pap test history, cancer-related knowledge and beliefs, and cultural consensus analysis about causes of cervical cancer and barriers to screening. For all the cultural consensus tasks, there was consensus (Eigenratios >3:1) among survey participants. Comparing the rankings of risk factor clusters, clusters related to sexual behaviors were ranked more severely than clusters related to genetic or other behavioral factors. There was agreement on ideas of cervical cancer causation and barriers to screening among these women. Hence, improved methods of disseminating important health information and greater access to care are needed, particularly in relationship to stigma about sex and birth control practices.

Human papillomavirus detection in cervical neoplasia attributed to 12 high-risk human papillomavirus genotypes by region

BACKGROUND

We estimated the proportion of cervical intraepithelial neoplasia (CIN) cases attributed to 14 HPV types, including quadrivalent (qHPV) (6/11/16/18) and 9-valent (9vHPV) (6/11/16/18/31/33/45/52/58) vaccine types, by region METHODS: Women ages 15-26 and 24-45 years from 5 regions were enrolled in qHPV vaccine clinical trials. Among 10,706 women (placebo arms), 1539 CIN1, 945 CIN2/3, and 24 adenocarcinoma in situ (AIS) cases were diagnosed by pathology panel consensus.

RESULTS

Predominant HPV types were 16/51/52/56 (anogenital infection), 16/39/51/52/56 (CIN1), and 16/31/52/58 (CIN2/3). In regions with largest sample sizes, minimal regional variation was observed in 9vHPV type prevalence in CIN1 (~50%) and CIN2/3 (81-85%). Types 31/33/45/52/58 accounted for 25-30% of CIN1 in Latin America and Europe, but 14-18% in North America and Asia. Types 31/33/45/52/58 accounted for 33-38% of CIN2/3 in Latin America (younger women), Europe, and Asia, but 17-18% of CIN2/3 in Latin America (older women) and North America. Non-vaccine HPV types 35/39/51/56/59 had similar or higher prevalence than qHPV types in CIN1 and were attributed to 2-11% of CIN2/3.

CONCLUSIONS

The 9vHPV vaccine could potentially prevent the majority of CIN1-3, irrespective of geographic region. Notwithstanding, non-vaccine types 35/39/51/56/59 may still be responsible for some CIN1, and to a lesser extent CIN2/3.

Abstract A29: Efficacy study of a group-based promotora intervention to increase cervical cancer screening among immigrant Latina women

Background: This study evaluates the feasibility and efficacy of a promotora-led, Spanish-language educational group session on cervical cancer screening (Pap tests), self-efficacy (belief in ability to schedule and complete a Pap test), and knowledge among Latina immigrants compared to a control condition.

Methods: The group-based promotora intervention, Salud es Vida, consisted of a toolkit of materials which includes a curriculum guide, a brochure, a flipchart, a short animated video, and in-class activities. Data from baseline and follow-up/post-intervention surveys were used to assess differences in obtaining a Pap test using the Chi-square test of independence and in self-efficacy and knowledge scores using t-tests.

Results: We recruited 38 women to the intervention and 52 women to the control who were due for Pap test screening. After an average of 8 months until the follow-up assessment, twelve (32%) intervention participants received the Pap test and 10 (19%) control participants received the Pap test (p = .178). At follow-up, the intervention group participants had higher total cervical cancer knowledge and higher self-efficacy scores, adjusting for the posttest scores, respectively (p's &lt; .05).

Conclusions: The findings from this feasibility study using a group intervention approach suggest intervention efficacy for increasing cervical cancer knowledge and self-efficacy; however, these secondary outcomes alone were not sufficient to increase cervical cancer screening rates in this Latina immigrant population during the study period.

Citation Format: John S. Luque, Yelena N. Tarasenko, Moya L. Alfonso, Claudia Reyes-Garcia, Laura Rebing, Daron G. Ferris. Efficacy study of a group-based promotora intervention to increase cervical cancer screening among immigrant Latina women. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A29.

Social network characteristics and cervical cancer screening among Quechua women in Andean Peru

Background

Peru has high cervical cancer incidence and mortality rates compared to other Andean countries. Therefore, partnerships between governmental and international organizations have targeted rural areas of Peru to receive cervical cancer screening via outreach campaigns. Previous studies have found a relationship between a person’s social networks and cancer screening behaviors. Screening outreach campaigns conducted by the nonprofit organization CerviCusco created an opportunity for a social network study to examine cervical cancer screening history and social network characteristics in a rural indigenous community that participated in these campaigns in 2012 and 2013. The aim of this study was to explore social network characteristics in this community related to receipt of cervical cancer screening following the campaigns.

Methods

An egocentric social network questionnaire was used to collect cross-sectional network data on community participants. Each survey participant (ego) was asked to name six other women they knew (alters) and identify the nature of their relationship or tie (family, friend, neighbor, other), residential closeness (within 5 km), length of time known, frequency of communication, topics of conversation, and whether they lent money to the person, provided childcare or helped with transportation. In addition, each participant was asked to report the nature of the relationship between all alters identified (e.g., friend, family, or neighbor). Bivariate and multivariate analyses were used to explore the relationship between Pap test receipt at the CerviCusco outreach screening campaigns and social network characteristics.

Results

Bivariate results found significant differences in percentage of alter composition for neighbors and family, and for mean number of years known, mean density, and mean degree centrality between women who had received a Pap test (n = 19) compared to those who had not (n = 50) (p’s < 0.05). The final logistic regression model was statistically significant (χ2 (2) = 20.911, p < .001). The model included the variables for percentage of family alter composition and mean density, and it explained 37.8 % (Nagelkerke R²) of the variance in Pap test receipt, correctly classifying 78.3 % of cases. Those women with higher percentages of family alter composition and higher mean density in their ego networks were less likely to have received a Pap test at the CerviCusco campaigns.

Conclusions

According to this exploratory study, female neighbors more than family members may have provided an important source of social support for healthcare related decisions related to receipt of a Pap test. Future studies should collect longitudinal social network data on participants to measure the network effects of screening interventions in rural indigenous communities in Latin American countries experiencing the highest burden of cervical cancer.

Reaching women in the Peruvian Andes through cervical cancer screening campaigns: assessing attitudes of stakeholders and patients

BACKGROUND

Peru is characterized by high cervical cancer incidence and mortality rates. The country also experiences significant gaps in quality cervical cancer screening coverage for the population.

OBJECTIVE

This descriptive mixed methods study conducted in Cusco, Peru, aimed to assess the attitudes and perceptions of medical staff, health care workers, and patients toward a cervical cancer screening program that included both clinic-based and community outreach services conducted by a nongovernmental organization clinic (CerviCusco). The study also explored patient knowledge and attitudes around cervical cancer and about the human papillomavirus (HPV) to inform patient education efforts.

METHODS

The study employed structured interviews with key informants (n=16) primarily from CerviCusco, which provides cervical cancer prevention, screening, diagnosis and treatment services, and surveys with a sample of patients (n=30) receiving services at the clinic and at screening campaigns.

RESULTS

The majority of key informant medical staff participants felt that the general public had a very negative view of government health services. One theme running throughout the interviews was the perception that the general population lacked a culture of preventive health care and would wait until symptoms were severe before seeking treatment. Regarding services that were received by patients at CerviCusco, the participants responded that the prices were reasonable and more affordable than some private clinics. Patients attending the rural health campaigns liked that the services were free and of good quality.

CONCLUSION

CerviCusco has demonstrated its capacity to provide screening outreach campaigns to populations who had not previously had access to liquid-based cytology services. The finding that patients had generally low levels of knowledge about cervical cancer and the HPV vaccine prompted the development of culturally and linguistically appropriate educational and promotional materials to improve the educational component of the periodic campaigns conducted primarily in rural areas of Andean Peru.

