Association of Inadvertent 9-Valent Human Papillomavirus Vaccine in Pregnancy With Spontaneous Abortion and Adverse Birth Outcomes

Defining and reporting adverse events of special interest in comparative maternal vaccine studies: a systematic review

Introduction

The GAIA (Global Alignment on Immunisation Safety Assessment in Pregnancy) consortium was established in 2014 with the aim of creating a standardised, globally coordinated approach to monitoring the safety of vaccines administered in pregnancy. The consortium developed twenty-six standardised definitions for classifying obstetric and infant adverse events. This systematic review sought to evaluate the current state of adverse event reporting in maternal vaccine trials following the publication of the case definitions by GAIA, and the extent to which these case definitions have been adopted in maternal vaccine safety research.

Methods

A comprehensive search of published literature was undertaken to identify maternal vaccine research studies. PubMed, EMBASE, Web of Science, and Cochrane were searched using a combination of MeSH terms and keyword searches to identify observational or interventional studies that examined vaccine safety in pregnant women with a comparator group. A two-reviewer screening process was undertaken, and a narrative synthesis of the results presented.

Results

14,737 titles were identified from database searches, 435 titles were selected as potentially relevant, 256 were excluded, the remaining 116 papers were included. Influenza vaccine was the most studied (25.0%), followed by TDaP (20.7%) and SARS-CoV-2 (12.9%).Ninety-one studies (78.4%) were conducted in high-income settings. Forty-eight (41.4%) utilised electronic health-records. The majority focused on reporting adverse events of special interest (AESI) in pregnancy (65.0%) alone or in addition to reactogenicity (27.6%). The most frequently reported AESI were preterm birth, small for gestational age and hypertensive disorders. Fewer than 10 studies reported use of GAIA definitions. Gestational age assessment was poorly described; of 39 studies reporting stillbirths 30.8% provided no description of the gestational age threshold.

Conclusions

Low-income settings remain under-represented in comparative maternal vaccine safety research. There has been poor uptake of GAIA case definitions. A lack of harmonisation and standardisation persists limiting comparability of the generated safety data.

Strategies for Improving Vaccine Communication and Uptake

Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.

Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes

BACKGROUND

Ectopic pregnancy is a major contributor to maternal morbidity and mortality across the globe.

OBJECTIVE

This study aims to investigate the clinical benefits of laparoscopic surgery in treating ectopic pregnancy, and its impact on tubal patency and reproductive outcomes.

METHODS

A clinical study was conducted to compare laparoscopic and medical conservative treatment for ectopic pregnancy. A total of 206 patients were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among them, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication.

RESULTS

The age range and average age of each group are provided, with no significant differences in these general demographic characteristics (p> 0.05). Both the salpingostomy and medication groups had higher rates of ectopic pregnancy compared to the salpingectomy group, with statistically significant differences (p< 0.05). The comparison of ectopic pregnancy rates between the salpingostomy and medication groups showed no significant difference. Within three years, the salpingostomy group had 10 cases of recurrent ectopic pregnancy, with 2 cases on the same side, while the medication group had 18 cases, with 8 cases on the same side. At 3 months after the normalization of blood β-HCG, the salpingostomy group showed 43 cases of tubal patency (patency rate: 79.63%), while the medication group showed 57 cases (patency rate: 53.77%), with a statistically significant difference between the two groups (p= 0.01).

CONCLUSION

Laparoscopic surgery for ectopic pregnancy offers significant clinical benefits over conservative medical treatment, including higher rates of tubal patency and improved reproductive outcomes. These findings support laparoscopic surgery as an effective approach for the management of ectopic pregnancy.

