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

Trends in Head and Neck Cancer Mortality from 1999 to 2019 in Japan: An Observational Analysis

Globally, the numbers of head and neck cancer (HNC) cases and related deaths have recently increased. In Japan, few studies have examined crude or age-adjusted HNC mortality rates. Therefore, this study aimed to determine the trends in crude and age-adjusted mortality rates for HNC per million individuals in Japan from 1999 to 2019. Data on HNC-associated deaths were extracted from the national death certificate database using the International Classification of Diseases, Tenth Revision (n = 156,742). HNC mortality trends were analysed using joinpoint regression models to estimate annual percentage change (APC) and average APC (AAPC). Among men, no significant change was observed in the age-adjusted death rate trend from 1999 to 2014; however, a marked decrease was observed from 2014 to 2019. No changing point was observed in women. Age-adjusted mortality rates continuously decreased over the 21-year period, with an AAPC of -0.7% in men and -0.6% in women. In conclusion, the overall trend in age-adjusted rates of HNC-associated deaths decreased, particularly among men, in the past 5 years. These results will contribute to the formulation of medical policies to develop targeted screening and prevention programmes for HNC in Japan and determine the direction of treatment strategies.

Recent Developments in Human Papillomavirus (HPV) Vaccinology

Human papillomavirus (HPV) is causally associated with 5% of cancers, including cancers of the cervix, penis, vulva, vagina, anus and oropharynx. The most carcinogenic HPV is HPV-16, which dominates the types causing cancer. There is also sufficient evidence that HPV types 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59 cause cervical cancer. The L1 protein, which, when assembled into virus-like particles, induces HPV-type-specific neutralising antibodies, forms the basis of all commercial HPV vaccines. There are six licensed prophylactic HPV vaccines: three bivalent, two quadrivalent and one nonavalent vaccine. The bivalent vaccines protect from HPV types 16 and 18, which are associated with more than 70% of cervical cancers. Prophylactic vaccination targets children before sexual debut, but there are now catch-up campaigns, which have also been shown to be beneficial in reducing HPV infection and disease. HPV vaccination of adults after treatment for cervical lesions or recurrent respiratory papillomatosis has impacted recurrence. Gender-neutral vaccination will improve herd immunity and prevent infection in men and women. HPV vaccines are immunogenic in people living with HIV, but more research is needed on the long-term impact of vaccination and to determine whether further boosters are required.

Accounting for Adverse Events Following Immunization in Economic Evaluation: Systematic Review of Economic Evaluations of Pediatric Vaccines Against Pneumococcus, Rotavirus, Human Papillomavirus, Meningococcus and Measles-Mumps-Rubella-Varicella

OBJECTIVES

Economic evaluations of vaccines should accurately represent all relevant economic and health consequences of vaccination, including losses due to adverse events following immunization (AEFI). We investigated to what extent economic evaluations of pediatric vaccines account for AEFI, which methods are used to do so and whether inclusion of AEFI is associated with study characteristics and the vaccine's safety profile.

METHODS

A systematic literature search (MEDLINE, EMBASE, Cochrane Systematic Reviews and Trials, Database of the Centre for Reviews and Dissemination of the University of York, EconPapers, Paediatric Economic Database Evaluation, Tufts New England Cost-Effectiveness Analysis Registry, Tufts New England Global Health CEA, International Network of Agencies for Health Technology Assessment Database) was performed for economic evaluations published between 2014 and 29 April 2021 (date of search) pertaining to the five groups of pediatric vaccines licensed in Europe and the United States since 1998: the human papillomavirus (HPV) vaccines, the meningococcal vaccines (MCV), the measles-mumps-rubella-varicella (MMRV) combination vaccines, the pneumococcal conjugate vaccines (PCV) and the rotavirus vaccines (RV). Rates of accounting for AEFI were calculated, stratified by study characteristics (e.g., region, publication year, journal impact factor, level of industry involvement) and triangulated with the vaccine's safety profile (Advisory Committee on Immunization Practices [ACIP] recommendations and information on safety-related product label changes). The studies accounting for AEFI were analyzed in terms of the methods used to account for both cost and effect implications of AEFI.

RESULTS

We identified 112 economic evaluations, of which 28 (25%) accounted for AEFI. This proportion was significantly higher for MMRV (80%, four out of five evaluations), MCV (61%, 11 out of 18 evaluations) and RV (60%, nine out of 15 evaluations) compared to HPV (6%, three out of 53 evaluations) and PCV (5%, one out of 21 evaluations). No other study characteristics were associated with a study's likelihood of accounting for AEFI. Vaccines for which AEFI were more frequently accounted for also had a higher frequency of label changes and a higher level of attention to AEFI in ACIP recommendations. Nine studies accounted for both the cost and health implications of AEFI, 18 studies considered only costs and one only health outcomes. While the cost impact was usually estimated based on routine billing data, the adverse health impact of AEFI was usually estimated based on assumptions.