Mobile fiber-optic sensor for detection of oral and cervical cancer in the developing world

Oral and cervical cancers are a growing global health problem that disproportionately impacts women and men living in the developing world. The high death rate in developing countries is largely due to the fact that these countries do not have the appropriate medical infrastructure and resources to support the organized screening and diagnostic programs that are available in the developed world. Diffuse reflectance spectroscopy (DRS) with a fiber-optic probe can noninvasively quantify the optical properties of epithelial tissues and has shown the potential as a cost-effective, easy-to-use, and sensitive tool for diagnosis of early precancerous changes in the cervix and oral cavity. However, current fiber-optic DRS systems have not been designed to be robust and reliable for use in developing countries. They are subject to various sources of systematic or random errors, arising from the uncontrolled probe-tissue interface and lack of real-time calibration, use bulky and expensive optical components, and require extensive training. This chapter describes a portable DRS device that is specifically designed for detection of oral and cervical cancers in resource-poor settings. The device uses an innovative smart fiber-optic probe to eliminate operator bias, state-of-the-art photonics components to reduce size and power consumption, and automated software to reduce the need of operator training. The size and cost of the smart fiber-optic DRS system may be further reduced by incorporating a smartphone based spectrometer.

Reliability of the Xpert HPV assay to detect high-risk human papillomavirus DNA in a colposcopy referral population

OBJECTIVES

The Xpert HPV Assay (Xpert; Cepheid, Sunnyvale, CA) was developed for the multianalytic GeneXpert platform.

METHODS

In a colposcopy referral population of 708 women living in the United States, two cervical specimens, A and B, were collected, and both were tested by the Xpert assay for high-risk human papillomavirus (hrHPV) DNA, permitting an evaluation of its test reliability. Specimen B was also tested by Hybrid Capture 2 (hc2; Qiagen, Germantown, MD) and the cobas HPV Test (cobas; Roche Molecular Systems, Pleasanton, CA).

RESULTS

The κ and percent agreement for any hrHPV for the two Xpert results were 0.88 and 94.5%, respectively. There was no statistical difference in testing positive on both specimens by Xpert (P = .62). The sensitivity for detection of cervical intraepithelial neoplasia grade 2 or more severe (CIN2+) was 89.0% using specimen A and 90.4% using specimen B for Xpert, 90.4% for cobas, and 81.6% for hc2.

CONCLUSIONS

The Xpert assay was sensitive and reliable for the detection of hrHPV and the identification of women with CIN2+.

Diffuse reflectance spectroscopy of epithelial tissue with a smart fiber-optic probe

Diffuse reflectance spectroscopy (DRS) with a fiber-optic probe can noninvasively quantify the optical properties of epithelial tissues and has shown the potential as a cost-effective, fast and sensitive tool for diagnosis of early precancerous changes in the cervix and oral cavity. However, current DRS systems are susceptible to several sources of systematic and random errors, such as uncontrolled probe-to-tissue pressure and lack of a real-time calibration that can significantly impair the measurement accuracy, reliability and validity of this technology as well as its clinical utility. In addition, such systems use bulky, high power and expensive optical components which impede their widespread use in low- and middle-income countries (LMICs) where epithelial cancer related death is disproportionately high. In this paper we report a portable, easy-to-use and low cost, yet accurate and reliable DRS device that can aid in the screening and diagnosis of oral and cervical cancer. The device uses an innovative smart fiber-optic probe to eliminate operator bias, state-of-the-art photonics components to reduce size and power consumption, and automated software to reduce the need of operator training. The device showed a mean error of 1.4 ± 0.5% and 6.8 ± 1.7% for extraction of phantom absorption and reduced scattering coefficients, respectively. A clinical study on healthy volunteers indicated that a pressure below 1.0 psi is desired for oral mucosal tissues to minimize the probe effects on tissue physiology and morphology.

Multimodal hyperspectral imaging for the noninvasive diagnosis of cervical neoplasia

OBJECTIVE

To determine the ability of Multimodal Hyperspectral Imaging (MHI) to noninvasively detect, localize and diagnose cervical neoplasia.

MATERIALS AND METHODS

The cervical epithelium was interrogated by MHI using tissue fluorescence and reflectance measurements after the probe was placed on the ectocervix. A Papanicolaou smear was taken, and a colposcopic examination was performed and cervical histologic specimens were collected, when indicated. MHI and Pap smear sensitivity and specificity data were compared with colposcopic and histologic results.

RESULTS

Nineteen patients had CIN2 or higher, 30 had CIN1, 34 had benign cellular changes or metaplasia, and 28 were normal by both Pap smear and colposcopic examination. At equal specificity (70%) for both tests, the sensitivity of MHI was 97%, compared to 72% for the Pap smear.

CONCLUSION

MHI detected cervical cancer precursors at a rate greater than that obtained by a simultaneously collected Pap smear.

Effect of the human papillomavirus (HPV) quadrivalent vaccine in a subgroup of women with cervical and vulvar disease: retrospective pooled analysis of trial data

OBJECTIVES

To determine the effect of human papillomavirus (HPV) quadrivalent vaccine on the risk of developing subsequent disease after an excisional procedure for cervical intraepithelial neoplasia or diagnosis of genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia.

DESIGN

Retrospective analysis of data from two international, double blind, placebo controlled, randomised efficacy trials of quadrivalent HPV vaccine (protocol 013 (FUTURE I) and protocol 015 (FUTURE II)).

SETTING

Primary care centres and university or hospital associated health centres in 24 countries and territories around the world.

PARTICIPANTS

Among 17,622 women aged 15-26 years who underwent 1:1 randomisation to vaccine or placebo, 2054 received cervical surgery or were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia.

INTERVENTION

Three doses of quadrivalent HPV vaccine or placebo at day 1, month 2, and month 6.

MAIN OUTCOME MEASURES

Incidence of HPV related disease from 60 days after treatment or diagnosis, expressed as the number of women with an end point per 100 person years at risk.

RESULTS

A total of 587 vaccine and 763 placebo recipients underwent cervical surgery. The incidence of any subsequent HPV related disease was 6.6 and 12.2 in vaccine and placebo recipients respectively (46.2% reduction (95% confidence interval 22.5% to 63.2%) with vaccination). Vaccination was associated with a significant reduction in risk of any subsequent high grade disease of the cervix by 64.9% (20.1% to 86.3%). A total of 229 vaccine recipients and 475 placebo recipients were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia, and the incidence of any subsequent HPV related disease was 20.1 and 31.0 in vaccine and placebo recipients respectively (35.2% reduction (13.8% to 51.8%)).

CONCLUSIONS

Previous vaccination with quadrivalent HPV vaccine among women who had surgical treatment for HPV related disease significantly reduced the incidence of subsequent HPV related disease, including high grade disease.

TRIAL REGISTRATIONS

NCT00092521 and NCT00092534.

Imiquimod 3.75% cream applied daily to treat anogenital warts: combined results from women in two randomized, placebo-controlled studies

OBJECTIVE

To evaluate if new imiquimod formulations using a shorter treatment duration are safe and efficacious to treat anogenital warts.

METHODS

In two studies 534 women ≥12 years of age (mean 33.4) with 2-30 warts (mean 7.9) and total wart area ≥10 mm(2) (mean 166.3) were randomized (1:2:2) to placebo (106), imiquimod 2.5% (212) or 3.75% (216) creams applied once daily until complete clearance or a maximum of 8 weeks.

RESULTS

For placebo, imiquimod 2.5% and 3.75%, respectively, complete clearance of all warts was achieved in 14.2%, 28.3%, and 36.6% of women (intent-to-treat, P = 0.008 imiquimod 2.5%, and P < 0.001 3.75% versus placebo). Mean changes in wart counts were -10.7%, -50.9%, and -63.5% (per-protocol, P < 0.001 each active versus placebo) and safety-related discontinuation rates 0.9%, 1.4%, and 2.3%.

CONCLUSIONS

Imiquimod 3.75% applied daily for up to 8 weeks was well tolerated and superior to placebo in treating women with external anogenital warts.