Safety of hepatitis E vaccination for pregnancy: a post-hoc analysis of a randomized, double-blind, controlled phase 3 clinical trial

Special attention has been paid to Hepatitis E (HE) prophylaxis for pregnant women due to poor prognosis of HE in this population. We conducted a post-hoc analysis based on the randomized, double-blind, HE vaccine (Hecolin)-controlled phase 3 clinical trial of human papillomavirus (HPV) vaccine (Cecolin) conducted in China. Eligible healthy women aged 18-45 years were randomly assigned to receive three doses of Cecolin or Hecolin and were followed up for 66 months. All the pregnancy-related events throughout the study period were closely followed up. The incidences of adverse events, pregnancy complications, and adverse pregnancy outcomes were analysed based on the vaccine group, maternal age, and interval between vaccination and pregnancy onset. During the study period, 1263 Hecolin receivers and 1260 Cecolin receivers reported 1684 and 1660 pregnancies, respectively. The participants in the two vaccine groups showed similar maternal and neonatal safety profiles, regardless of maternal age. Among the 140 women who were inadvertently vaccinated during pregnancy, the incidences of adverse reactions had no statistical difference between the two groups (31.8% vs 35.1%, p = 0.6782). The proximal exposure to HE vaccination was not associated with a significantly higher risk of abnormal foetal loss (OR 0.80, 95% CI 0.38-1.70) or neonatal abnormality (OR 2.46, 95% CI 0.74-8.18) than that to HPV vaccination, as did distal exposure. Significant difference was not noted between pregnancies with proximal and distal exposure to HE vaccination. Conclusively, HE vaccination during or shortly before pregnancy is not associated with increased risks for both the pregnant women and pregnancy outcomes.

Human Papillomavirus Vaccines

Human papillomavirus (HPV) vaccines are highly effective in preventing the transmission of HPV and thus downstream HPV-related lower genital tract neoplasias. First introduced in 2006, the HPV vaccine has demonstrated clinical efficacy in both men and women. Several commercially available vaccines now exist, but only one is available in the United States. Both prelicensure and postlicensure studies demonstrate robust safety profiles. HPV vaccines should be made available to everyone between the ages of 9 and 26 years of age. Newer vaccination recommendations in expanded populations rely on patient-provider shared decision making. Currently, available HPV vaccines offer little therapeutic benefit. Recent research has identified several new DNA vaccines and delivery modifications with early demonstrated success at eliminating prevalent HPV infections and precancerous lesions. Despite the success of the HPV vaccine, vaccination hesitancy and disinformation continue to threaten our ability to eliminate these deadly cancers. Informational, behavioral, and environmental interventions have mixed success in increasing vaccination rates, but several strategies do exist to increase rates of vaccination.

Association of periconceptional or pregnancy exposure of HPV vaccination and adverse pregnancy outcomes: a systematic review and meta-analysis with trial sequential analysis

Objective: To evaluate whether periconceptional or pregnancy exposure of human papillomavirus (HPV) vaccination would increase the risk of adverse pregnancy outcomes. Methods: The PubMed, Web of Science, Embase, the Cochrane Library of clinical trials were searched from inception to March 2023. We computed relative risk (RR) and 95% confidence intervals (CIs) and prediction intervals (PIs) regarding the association between HPV vaccination in periconceptional period or during pregnancy and the risks of adverse pregnancy outcomes by using R software Version 4.1.2 and STATA Version 12.0. A trial sequential analysis (TSA) was performed with TSA v0.9.5.10 Beta software. Results: Four randomized controlled trials (RCTs) and eight cohort studies were included in this meta-analysis. Analysis of RCTs showed that HPV vaccination in periconceptional period or during pregnancy did not increase the risks of spontaneous abortion (RR = 1.152, 95% CI: 0.909-1.460, 95% PI: 0.442-3.000), birth defects (RR = 1.171, 95% CI: 0.802-1.709, 95% PI: 0.320-4.342), stillbirth (RR = 1.053, 95% CI: 0.616-1.800, 95% PI: 0.318-3.540), preterm birth (RR = 0.940, 95% CI: 0.670-1.318) and ectopic pregnancy (RR = 0.807, 95% CI: 0.353-1.842, 95% PI: 0.128-5.335). In cohort studies, periconceptional or pregnancy exposures of HPV vaccine were not associated with the increased risk of spontaneous abortion (RR = 0.987, 95% CI: 0.854-1.140, 95% PI: 0.652-1.493), birth defects (RR = 0.960, 95% CI: 0.697-1.322, 95% PI: 0.371-2.480), stillbirth (RR = 1.033, 95% CI: 0.651-1.639, 95% PI: 0.052-21.064), small size for gestational age (SGA) (RR = 0.971, 95% CI: 0.873-1.081, 95% PI: 0.657-1.462) and preterm birth (RR = 0.977, 95% CI: 0.874-1.092, 95% PI: 0.651-1.444). Conclusion: HPV vaccine exposures in periconceptional period or during pregnancy did not increase the risks of adverse pregnancy outcomes, including spontaneous abortion, birth defects, stillbirth, SGA, preterm birth and ectopic pregnancy. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023399777.