DISCUSSION

Although (mild) AEFI were demonstrated for all five studied vaccines, only a quarter of reviewed studies accounted for these, mostly in an incomplete and inaccurate manner. We provide guidance on which methods to use to better quantify the impact of AEFI on both costs and health outcomes. Policymakers should be aware that the impact of AEFI on cost-effectiveness is likely to be underestimated in the majority of economic evaluations.

The Role of HPV in Determining Treatment, Survival, and Prognosis of Head and Neck Squamous Cell Carcinoma

Human papillomavirus (HPV) infection has been identified as a significant etiological agent in the development of head and neck squamous cell carcinoma (HNSCC). HPV's involvement has alluded to better survival and prognosis in patients and suggests that different treatment strategies may be appropriate for them. Only some data on the epidemiology of HPV infection in the oropharyngeal, oral cavity, and laryngeal SCC exists in Europe. Thus, this study was carried out to investigate HPV's impact on HNSCC patient outcomes in the Irish population, one of the largest studies of its kind using consistent HPV testing techniques. A total of 861 primary oropharyngeal, oral cavity, and laryngeal SCC (OPSCC, OSCC, LSCC) cases diagnosed between 1994 and 2013, identified through the National Cancer Registry of Ireland (NCRI), were obtained from hospitals across Ireland and tested for HPV DNA using Multiplex PCR Luminex technology based in and sanctioned by the International Agency for Research on Cancer (IARC). Both overall and cancer-specific survival were significantly improved amongst all HPV-positive patients together, though HPV status was only a significant predictor of survival in the oropharynx. Amongst HPV-positive patients in the oropharynx, surgery alone was associated with prolonged survival, alluding to the potential for de-escalation of treatment in HPV-related OPSCC in particular. Cumulatively, these findings highlight the need for continued investigation into treatment pathways for HPV-related OPSCC, the relevance of introducing boys into national HPV vaccination programs, and the relevance of the nona-valent Gardasil-9 vaccine to HNSCC prevention.

Increasing HPV vaccination coverage to prevent oropharyngeal cancer: A cost-effectiveness analysis

The incidence of oropharyngeal cancer (OPC) has been rising, especially among middle-aged men. While Human Papillomavirus (HPV) has been irrevocably implicated in the pathogenesis of oropharyngeal cancer (OPC), the current HPV vaccination uptake rate remains low in the US. The aim of our study was to evaluate the impact of increased HPV vaccination coverage on HPV-associated OPC incidence and costs. A decision analytic model was constructed for hypothetical cohorts of 9-year-old boys and girls. Two strategies were compared: 1) Maintaining the current vaccination uptake rates; 2) Increasing HPV vaccination uptake rates to the Healthy People 2030 target (80%) for both sexes. Increasing HPV vaccination coverage rates to 80% would be expected to prevent 5,339 OPC cases at a cost of $0.57 billion USD. Increased HPV vaccination coverage would result in 7,430 quality-adjusted life year (QALY) gains in the overall population, and it is estimated to be cost-effective for males with an incremental cost-effectiveness ratio of $86,940 per QALY gained under certain conditions. Expanding HPV vaccination rates would likely provide a cost-effective way to reduce the OPC incidence, particularly among males.

HPV vaccine for men: Where to? (Review)

Human papillomavirus (HPV) is one of the most widespread human pathogens. For a long time, it was treated as an opportunistic infection, but it is in actuality one of the most dangerous carcinogens. It is responsible for numerous malignancies: Cervical, penile, oropharyngeal, vaginal, vulvar and some anal neoplasia. The need for a long-term solution was evident and thus HPV vaccines were proven to be a viable solution. Women and men who have sex with men, and young men are included in the vaccination template. A thorough review using PubMed and other databases that included articles on vaccine templates and targeted male patients was carried out. After review of all of the studies conducted on this subject, there is a clear benefit for HPV vaccination for men. Yet, even with the introduction of a national vaccine program for HPV for women and girls in most developed countries, regarding the male vaccine program, few countries have established a national program. Still, a gender-neutral vaccine remains a controversial issue. It is important to monitor the impact of HPV vaccine in men and the benefits that occur, to inform and spread the results in order to implement this vaccine program worldwide. Any monitoring plan regarding the HPV vaccination must include HPV prevalence, anogenital warts, and anal cancer. The largest impact regarding the range of this type of vaccine is the surveillance of the specific targeted population. HPV vaccine is a very efficient immunization method. Women are obviously the first target, but there are still many contradictions regarding men. Most of the reasons reside in the cost-efficiency aspect, but there is still great debate regarding the most efficient vaccine in the male population.