Incident cervical HPV infections in young women: transition probabilities for CIN and infection clearance

BACKGROUND

We describe transition probabilities for incident human papillomavirus (HPV) 16/18/31/33/35/45/52/58/59 infections and cervical intraepithelial neoplasia (CIN) 1 lesions.

METHODS

Women ages 16 to 23 years underwent cytology and cervical swab PCR testing for HPV at approximately 6-month intervals for up to 4 years in the placebo arm of an HPV vaccine trial. The cumulative proportion of incident HPV infections with diagnosed CIN, clearing (infection undetectable), or persisting without CIN, were estimated.

RESULTS

Most incident infections cleared, without detection of CIN, ranging at 36 months from 66.9% for HPV31 to 91.1% for HPV59. There was little variation in the 36-month proportion of incident HPV16, 18, and 31 infections followed by a CIN1 lesion positive for the relevant HPV type (range 16.7%-18.6%), with lower risks for HPV59 (6.4%) and HPV33 (2.9%). Thirty-six-month transition probabilities for CIN2 ranged across types from 2.2% to 9.1%; however, the number of events was generally too small for statistically significant differences to be seen across types for this endpoint, or CIN3.

CONCLUSIONS

Some incident HPV types appear more likely to result in diagnosed CIN1 than others. The relative predominance of HPV16, vis-à-vis some other high-risk HPV types (e.g., HPV33) in prevalent CIN2/3, appears more directly associated with relatively greater frequency of incident HPV16 infections within the population, than a higher risk of infection progression to CIN2/3.

IMPACT

Nearly all incident HPV infections either manifest as detectable CIN or become undetectable within 36 months. Some HPV types (e.g., 16 and 33) appear to have similar risk of CIN2/3 despite widely varied incidence.

Impact of an HPV6/11/16/18 L1 virus-like particle vaccine on progression to cervical intraepithelial neoplasia in seropositive women with HPV16/18 infection

The impact of a human papillomavirus (HPV) vaccine on development of cervical intraepithelial neoplasia grade 2-3 or adenocarcinoma in situ (CIN2-3/AIS) in women with ongoing HPV16 or 18 infections prevaccination is reported. Seventeen thousand six-hundred and twenty-two women aged 16-26 were enrolled in 1 of 2 randomized, placebo-controlled, efficacy trials (Protocols 013 and 015). Vaccine or placebo was given at day 1, month 2 and 6. Women were tested for HPV6/11/16/18 DNA and antibodies at day 1. We focus on the subset of women who were seropositive and DNA positive to HPV16 or HPV18 prevaccination. Incidence is expressed as the number of women with an endpoint per 100 person-years-at-risk. In total, 419 vaccine and 446 placebo recipients were both seropositive and DNA positive to HPV16 or HPV18 prevaccination and had at least one follow-up visit. In Protocol 013, the incidence of HPV16/18-related CIN2-3/AIS among these women was 10.9 in the vaccine arm and 7.0 in the placebo arm (vaccine efficacy = -54.9; 95% CI: -181.7, 13.0). In Protocol 015, the incidence of HPV16/18-related CIN2-3/AIS was 5.5 in the vaccine arm and 6.2 in the placebo arm (vaccine efficacy = 12.2%; 95% CI: -29.8, 40.9). These data suggest HPV vaccination neither reduces nor enhances progression to HPV16/18-related high grade cervical lesions, and cervical cytology screening and corresponding management should continue as per local recommendations. Ultimately, population-based surveillance of vaccinated individuals beyond these clinical trials will be required to further address questions regarding the impact of vaccination in women exposed to vaccine HPV types before vaccination.

Chlamydia trachomatis infection and risk of cervical intraepithelial neoplasia

Objectives

High-risk human papillomavirus (hrHPV) is the primary cause of cervical cancer. As Chlamydia trachomatis is also linked to cervical cancer, its role as a potential co-factor in the development of cervical intraepithelial neoplasia (CIN) grade 2 or higher was examined.

Methods

The placebo arms of two large, multinational, clinical trials of an HPV6/11/16/18 vaccine were combined. A total of 8441 healthy women aged 15–26 years underwent cervicovaginal cytology (Papanicolaou (Pap) testing) sampling and C trachomatis testing at day 1 and every 12 months thereafter for up to 4 years. Protocol-specified guidelines were used to triage participants with Pap abnormalities to colposcopy and definitive therapy. The main outcome measured was CIN.

Results

At baseline, 2629 (31.1%) tested positive for hrHPV DNA and 354 (4.2%) tested positive for C trachomatis. Among those with HPV16/18 infection (n=965; 11.4%) or without HPV16/18 infection (n=7382, 87.5%), the hazard ratios (HRs) associated with development of any CIN grade 2 according to baseline C trachomatis status were 1.82 (95% CI: 1.06 to 3.14) and 1.74 (95% CI 1.05 to 2.90), respectively. The results were comparable when only the 12 most common hrHPV infections were considered, but the excess risk disappeared when the outcome was expanded to include CIN grade 3 or worse.

Conclusion

Further studies based on larger cohorts with longitudinal follow-up in relation to the C trachomatis acquisition and a thorough evaluation of temporal relationships of infections with hrHPV types, C trachomatis and cervical neoplasia are needed to demonstrate whether and how in some situations C trachomatis sets the stage for cervical carcinogenesis.

Trial registration

NCT00092521 and NCT00092534.

The accuracy of colposcopic biopsy: analyses from the placebo arm of the Gardasil clinical trials

We evaluated the overall agreement between colposcopically directed biopsies and the definitive excisional specimens within the context of three clinical trials. A total of 737 women aged 16-45 who had a cervical biopsy taken within 6 months before their definitive therapy were included. Per-protocol, colposcopists were to also obtain a representative cervical biopsy immediately before definitive therapy. Using adjudicated histological diagnoses, the initial biopsies and the same day biopsies were correlated with the surgically excised specimens. The overall agreement between the biopsies taken within 6 months of definitive therapy, and the definitive therapy diagnoses was 42% (weighted kappa = 0.34) (95% CI: 0.29-0.39). The overall underestimation of cervical intraepithelial neoplasia grade 2/3 or adenocarcinoma in situ (CIN2-3/AIS) and CIN3/AIS was 26 and 42%, respectively. When allowing for one degree of variance in the correlation, the overall agreement was 92% for CIN2-3/AIS. The overall agreement between the same day biopsy and definitive therapy specimen was 56% (weighted kappa = 0.41) (95% CI: 0.36-0.47), and the underestimation of CIN2-3/AIS was 57%. There were significant associations in the agreement between biopsies and excisional specimen diagnoses when patients were stratified by age, number of biopsies, lesion size, presence of human papillomavirus (HPV)16/18 and region. Of 178 diagnostic endocervical curettages performed, 14 (7.9%) found any HPV disease. Colposcopic accuracy improved when CIN2 and CIN3/AIS were grouped as a single predictive measure of high-grade disease. Colposcopy functioned well when allowed a one-degree difference between the biopsy and the surgical histologic interpretations, as done in clinical practice. Taking more than one biopsy improved colposcopic accuracy and could improve patient management.