Post-marketing surveillance for the safety of the 9-valent human papillomavirus vaccine: a retrospective real-world study in China

BACKGROUND

The 9-valent human papillomavirus (9vHPV) vaccine was introduced in China in 2018. This study was conducted to monitor the occurrence of new-onset autoimmune diseases (AIs) in Chinese women vaccinated with the 9vHPV vaccine and adverse pregnancy outcomes in infants born to mothers with inadvertent pregnancy exposure.

RESEARCH DESIGN AND METHODS

Women who received the first dose of the 9vHPV vaccine at age 16-26 years in Ningbo between January 2019 and March 2021 were monitored in the Ningbo Regional Health Information Platform. New-onset cases of seven pre-specified AIs diagnosed within six months after vaccination were collected. Cases of stillbirth and 23 major congenital anomalies diagnosed within three months of birth in target infants were collected.

RESULTS

A total of 102,670 doses of the 9vHPV vaccine were administered to 41,609 women who had received no other HPV vaccine. New-onset AIs were diagnosed in 36 women, comprising 21 Hashimoto's, 11 Graves', and 4 uveitis disease cases. Among 50 women with maternal vaccination exposure, no stillbirths were observed. One case of microtia was observed.

CONCLUSIONS

In this first post-marketing surveillance of the 9vHPV vaccine in China, no safety signals were identified when putting the results in context to published data.

Use of Population-Level Administrative Data in Developmental Science

Population-level administrative data-data on individuals' interactions with administrative systems (e.g., health, criminal justice, and education)-have substantially advanced our understanding of life-course development. In this review, we focus on five areas where research using these data has made significant contributions to developmental science: (a) understanding small or difficult-to-study populations, (b) evaluating intergenerational and family influences, (c) enabling estimation of causal effects through natural experiments and regional comparisons, (d) identifying individuals at risk for negative developmental outcomes, and (e) assessing neighborhood and environmental influences. Further advances will be made by linking prospective surveys to administrative data to expand the range of developmental questions that can be tested; supporting efforts to establish new linked administrative data resources, including in developing countries; and conducting cross-national comparisons to test findings' generalizability. New administrative data initiatives should involve consultation with population subgroups including vulnerable groups, efforts to obtain social license, and strong ethical oversight and governance arrangements.

Human papillomavirus (HPV) in pregnancy - An update

Human papilloma viruses (HPV) are small epitheliotropic DNA viruses, of which there are 200 genotypes, 40 of which are known to cause genital infections and are also oncogenic. HPV is the most common sexually transmitted infection. Clinical features vary from asymptomatic (identified at routine cervical cancer screening) to large lesions on the vulva, vagina, cervix and some extragenital sites. Its prevalence in pregnancy varies from 5.5% to 65% depending on age, geography and gestational age (increasing with gestational age). Infection in pregnancy has been associated with adverse outcomes such as spontaneous miscarriage, preterm birth, placental abnormalities and fetal growth restriction. However, the evidence for these adverse outcomes is varied. Besides being oncogenic (and thus associated with cancer of the cervix in pregnancy), vertical transmission to the fetus/neonate can cause neonatal infections, especially juvenile-onset recurrent oral and respiratory papillomatosis (JORRP). Where there are very large lesions on the vulva, delivery may be obstructed. Diagnosis in pregnancy is mainly by viral PCR or from the clinical appearance of the characteristic lesions on the vulva. Treatment is local by either surgical or laser excision or application of trichloroacetic acid. Podophyllin/podophyllotoxin is contraindicated in pregnancy. HPV Infection is not an indication for caesarean delivery as this has not been shown to prevent vertical transmission. For those diagnosed at routine cervical cancer screening, management should follow guidelines for cervical cancer screening in pregnancy. Vaccination is currently not recommended for pregnant women, although studies on those inadvertently vaccinated in pregnancy have not shown any adverse effects on either the fetus or mother.