Landscape assessment for gender neutral human papillomavirus vaccination recommendations including head and neck cancer burden data

INTRODUCTION

Head and neck cancers (HNC) accounted for over 450,000 deaths and 900,000 cases in 2018 worldwide. Of those, 38,000 cases were attributable to human papillomavirus (HPV). HNC is two to four times more prevalent in men than in women. The incidence of oropharyngeal cancers (OPC) and oral cavity cancers caused by HPV has increased in recent decades. Given the substantial burden of HPV-related HNC in males, this study aimed to assess whether and how national agencies included HPV-related HNC when evaluating HPV genderneutral vaccination (GNV) programs.

METHODS

A systematic literature review was conducted in MEDLINE® and EMBASE®, and on the websites of selected national agencies.

RESULTS

Searches identified a potential 205 records; seventeen were eligible for the review. Seventy percent of assessments were published by European countries and most were recent (2014-2019). Eleven (65%) reports considered OPC when discussing HNC, and a few included other anatomic sites. All reports that considered incidence data were in consensus that incidence of OPC was higher in men and showed that the mortality rates for HPV-related HNC were also higher in men. When looking at the economic impact, the incremental cost-effectiveness ratios in the assessments varied widely, as the inputs into the analyses were heterogeneous. However, several reports concluded GNV programs were likely to be cost-effective versus not vaccinating males.

CONCLUSION

The burden of HPV-related HNC in the general male population has been recognized by several Heatlth Technology Assessment (HTA) agencies and National Immunization Technical Advisory Groups (NITAGs) when evaluating HPV GNV programs. The assessments identified on GNV programs strongly indicate a cost-effective clinical benefit. Nevertheless, the epidemiological burden of HNC may have been underestimated in some countries due to limited data. Further research is crucial to obtain more robust data that will help address the information gap in epidemiological and economic burden of HPV-associated HNC in men.

Manifestations of Human Papillomavirus in the Head and Neck

Human papillomavirus (HPV)-positive oropharyngeal cancers (OPC) are increasing due to infection with the virus. Most of the patients diagnosed with HPV-positive OPC are white men with numerous lifetime sexual partners who have smoked marijuana excessively. In working up the patient, it is important to obtain an extensive history and physical examination and obtain proper imaging. Once a full workup is done, it is crucial to engage a multidisciplinary team in treatment and continue following-up with the patient through posttreatment surveillance. Administering the HPV vaccine at a young age may help reduce the increasing rate of HPV-positive OPC in the future.

An economic and disease transmission model of human papillomavirus and oropharyngeal cancer in Texas

In 2017, 46,157 and 3,127 new oropharyngeal cancer (OPC) cases were reported in the U.S. and Texas, respectively. About 70% of OPC were attributed to human papillomavirus (HPV). However, only 51% of U.S. and 43.5% of Texas adolescents have completed the HPV vaccine series. Therefore, modeling the demographic dynamics and transmission of HPV and OPC progression is needed for accurate estimation of the economic and epidemiological impacts of HPV vaccine in a geographic area. An age-structured population dynamic model was developed for the U.S. state of Texas. With Texas-specific model parameters calibrated, this model described the dynamics of HPV-associated OPC in Texas. Parameters for the Year 2010 were used as the initial values, and the prediction for Year 2012 was compared with the real age-specific incidence rates in 23 age groups for model validation. The validated model was applied to predict 100-year age-adjusted incidence rates. The public health benefits of HPV vaccine uptake were evaluated by computer simulation. Compared with current vaccination program, increasing vaccine uptake rates by 50% would decrease the cumulative cases by 4403, within 100 years. The incremental cost-effectiveness ratio of this strategy was $94,518 per quality-adjusted life year (QALY) gained. Increasing the vaccine uptake rate by 50% can: (i) reduce the incidence rates of OPC among both males and females; (ii) improve the quality-adjusted life years for both males and females; (iii) be cost-effective and has the potential to provide tremendous public health benefits in Texas.

Oral HPV prevalence and HPV vaccination among special needs population in the US

Introduction

Special needs population have barriers accessing healthcare, higher incidence of sexual assaults and lower sexual education. Due to the above this study was conducted- 1) To assess the current prevalence of oral HPV infection among individuals with SHCN (special health care needs) as compared to the general population and 2) To compare the prevalence of HPV vaccination in SHCN individuals (within the recommended age groups) to general population.

Methods

This data was obtained from NHANES 2013-14 and included 665 individuals with special needs. Weighted prevalence estimates and prevalence ratios (PR) were calculated for oral HPV infection by gender, age (18–59 years), race, smoking history, economic status, and sexual behavior. Prevalence rates were calculated for HPV vaccination.