The humoral response to Gardasil over four years as defined by total IgG and competitive Luminex immunoassay

Safe and effective vaccines against anogenital human papillomaviruses (HPV) are now available. These vaccines, composed of virus-like particles (VLPs) made from the L1 major capsid protein of specific HPV types, induce a polyclonal antibody response directed against specific conformational and linear epitopes displayed on the VLP. Numerous studies indicated the importance of neutralizing antibodies in protection from infection. However, our understanding of the antibody responses to these vaccines is not complete, and there is no established immune correlate of protection nor antibody threshold that correlates with protection against HPV infection or disease. In the current study, antibody responses of young women to Gardasil®, the quadrivalent HPV 6, 11, 16 and 18 L1 VLP vaccine (qHPV), were assessed through 48 months (M) in total IgG and competitive Luminex immunoassays (total IgG LIA and cLIA). The total IgG LIA was developed as a research assay to evaluate preclinical multivalent HPV VLP vaccine formulations. The cLIA simultaneously evaluates the antibody response to a unique conformational, neutralizing epitope on each of the four HPV types present in the quadrivalent vaccine; HPV 6, 11, 16 and 18. The same sera from women vaccinated with the qHPV vaccine were tested in both the total IgG LIA and the cLIA assays. The proportion of vaccinated women achieving seropositivity and the anti-HPV VLP total IgG and cLIA geometric mean titers (GMTs) were summarized at M7, M24, M48 based on the serostatus cut-points defined for each immunoassay. Overall, greater than 99% of subjects seroconverted to all four vaccine types in both assays; GMTs peaked at M7. For all four HPV types, regardless of the immunoassay used, the most significant decline in GMTs was observed between M7 and M24. By M24, the antibody titers had reached a plateau and minimal declines in antibody titers were observed between M24 and M48 for all four HPV types in both immunoassays. Testing the same sera, seropositivity for M48 HPV18 remained high (96.7%) in the total IgG LIA, but was 64.8% in the cLIA. The current study illustrates potential important differences in serologic assays utilized in the clinical trials of the two currently available HPV VLP vaccines (quadrivalent and bivalent). Differences in seropositivity status are attributed to the measurement parameters and sensitivity of the individual immunoassays and do not indicate reduced anti-HPV18 protective antibodies.

Adenocarcinoma in situ and associated human papillomavirus type distribution observed in two clinical trials of a quadrivalent human papillomavirus vaccine

The primary objective of this report is to describe the detection of adenocarcinoma in situ (AIS) and associated human papillomavirus (HPV) type distribution that was observed in the context of two phase 3 clinical trials of a quadrivalent HPV6/11/16/18 vaccine. In this intention-to-treat analysis, we include all women who had at least one follow-up visit postenrollment. Healthy women (17,622) aged 15-26 with no history of HPV disease and a lifetime number of less than five sex partners (average follow-up of 3.6 years) were randomized (1:1) to receive vaccine or placebo at day 1, months 2, and 6. Women underwent colposcopy and biopsy according to a Papanicolaou triage algorithm. All tissue specimens were tested for 14 HPV types and were adjudicated by a pathology panel. During the trials, 22 women were diagnosed with AIS (six vaccine and 16 placebo). There were 25 AIS lesions in total, with HPV16/18 present in 96% (24 of 25 with 15 of 25 as single infections). Only two of 22 women had concomitant cytology results suggesting glandular abnormality. Colposcopic impressions (25 total) were either negative or indicated squamous lesions only. Of women with AIS, all six in the vaccine cohort and seven of 16 in the placebo cohort were infected at baseline with the same HPV type that was detected in the AIS lesion. Concurrent squamous lesions were detected in 20 of these 22 women. In summary, our findings show that AIS evades colposcopic and cervical cytologic detection. As most AIS lesions were HPV16/18-related, prophylactic HPV vaccination should reduce the incidence of invasive adenocarcinoma.

Prevalence of and risk factors for human papillomavirus (HPV) infection among HIV-seronegative men who have sex with men

BACKGROUND

We examined the baseline prevalence of penile, scrotal, perineal/perianal, and intra-anal human papillomavirus (HPV) infection in human immunodeficiency virus (HIV)-seronegative men who have sex with men (MSM).

METHODS

Data were analyzed from 602 MSM aged 16-27 years with ≤ 5 lifetime sexual partners. Serum samples were tested for antibodies to HPV6/11/16/18. Swab samples were collected separately from several anogenital areas for detection of HPV6/11/16/18/31/33/35/39/45/51/52/56/58/59 DNA.

RESULTS

The prevalence of any tested HPV type was 18.5% at the penis, 17.1% at the scrotum, 33.0% at the perineal/perianal region, 42.4% in the anal canal, and 48.0% at any site. Overall, 415 MSM (69.7%) were negative to HPV 6, 11, 16, and 18 at enrollment by both serology and DNA detection. Men residing in Europe and Latin America had significantly increased risk of HPV infection at external genital sites and the anal canal compared to men from Australia. Tobacco use and greater number of lifetime sexual partners was associated with higher HPV infection prevalence.

CONCLUSIONS

The prevalence of HPV infection is high among young sexually active MSM, with the anal canal being the most common site of infection. Lifetime number of sexual partners was the most important modifiable risk factor for anogenital HPV infection.

External genital human papillomavirus prevalence and associated factors among heterosexual men on 5 continents

BACKGROUND

We examined the baseline prevalence of penile, scrotal, and perineal/perianal human papillomavirus (HPV) in heterosexual men (HM). We also evaluated baseline characteristics of HM to assess factors associated with prevalent HPV detection.

METHODS

We tested serum samples from 3463 HM aged 16-24 years with 1-5 lifetime female sexual partners for antibodies to HPV 6, 11, 16, and 18. We collected baseline swab specimens for the detection of DNA of HPV 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 from 3 areas: penile, scrotal, and perineal/perianal. Risk factors for prevalent HPV DNA detection were evaluated.

RESULTS

The prevalence of any tested HPV type was 18.7% at the penis, 13.1% at the scrotum, 7.9% at the perineal/perianal region, and 21.0% at any site. Having >3 lifetime female sexual partners had the greatest impact on HPV prevalence: odds ratio (OR) 3.2 (95% confidence interval (CI) 2.1-4.9) for HPV 6, 11, 16, and 18; and OR 4.5 (95% CI 3.3-6.1) for all HPV types tested. HPV DNA detection was highest in Africa. Neither condom usage nor circumcision was associated with HPV DNA prevalence.

CONCLUSION

Genital-HPV DNA detection is common in young, sexually active HM. We found HPV to be most prevalent in African men and least prevalent in men from the Asia-Pacific region. Increased numbers of sexual partners was an important risk factor for HPV DNA prevalence.

Incidence, duration, and reappearance of type-specific cervical human papillomavirus infections in young women

BACKGROUND

We describe the incidence and duration of cervical human papillomavirus (HPV) infection episodes along with the risk of infection reappearance following a period of nondetection.

METHODS

Women (1,788) ages 16 to 23 years underwent cytologic testing and PCR-based testing of cervical swab samples for HPV DNA (HPV-16/18/31/33/35/45/52/58/59) at approximately 6-month intervals for up to 4 years in the context of a phase 3 clinical trial (placebo arm). HPV type-specific incidence rates were estimated per 100 person-years. Duration of type-specific cervical infection episodes and risk of reappearance following a period of nondetection were estimated using Kaplan-Meier methods.

RESULTS

HPV-16 exhibited the highest (5.9), and HPV-35 and HPV-33 exhibited the lowest (1.0) incidence rates per 100 person-years. Mean cervical infection durations ranged from 13 months for HPV-59 to 20 months for HPV-16 and 58 (with ongoing infections censored at the time of treatment, if done). The risk of cervical infection reappearance within approximately 3 years following a period of nondetection ranged from 0% to 16% across HPV types, with a mean of 8%. Limited evidence was found for a role of false-positive HPV tests, missed infections that were above the threshold for detection, or new acquisition of infection in accounting for patterns of infection reappearance.

CONCLUSIONS

Incidence of high-risk cervical infection was observed to vary considerably more across HPV types than infection duration. A nontrivial proportion of women exhibited infection reappearance following a period of nondetection, with a potential explanation for many such events observed within this analysis being a return to detectable levels of a previously acquired infection.

IMPACT

The risk of HPV infection reappearance following a period of nondetection has not been previously reported for individual HPV types, and this study finds that a nontrivial proportion of infected women exhibit reappearances. Future studies could ascertain subject-level factors that potentially modify the risk of infection reappearance.

Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial

OBJECTIVES

To evaluate the prophylactic efficacy of the human papillomavirus (HPV) quadrivalent vaccine in preventing low grade cervical, vulvar, and vaginal intraepithelial neoplasias and anogenital warts (condyloma acuminata).

DESIGN

Data from two international, double blind, placebo controlled, randomised efficacy trials of quadrivalent HPV vaccine (protocol 013 (FUTURE I) and protocol 015 (FUTURE II)). The trials were to be 4 years in length, and the results reported are from final study data of 42 months' follow-up.

SETTING

Primary care centres and university or hospital associated health centres in 24 countries and territories around the world.

PARTICIPANTS

17 622 women aged 16-26 years enrolled between December 2001 and May 2003. Major exclusion criteria were lifetime number of sexual partners (>4), history of abnormal cervical smear test results, and pregnancy.

INTERVENTION

Three doses of quadrivalent HPV vaccine (for serotypes 6, 11, 16, and 18) or placebo at day 1, month 2, and month 6.

MAIN OUTCOME MEASURES

Vaccine efficacy against cervical, vulvar, and vaginal intraepithelial neoplasia grade I and condyloma in a per protocol susceptible population that included subjects who received all three vaccine doses, tested negative for the relevant vaccine HPV types at day 1 and remained negative through month 7, and had no major protocol violations. Intention to treat, generally HPV naive, and unrestricted susceptible populations were also studied.

RESULTS

In the per protocol susceptible population, vaccine efficacy against lesions related to the HPV types in the vaccine was 96% for cervical intraepithelial neoplasia grade I (95% confidence interval 91% to 98%), 100% for both vulvar and vaginal intraepithelial neoplasia grade I (95% CIs 74% to 100%, 64% to 100% respectively), and 99% for condyloma (96% to 100%). Vaccine efficacy against any lesion (regardless of HPV type) in the generally naive population was 30% (17% to 41%), 75% (22% to 94%), and 48% (10% to 71%) for cervical, vulvar, and vaginal intraepithelial neoplasia grade I, respectively, and 83% (74% to 89%) for condyloma.

CONCLUSIONS

Quadrivalent HPV vaccine provided sustained protection against low grade lesions attributable to vaccine HPV types (6, 11, 16, and 18) and a substantial reduction in the burden of these diseases through 42 months of follow-up.

TRIAL REGISTRATIONS

NCT00092521 and NCT00092534.

Qualitative assessment of telemedicine network and computer-based telecolposcopy

OBJECTIVE

To qualitatively assess telemedicine network and computer-based telecolposcopy.

MATERIALS AND METHODS

A site expert and local colposcopist examined women presenting consecutively for colposcopic examination at 1 of 2 rural clinics. Images from the exam were transmitted to distant experts at a telemedicine center by an existing telemedicine network and computer-based telecolposcopy system. Colposcopists rated both systems with respect to complications, ease and confidence of procedure, and system resolution and visualization.

RESULTS

Rates of technically defective examinations were similar for network (25.1%) and computer-based (22.5%) telecolposcopy (p =.46). The ease of telecolposcopic examinations and colposcopists' confidence in and comfort with telecolposcopy were practically equal for both systems. Mean perceived quality of care was greater for network (3.92) compared with computer-based (3.82) telecolposcopy (Wilcoxon signed rank test, p =.03; Likert scale, 1 = minimal, 5 = maximum). Image resolution was rated better for computer-based (3.36) compared with network (3.07, p <.0001) telecolposcopy. However, visualization was better for the latter system in comparison (3.43 vs 3.07, p <.0001).

CONCLUSIONS

The quality of telecolposcopy was considered above average based on all parameters evaluated for each type of telecolposcopy. Although a few significant differences were detected, colposcopists perceived network and computer-based telecolposcopy to be very similar by subjective assessment.

Identification of cervical neoplasia using a simulation of human vision

OBJECTIVE

To determine whether a computer simulation of human vision could detect and discriminate cervical cancer precursors and cancer from normal epithelium.

METHODS

The Georgia Tech Vision (GTV) system was trained to recognize normal and abnormal cervical features. GTV then assessed a new series of images to determine whether it could detect and diagnose cervical neoplasia without any a priori information about the images.

RESULTS

After training on one set and testing on another set of images, GTV demonstrated 100% sensitivity and 98% specificity to detect cervical intraepithelial neoplasia 3 (CIN3). GTV also had 88% sensitivity and 93% specificity to detect cervical cancer following training on one set and testing on another set of digitized cervical colposcopic images.

CONCLUSION

This study demonstrated that GTV can detect CIN3 and cancer from digitized cervical colposcopic images. Furthermore, GTV could discriminate cervical cancer precursors and cancer from normal cervical epithelium, including immature metaplasia.

Use of the VS-sense swab in diagnosing vulvovaginitis

BACKGROUND

Although pH assessment of vaginal secretions is beneficial for diagnosing vaginitis, it is not commonly done. The purpose of this study was to determine the performance characteristics of the VS-Sense (pH test) swab (Common Sense, Ltd., Caesarea, Israel) in augmenting the diagnosis of vaginitis.

METHODS

We prospectively studied 193 women with acute vulvovaginal symptoms and 74 asymptomatic controls at three medical centers. The VS-Sense swab was administered intravaginally, and results were interpreted by a nurse. These results were compared with final clinical and laboratory diagnoses.

RESULTS

In women with an elevated pH caused by bacterial vaginosis (BV), trichomonas, and other types of vaginitis, the VS-Sense test sensitivity and specificity were 82.3% (102 of 124) (95% CI 74.4%-88.5%) and 94.2% (129 of 137) (95% CI 88.8%-97.4%), respectively. There was an 86.2% (95% CI 81.3%-90.1%) overall agreement between pH paper and VS-Sense swab results.

CONCLUSIONS

The VS-Sense test offers an alternative approach to measuring vaginal pH with nitrazine paper. Use of this simple, more rapid test may facilitate the diagnosis of vulvovaginitis.

Development and psychometric properties of the HPV Impact Profile (HIP) to assess the psychosocial burden of HPV

OBJECTIVE

A comprehensive questionnaire designed to assess the full spectrum of potential human papillomavirus (HPV)-related psychosocial effects in women does not exist. The HPV Impact Profile (HIP) was developed to determine the psychosocial impact of HPV infection and related interventions.

RESEARCH DESIGN AND METHODS

Draft instrument items and domains were developed using a literature review and cognitive debriefing interviews with women who had experienced HPV-related conditions. An importance rating questionnaire guided item ranking and reduction. A draft questionnaire was pilot-tested for comprehension and ease of completion. Psychometric evaluation of the final HIP was conducted in a survey of 583 women. Data quality, item acceptability, scale acceptability, reliability, and discriminate construct validity were assessed.

OUTCOME MEASURE

The final HIP contained 29 items rated on a 0-10 point discretized visual analog scales grouped into seven hypothesized domains.

RESULTS

Total HIP scores ranged from 0 (no impact) to 100 (worst impact). Data quality was high, with missing data for items ranging from 0 to 0.7% and over 99% of the scores were computable. Cronbach's alpha ranged from 0.64 to 0.90 and was > or =0.7 for 5/7 domains. Discriminant construct validity was demonstrated. Appropriate modifications could potentially be made to improve some aspects of the HIP, including modification to include other HPV diseases such as head and neck, anal, and vulvovaginal cancers and HPV disease in men.

CONCLUSIONS

The disease-specific HIP has favorable reliability and construct validity and a good ability to discriminate among disease severity.

Evaluation of quadrivalent HPV 6/11/16/18 vaccine efficacy against cervical and anogenital disease in subjects with serological evidence of prior vaccine type HPV infection

OBJECTIVE

In the quadrivalent (types 6/11/16/18) HPV vaccine (GARDASIL/SILGARD) clinical program, 73% of women aged 16-26 were naïve to all vaccine HPV types. In these women, prophylactic administration of the vaccine was highly effective in preventing HPV 6/11/16/18-related cervical disease. Of the remaining women, 15% of had evidence of past infection with one or more vaccine HPV types (seropositive and DNA negative) at the time of enrollment. Here we present an analysis in this group of women to determine the efficacy of the HPV 6/11/16/18 vaccine against new cervical and external anogenital disease related to the same vaccine HPV type which had previously been cleared. Vaccine tolerability in this previously infected population was also assessed.