Results

Oral HPV was detected in 9% (7.1–11.5; p = 0.05) of special needs adults. High-risk HPV genotypes prevalence was also higher among adults with special needs [5.56% (3.9–7.9) vs 3.87% (2.7–5.4)]. The HPV vaccination rates among 9–26 years special needs females (33.5% vs 37%) and males aged 9–21 years (16.7% vs 21.2%) with special needs was lower than non-special needs individuals.

Conclusion

There is higher burden of oral HPV infection among adults with special needs compared to general population. Contrastingly, lower vaccination rates were observed among them within the recommended age groups. Further studies are required to determine the barriers to HPV vaccination among individuals with special needs.

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The prevalence of Oral HPV infection is higher among the adults with special health care needs.

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Individuals with Special health care needs have lower uptake of HPV vaccination with in the recommended age groups, compared to the general population.

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Males are more likely to have high-risk Oral HPV infection and lower vaccination rates compared to females.

Prevention of HPV-Related Oral Cancer by Dentists: Assessing the Opinion of Dutch Dental Students

The aim of this study is to assess dental students' opinions of the dentists' role in primary prevention of human papillomavirus (HPV)-related oral cancer using a cross-sectional web-based survey. A questionnaire, containing questions about knowledge of HPV and oral cancer, confidence in head and neck examination and role of the dentist in preventing HPV-related oral cancer, was sent to all students of the Academic Centre of Dentistry Amsterdam (n = 912). One hundred and twenty-six (n = 126) students completed the questionnaire. Significantly, more master students (75%) than bachelor students (54.3%) were aware that HPV is a causative factor for oral cancer. Master students had more knowledge of HPV than bachelor students, but knowledge about HPV vaccination was irrespective of the study phase. The majority of dental students agreed that it is important to discuss HPV vaccination with patients. Eighty-nine percent of the students think that more education about symptoms of oral cancer will increase screening for oral cancer. Development of a protocol for screening in dental practices was considered even more important. According to dental students, dentists should discuss HPV as a risk factor for oral cancer with patients. Future dentists are willing to be involved in both primary and secondary prevention of HPV-related oral cancer. Therefore, screening for oral cancer and education about HPV vaccination should be integral elements of the dental curriculum.

Present challenges in cervical cancer prevention: Answers from cost-effectiveness analyses

Simulation models are commonly used to address important health policy issues that cannot be explored through experimental studies. These models are especially useful to determine a set of strategies that result in a good value for money (cost-effectiveness). Several mathematical models simulating the natural history of HPV and related diseases, especially cervical cancer, have been developed to calculate a relative effectiveness and cost-effectiveness of HPV vaccination and cervical cancer screening interventions. Virtually all cost-effectiveness analyses identify HPV vaccination programmes for preadolescent girls to be cost-effective, even for relatively low vaccination coverage rates. Routine vaccination of preadolescent girls is the primary target population for HPV vaccination as it shows to provide the greatest health impact. Cost-effectiveness analyses assessing other vaccine target groups are less conclusive. Adding additional age-cohorts would accelerate health benefits in some years, although cost-effectiveness becomes less favourable as age at vaccination increases. Including men in HPV vaccination programmes may be a less efficient strategy if done at the expense of female vaccination coverage for reducing the burden of HPV in the population. However, as the HPV vaccine price decreases, the cost-effectiveness of universal vaccination improves, becoming equally as efficient as female-only vaccination. Vaccine price is a decisive factor in the cost-effectiveness analyses. The lower the price, the greater the likelihood that vaccination groups other than the primary target would be considered cost-effective.

Should human papillomavirus vaccination target women over age 26, heterosexual men and men who have sex with men? A targeted literature review of cost-effectiveness

BACKGROUND

Human papillomavirus (HPV) vaccination for young women up to age 26 is highly cost-effective and has been implemented in 65 countries globally. We investigate the cost-effectiveness for HPV vaccination program in older women (age > 26 years), heterosexual men and men who have sex with men (MSM).

METHOD

A targeted literature review was conducted on PubMed for publications between January 2000 and January 2017 according to the PRISMA guidelines. We included English-language articles that reported the incremental cost-effectiveness ratio (ICER) of HPV vaccination programs for women over age 26, heterosexual men, and MSM and identified the underlying factors for its cost-effectiveness.

RESULTS

We included 36 relevant articles (six, 26 and four in older women, heterosexual men and MSM, respectively) from 17 countries (12 high-income (HICs) and five low- and middle-income (LMICs) countries). Most (4/6) studies in women over age 26 did not show cost-effectiveness ($65,000-192,000/QALY gained). Two showed cost-effectiveness, but only when the vaccine cost was largely subsidised and protection to non-naïve women was also considered. Sixteen of 26 studies in heterosexual men were cost-effective (ICER = $19,600-52,800/QALY gained in HICs; $49-5,860/QALY gained in LMICs). Nonavalent vaccines, a low vaccine price, fewer required doses, and a long vaccine protection period were key drivers for cost-effectiveness. In contrast, all four studies on MSM consistently reported cost-effectiveness (ICER = $15,000-$43,000/QALY gained), particularly in MSM age < 40 years and those who were HIV-positive. Countries' vaccination coverage did not significantly correlate with its per-capita Gross National Income.

CONCLUSION

Targeted HPV vaccination for MSM should be next priority in HPV prevention after having established a solid girls vaccination programme. Vaccination for heterosexual men should be considered when 2-dose 4vHPV/9vHPV vaccines become available with a reduced price, whereas targeted vaccination for women over age 26 is unlikely to be cost-effective.

What Drives Health Professionals to Tweet About #HPVvaccine? Identifying Strategies for Effective Communication

Introduction

We conducted this study to quantify how health professionals use Twitter to communicate about the human papillomavirus (HPV) vaccine.

Methods

We collected 193,379 tweets from August 2014 through July 2015 that contained key words related to HPV vaccine. We classified all tweets on the basis of user, audience, sentiment, content, and vaccine characteristic to examine 3 groups of tweets: 1) those sent by health professionals, 2) those intended for parents, and 3) those sent by health professionals and intended for parents. For each group, we identified the 7-day period in our sample with the most number of tweets (spikes) to report content.

Results

Of the 193,379 tweets, 20,451 tweets were from health professionals; 16,867 tweets were intended for parents; and 1,233 tweets overlapped both groups. The content of each spike varied per group. The largest spike in tweets from health professionals (n = 851) focused on communicating recently published scientific evidence. Most tweets were positive and were about resources and boys. The largest spike in tweets intended for parents (n = 1,043) centered on a national awareness day and were about resources, personal experiences, boys, and girls. The largest spike in tweets from health professionals to parents (n = 89) was in January and centered on an event hosted on Twitter that focused on cervical cancer awareness month.

Conclusion

Understanding drivers of tweet spikes may help shape future communication and outreach. As more parents use social media to obtain health information, health professionals and organizations can leverage awareness events and personalize messages to maximize potential reach and parent engagement.

Strengthening the case for gender-neutral and the nonavalent HPV vaccine

PURPOSE

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020.

METHODS

PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)].

RESULTS

There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a "herd effect" for females by preventing the propagation of the virus.

CONCLUSION

Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

Human papillomavirus-related oropharyngeal cancer in the HIV-infected population

Human papillomavirus (HPV) is a common sexually transmitted virus and an important etiologic factor in head and neck cancers. HIV-infected individuals are at increased risk of developing oropharyngeal cancers (OPC) compared with the general population. HPV-positive OPC are also increasingly a significant cause of morbidity and mortality for HIV-infected individuals in the era of effective combination antiretroviral therapy. The epidemiology and natural history of oral HPV infection have not been well established, but it appears that oral HPV infection is less common than anal infection, and more common among HIV-infected persons than the general population. Prevention of OPC is therefore increasingly important in HIV-infected individuals. Although not demonstrated in randomized controlled trials, HPV vaccination may prevent oral HPV infection as well. The focus of organized HPV cancer prevention programs should include prophylactic HPV vaccination to reduce the burden of high-risk HPV and low-risk HPV types who have not yet been exposed.

A Multiple Streams analysis of the decisions to fund gender-neutral HPV vaccination in Canada

In Canada, the human papillomavirus (HPV) vaccine is licensed and recommended for females and males. Although all Canadian jurisdictions fund school-based HPV vaccine programs for girls, only six jurisdictions fund school-based HPV vaccination for boys. The research aimed to analyze the factors that underpin government decisions to fund HPV vaccine for boys using a theoretical policy model, Kingdon's Multiple Streams framework. This approach assesses policy development by examining three concurrent, but independent, streams that guide analysis: Problem Stream, Policy Stream, and Politics Stream. Analysis from the Problem Stream highlights that males are affected by HPV-related diseases and are involved in transmitting HPV infection to their sexual partners. Policy Stream analysis makes clear that while the inclusion of males in HPV vaccine programs is suitable, equitable, and acceptable; there is debate regarding cost-effectiveness. Politics Stream analysis identifies the perspectives of six different stakeholder groups and highlights the contribution of government officials at the provincial and territorial level. Kingdon's Multiple Streams framework helps clarify the opportunities and barriers for HPV vaccine policy change. This analysis identified that the interpretation of cost-effectiveness models and advocacy of stakeholders such as citizen-advocates and HPV-affected politicians have been particularly important in galvanizing policy change.