METHODS

18,174 women were enrolled into 3 clinical studies. The data presented comprise a subset of these subjects (n = 2,617) who were HPV seropositive and DNA negative at enrollment (for >or=1 vaccine type). In each study, subjects were randomized in a 1:1 ratio to receive HPV 6/11/16/18 vaccine or placebo at day 1, month 2 and month 6 (without knowledge of baseline HPV status). Procedures performed for efficacy data evaluation included detailed genital examination, Pap testing, and collection of cervicovaginal and external genital specimens. Analyses of efficacy were carried out in a population stratified by HPV serology and HPV DNA status at enrollment.

RESULTS

Subjects were followed for an average of 40 months. Seven subjects in the placebo group developed cervical disease, and eight subjects developed external genital disease related to a vaccine HPV type they had previously encountered. No subject receiving HPV 6/11/16/18 vaccine developed disease to a vaccine HPV type to which they were seropositive and DNA negative at enrolment.

CONCLUSIONS

These results suggest that natural HPV infection-elicited antibodies may not provide complete protection over time, however the immune response to the HPV 6/11/16/18 vaccine appears to prevent reinfection or reactivation of disease with vaccine HPV types. Vaccine-related adverse experiences were higher among subjects receiving vaccine, mostly due to increased injection site adverse experiences.

A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (Types 6/11/16/18) vaccine against high-grade cervical and external genital lesions

Quadrivalent human papillomavirus (HPV) vaccine has been shown to provide protection from HPV 6/11/16/18-related cervical, vaginal, and vulvar disease through 3 years. We provide an update on the efficacy of the quadrivalent HPV vaccine against high-grade cervical, vaginal, and vulvar lesions based on end-of-study data from three clinical trials. Additionally, we stratify vaccine efficacy by several baseline characteristics, including age, smoking status, and Papanicolaou (Pap) test results. A total of 18,174 females ages 16 to 26 years were randomized and allocated into one of three clinical trials (protocols 007, 013, and 015). Vaccine or placebo was given at baseline, month 2, and month 6. Pap testing was conducted at regular intervals. Cervical and anogenital swabs were collected for HPV DNA testing. Examination for the presence of vulvar and vaginal lesions was also done. Endpoints included high-grade cervical, vulvar, or vaginal lesions (CIN 2/3, VIN 2/3, or VaIN 2/3). Mean follow-up time was 42 months post dose 1. Vaccine efficacy against HPV 6/11/16/18-related high-grade cervical lesions in the per-protocol and intention-to-treat populations was 98.2% [95% confidence interval (95% CI), 93.3-99.8] and 51.5% (95% CI, 40.6-60.6), respectively. Vaccine efficacy against HPV 6/11/16/18-related high-grade vulvar and vaginal lesions in the per-protocol and intention-to-treat populations was 100.0% (95% CI, 82.6-100.0) and 79.0% (95% CI, 56.4-91.0), respectively. Efficacy in the intention-to-treat population tended to be lower in older women, women with more partners, and women with abnormal Pap test results. The efficacy of quadrivalent HPV vaccine against high-grade cervical and external anogenital neoplasia remains high through 42 months post vaccination.

Large-scale analysis of protein expression changes in human keratinocytes immortalized by human papilloma virus type 16 E6 and E7 oncogenes

Background

Infection with high-risk type human papilloma viruses (HPVs) is associated with cervical carcinomas and with a subset of head and neck squamous cell carcinomas. Viral E6 and E7 oncogenes cooperate to achieve cell immortalization by a mechanism that is not yet fully understood. Here, human keratinocytes were immortalized by long-term expression of HPV type 16 E6 or E7 oncoproteins, or both. Proteomic profiling was used to compare expression levels for 741 discrete protein features.

Results

Six replicate measurements were performed for each group using two-dimensional difference gel electrophoresis (2D-DIGE). The median within-group coefficient of variation was 19–21%. Significance of between-group differences was tested based on Significance Analysis of Microarray and fold change. Expression of 170 (23%) of the protein features changed significantly in immortalized cells compared to primary keratinocytes. Most of these changes were qualitatively similar in cells immortalized by E6, E7, or E6/7 expression, indicating convergence on a common phenotype, but fifteen proteins (~2%) were outliers in this regulatory pattern. Ten demonstrated opposite regulation in E6- and E7-expressing cells, including the cell cycle regulator p16^INK4a; the carbohydrate binding protein Galectin-7; two differentially migrating forms of the intermediate filament protein Cytokeratin-7; HSPA1A (Hsp70-1); and five unidentified proteins. Five others had a pattern of expression that suggested cooperativity between the co-expressed oncoproteins. Two of these were identified as forms of the small heat shock protein HSPB1 (Hsp27).

Conclusion

This large-scale analysis provides a framework for understanding the cooperation between E6 and E7 oncoproteins in HPV-driven carcinogenesis.

The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in generally HPV-naive women aged 16-26 years

BACKGROUND

Human papillomavirus (HPV)-6/11/16/18 vaccine reduces the risk of HPV-6/11/16/18-related cervical intraepithelial neoplasia (CIN) 1-3 or adenocarcinoma in situ (AIS). Here, its impact on CIN1-3/AIS associated with nonvaccine oncogenic HPV types was evaluated.

METHODS

We enrolled 17,622 women aged 16-26 years. All underwent cervicovaginal sampling and Pap testing at regular intervals for up to 4 years. HPV genotyping was performed for biopsy samples, and histological diagnoses were determined by a pathology panel. Analyses were conducted among subjects who were negative for 14 HPV types on day 1. Prespecified analyses included infection of 6 months' duration and CIN1-3/AIS due to the 2 and 5 most common HPV types in cervical cancer after HPV types 16 and 18, as well as all tested nonvaccine types.

RESULTS

Vaccination reduced the incidence of HPV-31/45 infection by 40.3% (95% confidence interval [CI], 13.9% to 59.0%) and of CIN1-3/AIS by 43.6% (95% CI, 12.9% to 64.1%), respectively. The reduction in HPV-31/33/45/52/58 infection and CIN1-3/AIS was 25.0% (95% CI, 5.0% to 40.9%) and 29.2% (95% CI, 8.3% to 45.5%), respectively. Efficacy for CIN2-3/AIS associated with the 10 nonvaccine HPV types was 32.5% (95% CI, 6.0% to 51.9%). Reductions were most notable for HPV-31.

CONCLUSIONS

HPV-6/11/16/18 vaccine reduced the risk of CIN2-3/AIS associated with nonvaccine types responsible for approximately 20% of cervical cancers. The clinical benefit of cross-protection is not expected to be fully additive to the efficacy already observed against HPV-6/11/16/18-related disease, because women may have >1 CIN lesion, each associated with a different HPV type.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT00092521 , NCT00092534 , and NCT00092482.

The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in sexually active women aged 16-26 years

BACKGROUND

We evaluated the impact of a quadrivalent human papillomavirus (HPV) vaccine on infection and cervical disease related to 10 nonvaccine HPV types (31, 33, 35, 39, 45, 51, 52, 56, 58, and 59) associated with >20% of cervical cancers. The population evaluated included HPV-naive women and women with preexisting HPV infection and/or HPV-related disease at enrollment.

METHODS

Phase 3 efficacy studies enrolled 17,622 women aged 16-26 years. Subjects underwent cervicovaginal sampling and Pap testing on day 1 and then at 6-12-month intervals for up to 4 years. HPV typing was performed on samples from enrollment and follow-up visits, including samples obtained for diagnosis or treatment of HPV-related disease. All subjects who received 1 dose and returned for follow-up were included.

RESULTS

Vaccination reduced the rate of HPV-31/33/45/52/58 infection by 17.7% (95% confidence interval [CI], 5.1% to 28.7%) and of cervical intraepithelial neoplasia (CIN) 1-3 or adenocarcinoma in situ (AIS) by 18.8% (95% CI, 7.4% to 28.9%). Vaccination also reduced the rate of HPV-31/58/59-related CIN1-3/AIS by 26.0% (95% CI, 6.7% to 41.4%), 28.1% (95% CI, 5.3% to 45.6%), and 37.6% (95% CI, 6.0% to 59.1%), respectively. Although a modest reduction in HPV-31/33/45/52/58-related CIN2 or worse was observed, the estimated reduction was not statistically significant.

CONCLUSIONS

These cross-protection results complement the vaccine's prophylactic efficacy against disease associated with HPV-6, -11, -16, and -18. Long-term monitoring of vaccinated populations are needed to fully ascertain the population-based impact and public health significance of these findings.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT00092521 , NCT00092534 , and NCT00092482.

Using acetowhite opacity index for detecting cervical intraepithelial neoplasia

Cervical intraepithelial neoplasia (CIN) exhibits certain morphologic features that can be identified during a colposcopic exam. Immature metaplastic and dysplastic cervical squamous epithelia turn white after application of acetic acid during the exam. The whitening process occurs visually over several minutes and subjectively helps to discriminate between dysplastic and normal tissue. Digital imaging technologies enable us to assist the physician in analyzing acetowhite (acetic-acid-induced) lesions in a fully automatic way. We report a study designed to measure multiple parameters of the acetowhitening process from two images captured with a digital colposcope. One image is captured before the acetic acid application, and the other is captured after the acetic acid application. The spatial change of the acetowhitening is extracted using color and texture information in the post-acetic-acid image; the temporal change is extracted from the intensity and color changes between the post-acetic-acid and pre-acetic-acid images with an automatic alignment. In particular, we propose an automatic means to calculate an opacity index that indicates the grades of temporal change. The imaging and data analysis system is evaluated with a total of 99 human subjects. The proposed opacity index demonstrates a sensitivity and specificity of 94 and 87%, respectively, for discriminating high-grade dysplasia (CIN2+) from normal and low-grade subjects, considering histology as the gold standard.

HPV antibody levels and clinical efficacy following administration of a prophylactic quadrivalent HPV vaccine

The efficacy of the quadrivalent Human Papillomavirus (HPV) vaccine is thought to be mediated by humoral immunity. We evaluated the correlation between quadrivalent HPV vaccine-induced serum anti-HPV responses and efficacy. 17,622 women were vaccinated at day 1, and months 2 and 6. At day 1 and at 6-12 months intervals for up to 48 months, subjects underwent Papanicolaou and genital HPV testing. No immune correlate of protection could be found due to low number of cases. Although 40% of vaccine subjects were anti-HPV 18 seronegative at end-of-study, efficacy against HPV 18-related disease remained high (98.4%; 95% CI: 90.5-100.0) despite high attack rates in the placebo group. These results suggest vaccine-induced protection via immune memory, or lower than detectable HPV 18 antibody titers.

Effectiveness of Two Tinidazole Regimens in Treatment of Bacterial Vaginosis

OBJECTIVE

To assess the effectiveness at 21-30 days after treatment of tinidazole administered orally at 1 g once daily for 5 days and 2 g once daily for 2 days, compared with placebo, in the treatment of bacterial vaginosis, using rigorous U.S. Food and Drug Administration (FDA)-recommended criteria to define cure.

METHODS

A total of 235 women at 10 U.S. centers participated in this prospective, randomized, double-blinded, placebo-controlled trial. Presence or absence of all five following criteria was required to define diagnosis or cure of bacterial vaginosis: 1) clue cells were at least 20% of squamous cells in microscopic examination of vaginal fluid; 2) positive potassium hydroxide whiff test; 3) a homogeneous, thin, white-gray vaginal discharge; 4) vaginal pH greater than 4.5; and 5) Nugent score greater than or equal to 4 on Gram-stained vaginal fluid. Compliance, tolerability, and safety were assessed using patient diaries and interviews at 8-10 days and 21-30 days after treatment. Cochran-Mantel-Haenszel statistical analysis with Bonferroni adjustment was used to compare outcomes.

RESULTS

Superior efficacy was demonstrated by tinidazole for the 1 g once daily for 5 days regimen (36.8% cured, P<.001, number needed to treat 3.2) and for the 2 g once daily for 2 days regimen (27.4% cured, P<.001, number needed to treat 4.5), when compared with placebo (5.1% cured) in the primary endpoint analysis. Using more traditional criteria for cure, efficacy was greater. Compliance with study therapy and tolerability were comparable in the three treatment groups.

CONCLUSION

Both tinidazole regimens studied provided effective treatment for bacterial vaginosis.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00229216

LEVEL OF EVIDENCE

I.

Midadult Women's Attitudes About Receiving the Prophylactic Human Papillomavirus Vaccine

OBJECTIVE

To determine midadult (age, > or =25 years) women's attitudes about receiving the prophylactic human papillomavirus (HPV) vaccine.

MATERIALS AND METHODS

Four hundred seventy-two women 25 years or older completed a 46-question survey, read an educational sheet about HPV and HPV vaccines, and then completed a 23-item survey. Frequency data were reported, and interventional effects measured by Bowker test of symmetry.

RESULTS

After educational intervention, 50% of mid-adult women wanted to receive the vaccine, and 34.3% were undecided. A desire to be healthy (48.9%), prevent cervical cancer (42.8%), and fear of cervical cancer (35.8%) were the most common reasons for wanting the vaccine. The main reasons for not wanting the vaccine included being in a monogamous relationship (29.5%), not being at risk for acquiring HPV (15.0%), and practicing safe sex (10.8%).

CONCLUSIONS

Midadult women have a high level of acceptance for the HPV vaccine. Our findings help support future implementation of the vaccine in this catch-up population of receptive women.

Efficacy of a quadrivalent prophylactic human papillomavirus (types 6, 11, 16, and 18) L1 virus-like-particle vaccine against high-grade vulval and vaginal lesions: a combined analysis of three randomised clinical trials

BACKGROUND

Vulval and vaginal cancers among younger women are often related to infection with human papillomavirus (HPV). These cancers are preceded by high-grade vulval intraepithelial neoplasia (VIN2-3) and vaginal intraepithelial neoplasia (VaIN2-3). Our aim was to do a combined analysis of three randomised clinical trials to assess the effect of a prophylactic quadrivalent HPV vaccine on the incidence of these diseases.

METHODS

18 174 women (16-26 years) were enrolled and randomised to receive either quadrivalent HPV6/11/16/18 L1 virus-like-particle vaccine or placebo at day 1, and months 2 and 6. Individuals underwent detailed anogenital examination at day 1, 1 month after dose three, and at 6-12-month intervals for up to 48 months. Suspect genital lesions were biopsied and read by a panel of pathologists and vaccine HPV type-specific DNA testing was done. The primary endpoint was the combined incidence of VIN2-3 or VaIN2-3 associated with HPV16 or HPV18. Primary efficacy analyses were done in a per-protocol population.

FINDINGS

The mean follow-up time was 3 years. Among women naive to HPV16 or HPV18 through 1 month after dose three (per-protocol population; vaccine n=7811; placebo n=7785), the vaccine was 100% effective (95% CI 72-100) against VIN2-3 or VaIN2-3 associated with HPV16 or HPV18. In the intention-to-treat population (which included 18 174 women who, at day 1, could have been infected with HPV16 or HPV18), vaccine efficacy against VIN2-3 or VaIN2-3 associated with HPV16 or HPV18 was 71% (37-88). The vaccine was 49% (18-69) effective against all VIN2-3 or VaIN2-3, irrespective of whether or not HPV DNA was detected in the lesion. The most common treatment-related adverse event was injection-site pain.