A study of physicians' experiences with recommending HPV vaccines to adolescent boys

Assessing physicians' experiences in HPV vaccine recommendation and delivery to adolescent boys is essential to providing an understanding of the issues of vaccine acceptance and an insight for policymakers to enhance HPV vaccinations among adolescent boys. Between January and April 2014 a mail survey was conducted using physicians in Malaysia known to provide either one or both HPV vaccine (Gardasil and Cervarix) immunisation services. A total of 357 completed questionnaires were received (response rate 22.5%). Of these, 335 physicians see adolescent boys aged 11 to 18 years old in their practice. Only 26.3% (n = 88) recommended the HPV vaccine to these boys. A total of 46.6% (n = 41) have successfully given the HPV vaccine to adolescent boys. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to the boys (37.2%) and a lack of awareness of the availability of the vaccine for boys (32.8%) were the most commonly cited reasons for non-recommendation. Impact statement Recommending the HPV vaccine for adolescent boys remains a challenge for physicians. Our study provides evidence of challenges and barriers faced by Malaysian physicians who recommend the HPV vaccines (Gardasil and Cervarix) in their practices. In this study, physicians reported HPV vaccine uptake by adolescent boys was very poor. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to boys and a lack of awareness of the availability of the vaccine for boys were the most commonly cited reasons for non-recommendation. Physicians viewed that support and encouragement from the health authorities are needed to promote the recommendation of the HPV vaccine to adolescent boys. Physicians were also of the opinion that the lay public should be educated about the availability of the HPV vaccine for boys, and its benefits, safety and efficacy, and the high susceptibility of boys to getting HPV infections. The findings provide insights that could be helpful to policymakers or high-level decision-makers of the potential strategies to enhance HPV uptake among adolescent boys.

Adolescent human papillomavirus vaccination in the United States: Opportunities for integrating pharmacies into the immunization neighborhood

Human Papillomavirus (HPV) vaccination faces several barriers, including a social stigma which carries religious and philosophical implications among parents of adolescents as well as young adults. Hundreds of immunization interventions and programs have been developed to address these factors and boost HPV vaccination rates in the United States. We sought to review the existing literature highlighting barriers to HPV immunization, as well as programs targeting increased HPV vaccine uptake in effort to develop novel vaccination initiatives. The most impactful barriers identified were parental stigma and low quality of provider recommendations for the vaccine. Despite the implementation of many HPV initiatives, outcomes of these programs are largely limited to modest improvements in vaccine uptake in small, homogeneous populations. We describe pharmacies as distinctly advantageous but underutilized resources within the immunization neighborhood and propose a novel concept to improve vaccination rates as well as reduce HPV-related disease burden in all demographics.

A Survey of Wisconsin Pediatricians’ Knowledge and Practices Regarding the Human Papillomavirus Vaccine

Objective

The human papillomavirus (HPV) is common and carries a significant burden of disease. This is increasingly apparent in males with the rising incidence of HPV-related oropharyngeal cancer. Unfortunately, vaccination rates remain poor and are lowest in males. It is unclear if pediatricians are aware of the alarming rise of HPV-mediated head and neck cancers and the disproportionate effect on males.

Study Design

This investigation used a cross-sectional descriptive survey research design.

Setting

The survey was developed by investigators in the University of Wisconsin Division of Otolaryngology.

Subjects and Methods

The survey was distributed to 831 members of the Wisconsin Chapter of the American Academy of Pediatrics.

Results

A total response rate of 49.6% was achieved. Most supported routine vaccination in both sexes. Females are regarded as being at higher risk of an HPV-related cancer and are more often recommended vaccination. Most providers are unaware of the magnitude of HPV-related oropharyngeal cancer and the greater affliction in males.

Conclusions

Male vaccination is overwhelmingly supported by Wisconsin pediatricians, yet there is a preponderance toward vaccinating females, who are perceived as having greater risk for HPV-associated disease. This is likely because providers are unaware of the magnitude of HPV-driven oropharyngeal cancer and its predilection for males. A lack of provider awareness, in combination with out-of-date education material for parents, likely contributes to poor vaccination rates in males.

Vaccination Expectations in HNSCC

HPV-associated head and neck squamous cell carcinoma (HNSCC), more specifically the incidence of oropharyngeal cancer, is dramatically increasing in industrialized countries. According to what has been learned from anogenital vaccination programs, there are reasons to believe that current human papillomavirus (HPV) vaccinations may be potentially effective also against HNSCC. However, before specific results on HNSCC are available, one must keep in mind that carcinogenesis in the head and neck region may differ from that of the anogenital tract. Furthermore, the current evidence supports the view that HPV infection is much more complex than simply a sexually transmitted disease. HPV is present in the semen, placenta and in the newborns, and these infections of the newborns create cell-mediated immunity (CMI) against HPV, including the T memory cells. Acquisition of HPV infection in early life will rise new series of questions in the field of HPV vaccination.

Psychosocial determinants of parental human papillomavirus (HPV) vaccine decision-making for sons: Methodological challenges and initial results of a pan-Canadian longitudinal study

Background

HPV vaccination decision-making is a complex process that is influenced by multiple psychosocial determinants. Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand where Canadian parents were situated in the HPV vaccine decision-making process for their son, how they changed over time and which psychosocial determinants were relevant for this process.

Methods

We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline (T1, February 2014) and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.

Results

At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.

Conclusions

HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users.

HPV Vaccine Uptake Among Canadian Youth and The Role of the Nurse Practitioner

The human papillomavirus (HPV) infects approximately 550,000 Canadians annually. Cancers of the cervix, mouth, anus, throat and neck are caused by various strains of the virus. The virus also causes genital warts. The disease and economic burden of HPV is high. Primary prevention through vaccine administration prior to onset of sexual activity is evidenced as best practice. Two vaccines are available, Gardasil and Cervarix. Consistent with global practices in developed countries, these vaccines are currently publicly funded for females and provided in school-based clinics in all provinces and territories in Canada. Despite well-documented efficacy with minimal adverse effects, the uptake of these vaccines remains low in all countries, including Canada. Although HPV immunization rates have increased, they remain significantly below the rates of other vaccine-preventable diseases. This is puzzling since school-based clinics and public funding presumably increase vaccine access. Barriers explicated include family lack of knowledge about the vaccine, and attitudes that are not informed by science and epidemiology. There is evidence that a health provider's recommendation is the single biggest influence on uptake. However, not all providers are cognizant about emerging issues in this area, including controversies about universal coverage for boys as well as girls, new vaccines and more. Nurse practitioners are in a position to collaborate with public health agencies to expand knowledge and coverage across Canada.

Clinical features and treatment strategy for HPV-related oropharyngeal cancer

Among head and neck squamous cell carcinoma (HNSCC), the incidence of oropharyngeal SCC (OPSCC) is increasing in contrast to carcinoma with origin in other subsites. Human papillomavirus (HPV) is now recognized as a significant risk factor of the carcinogenesis of OPSCC. The HPV-related OPSCC patients tend to be relatively young, less exposed to tobacco and alcohol, and have a relatively high socioeconomic status and education level, which is distinct from HPV-unrelated classical OPSCC. The neck metastases tend to be aggressive and cystic. The better response to treatment resulting in improved prognosis of HPV-related OPSCC led to reconsidering the clinical staging and treatment approaches. Clinical trials of treatment deintensification to reduce the acute and late toxicity without compromising efficacy have been conducted. This review of HPV-related OPSCC focuses on current and generally accepted facts regarding the biology, epidemiology, and therapeutic strategy of this new disease entity.

HPV vaccine uptake among overweight and obese US adolescents: An analysis of the National Health and Nutrition Examination Survey (NHANES) 2009-2014

BACKGROUND

Human papillomavirus (HPV) vaccine uptake in the US is suboptimal; identifying risk factors associated with low vaccine uptake is critical to increase vaccination coverage. Some evidence suggests body mass index (BMI) is associated with low HPV vaccine uptake and increased risk of HPV infection in adults. BMI may therefore be an important factor in targeting HPV vaccine to US adolescents.

METHODS

We investigated the relationship between BMI categories (underweight, normal weight, overweight and obese) and HPV vaccine uptake in 4109 adolescents (9-18 years old) using data from the 2009 to 2014 National Health and Nutrition Examination Survey (NHANES). We used modified Poisson regression to assess the relationship between BMI and receipt of at least one HPV vaccine, and BMI and completion of the vaccine three-dose series. We assessed the relationship between BMI and age at first HPV vaccination using linear regression.

RESULTS

Receipt of at least one dose of HPV vaccine was low in both females (35%) and males (10%). High BMI was not associated with initiation of the HPV vaccine series, age at first HPV vaccination, or completion of the HPV vaccine three-dose course.

CONCLUSIONS

We found no evidence that high BMI is associated with reduced initiation or completion of the HPV vaccination series, or age at initiation of the three-dose course among a general population sample of US adolescents. Our results suggest that efforts to increase HPV vaccine uptake need not consider targeting by weight status at this time.