INTERPRETATION

Prophylactic administration of quadrivalent HPV vaccine was effective in preventing high-grade vulval and vaginal lesions associated with HPV16 or HPV18 infection in women who were naive to these types before vaccination. With time, such vaccination could result in reduced rates of HPV-related vulval and vaginal cancers.

Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases

BACKGROUND

A phase 3 trial was conducted to evaluate the efficacy of a prophylactic quadrivalent vaccine in preventing anogenital diseases associated with human papillomavirus (HPV) types 6, 11, 16, and 18.

METHODS

In this randomized, placebo-controlled, double-blind trial involving 5455 women between the ages of 16 and 24 years, we assigned 2723 women to receive vaccine and 2732 to receive placebo at day 1, month 2, and month 6. The coprimary composite end points were the incidence of genital warts, vulvar or vaginal intraepithelial neoplasia, or cancer and the incidence of cervical intraepithelial neoplasia, adenocarcinoma in situ, or cancer associated with HPV type 6, 11, 16, or 18. Data for the primary analysis were collected for a per-protocol susceptible population of women who had no virologic evidence of HPV type 6, 11, 16, or 18 through 1 month after administration of the third dose.

RESULTS

The women were followed for an average of 3 years after administration of the first dose. In the per-protocol population, those followed for vulvar, vaginal, or perianal disease included 2261 women (83%) in the vaccine group and 2279 (83%) in the placebo group. Those followed for cervical disease included 2241 women (82%) in the vaccine group and 2258 (83%) in the placebo group. Vaccine efficacy was 100% for each of the coprimary end points. In an intention-to-treat analysis, including those with prevalent infection or disease caused by vaccine-type and non-vaccine-type HPV, vaccination reduced the rate of any vulvar or vaginal perianal lesions regardless of the causal HPV type by 34% (95% confidence interval [CI], 15 to 49), and the rate of cervical lesions regardless of the causal HPV type by 20% (95% CI, 8 to 31).

CONCLUSIONS

The quadrivalent vaccine significantly reduced the incidence of HPV-associated anogenital diseases in young women. (ClinicalTrials.gov number, NCT00092521 [ClinicalTrials.gov].).

Noninferiority of antibody response to human papillomavirus type 16 in subjects vaccinated with monovalent and quadrivalent L1 virus-like particle vaccines

The incorporation of multiple antigens into a single human papillomavirus (HPV) vaccine may induce immune interference. To evaluate whether interference occurs when HPV type 16 (HPV16) virus-like particles are combined in a multivalent vaccine, we conducted a study to evaluate anti-HPV16 responses among subjects receiving three-dose regimens of either a monovalent HPV16 vaccine or a quadrivalent HPV (types 6, 11, 16, and 18) vaccine.

American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors

The American Cancer Society (ACS) has developed guidelines for the use of the prophylactic human papillomavirus (HPV) vaccine for the prevention of cervical intraepithelial neoplasia and cervical cancer. These recommendations are based on a formal review of the available evidence. They address the use of prophylactic HPV vaccines, including who should be vaccinated and at what age, as well as a summary of policy and implementation issues. Implications for screening are also discussed.

Variability of vaginal pH determination by patients and clinicians

PURPOSE

Measurement of intravaginal pH provides a reasonable assessment of vaginal health but is fraught with the potential for several sampling errors. The purposes of the study were to determine the variability of self-sampled vaginal pH among women using an inexpensive swab-based pH test compared with a clinician-obtained specimen, and variability of vaginal pH within 3 regions of the normal vagina.

METHODS

In this cross-sectional study, women obtained a vaginal specimen using a cotton-tip applicator, transferred it to pH paper, and interpreted the results. A clinician also blindly interpreted these tests. Thereafter, a clinician obtained 3 swab specimens from the proximal, middle, and distal vagina for pH testing. Results were compared using Wilcoxon signed rank test, interclass correlation coefficients, Bland-Altman plots, and mixed-model analysis of variance.

RESULTS

Interclass correlation coefficients were moderately high comparing subjects with clinician for the swab-based pH test (0.74). Subjects' swab pH values (4.5) were significantly lower than clinicians' pH values (4.7, P = .0001). Intravaginal pH did not vary between the 3 anatomic locations.

CONCLUSIONS

Self-sampled intravaginal pH interpretations vary slightly compared with clinician-obtained specimens. Because swab pH sampling does not detect an intravaginal pH gradient in normal women, self-sampling technique may vary considerably without affecting outcomes. Our findings support self-sampling for vaginal pH before using over-the-counter products for presumed vaginitis.

Smokers at Higher Risk for Undetected Antibody for Oncogenic Human Papillomavirus Type 16 Infection

OBJECTIVE

To determine the association between tobacco smoking and serologic evidence of human papillomavirus type 16 (HPV16)-specific antibodies among HPV16 DNA-positive women.

DESIGN, SETTING, AND PARTICIPANTS

Baseline health history, physical examination, and laboratory data for 205 HPV16 DNA-positive women with no prior cytologic evidence of squamous intraepithelial lesions who were enrolled subsequently in a randomized clinical trial.

MAIN OUTCOME MEASURE

HPV16-L1 antibody (anti-HPV16 antibody) detected from serum using RIA or ELISA.

RESULTS

Eighty-seven percent (179 of 205) of women tested positive for HPV16 DNA using cervicovaginal swabs or lavage specimens, and 26 women showed similar results using swab specimens of external genitalia alone. HPV16-infected women who reported increasingly greater levels of daily cigarette smoking were less likely to test positive for anti-HPV16 antibodies than nonsmoking women (P = 0.02). Smokers were twice as likely as nonsmokers to test negative for anti-HPV16 antibodies, even after controlling for the effects of other covariates in the analyses (adjusted odds ratio, 0.5; 95% confidence limits, 0.2-0.9). Although Papanicolaou test findings and smoking characteristics were poorly correlated (r(2) = 0.01), women who showed atypical cells of unknown significance or squamous intraepithelial lesion were twice as likely to test anti-HPV16 antibody positive as women who showed normal Papanicolaou tests (adjusted odds ratio, 2.0; 95% confidence limits, 1.1-3.7).

CONCLUSION

These data suggest that smoking may influence the long-term risk for cancer by perturbing early immune responses to the virus and may increase the likelihood of persistent infection. Patient education messages should alert women to this additional risk of smoking. A clinical trial of smoking cessation should be explored as a therapeutic intervention for primary HPV16 infection.

Prediction of cervical histologic results using an abbreviated Reid Colposcopic Index during ALTS

OBJECTIVE

The purpose of this study was to determine the accuracy of an abbreviated Reid Colposcopic Index (RCI) to detect cervical intraepithelial neoplasia (CIN) 2 and CIN 3 during the National Cancer Institute (NCI) ASCUS LSIL Triage Study (ALTS).

STUDY DESIGN

Colposcopists from 4 ALTS clinical centers indicated an RCI score after colposcopically examining subjects. Colposcopy quality control reviewers also documented an RCI score for the same subjects after assessing their digitized cervical images. Associations of colposcopist and reviewer RCI scores with histologic results were evaluated. Agreement rates between colposcopists and reviewers were calculated for colposcopic impression.

RESULTS

Overall RCI score agreement was poor (weighted Kappa = 0.17). The sensitivity, specificity, positive and negative predictive values of a colposcopist's RCI score of >3/6 to detect CIN 3 or worse were 37.3% (95% CI 32.5%-42.3%), 89.7% (88.6%-90.8%), 30.8% (26.7%-35.2%), and 92.1% (91.1%-93.0%), respectively. The 3 colposcopic signs were not individually sensitive in detecting CIN 3.

CONCLUSION

Colposcopists using the RCI in the ALTS trial failed to detect CIN 2/3 at the levels expected.