The potential impact of prophylactic human papillomavirus vaccination on oropharyngeal cancer

The incidence of oropharyngeal cancer (OPC) is significantly increasing in the United States. Given that these epidemiologic trends are driven by human papillomavirus (HPV), the potential impact of prophylactic HPV vaccines on the prevention of OPC is of interest. The primary evidence supporting the approval of current prophylactic HPV vaccines is from large phase 3 clinical trials focused on the prevention of genital disease (cervical and anal cancer, as well as genital warts). These trials reported vaccine efficacy rates of 89% to 98% for the prevention of both premalignant lesions and persistent genital infections. However, these trials were designed before the etiologic relationship between HPV and OPC was established. There are differences in the epidemiology of oral and genital HPV infection, such as differences in age and sex distributions, which suggest that the vaccine efficacy observed in genital cancers may not be directly translatable to the cancers of the oropharynx. Evaluation of vaccine efficacy is challenging in the oropharynx because no premalignant lesion analogous to cervical intraepithelial neoplasia in cervical cancer has yet been identified. To truly investigate the efficacy of these vaccines in the oropharynx, additional clinical trials with feasible endpoints are needed. Cancer 2016;122:2313-2323. © 2016 American Cancer Society.

Future perspectives: United Kingdom National Multidisciplinary Guidelines

The multidisciplinary management of head and cancer has changed radically in the last decade. This paper provides a glimpse of the emerging surgical and oncological interventions that may play major roles in the treatment paradigms of tomorrow.

Increasing incidence of anogenital warts with an urban-rural divide among males in Manitoba, Canada, 1990-2011

Background

Anogenital warts (AGW) are caused by the most common sexually transmitted infection, human papillomavirus. The objective of this study was to examine AGW incidence from 1990 to 2011 by sex, age, income quintile, and residential area category (urban/rural). The study period included the initiation of school-based HPV vaccination for girls in the sixth grade, which began in 2008. The data presented in this paper may also be useful for establishing baseline rates of AGW incidence which may be used to evaluate the success of the school-based HPV immunization program.

Methods

Cases of anogenital warts were identified using Manitoba’s administrative databases of Physician Claims and Hospital Discharge Abstracts. Annual age-standardized incidence in Manitoba from 1990 to 2011 was calculated. Incident AGW rates were compared by sex, age group, residential area category (urban/rural), and household income quintile using logistic regression. Joinpoint regression analyses were used to evaluate the time trends of AGW.

Results

Prior to 2000, AGW incidence was higher among females than males. However, from 2000 to 2011 the incidence was higher among males and increased steadily over time. AGW incidence tended to peak in younger age groups among females compared to males. Females and males living in urban areas had nearly twice the odds of AGW occurrence compared to those in rural areas.

Conclusions

There is a need for education about AGW in male population. The upcoming initiation of HPV vaccination among boys may reduce the incidence and should be evaluated.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2885-4) contains supplementary material, which is available to authorized users.

HPV vaccination to prevent oropharyngeal carcinoma: What can be learned from anogenital vaccination programs?

Human papillomavirus (HPV) infections are well known causes of anogenital cancers. Recent studies show that HPV also plays a role in oropharyngeal cancer (OPC). A review on the role of HPV vaccination in the prevention of head and neck squamous cell carcinoma (HNSCC) with special emphasis on OPC was conducted and available vaccines and vaccination strategies in HNSCC and OPC are discussed. Prophylactic vaccination is known to be effective for prevention of anogenital HPV infection and precursor lesions in the cervix and anus. While the value of vaccination for prevention of OPC and possibly as an adjuvant treatment is still an open question, evidence to date supports the possibility that HPV vaccination may prove to be effective in reducing the incidence of this malignancy.

HPV Infection of the Head and Neck Region and Its Stem Cells

The human papillomavirus (HPV) is an etiologic agent associated with the development of head and neck squamous carcinoma (HNSCC)-in particular, oropharyngeal squamous cell carcinoma. The HPV-positive HNSCC is characterized by genetic alterations, clinical progression, and therapeutic response, which are distinct from HPV-negative head and neck cancers, suggesting that virus-associated tumors constitute a unique entity among head and neck cancers. Malignant stem cells, or cancer stem cells, are a subpopulation of tumor cells that self-renew, initiate new tumors upon transplantation, and are resistant to therapy, and their discovery has revealed novel effects of oncovirus infection in cancer. In this review, we provide a virus-centric view and novel insights into HPV-positive head and neck pathogenesis. We discuss the influence of cancer stem cells, HPV oncoproteins, altered molecular pathways, and mutations in cancer initiation and cancer progression. We compiled a catalogue of the mutations associated with HPV-positive HNSCC, which may be a useful resource for genomic-based studies aiming to develop personalized therapies. We also explain recent changes in mass vaccination campaigns against HPV and the potential long-term impact of vaccinations on the prevention and treatment of HPV-positive head and neck cancers.