Human papillomavirus vaccine disease impact beyond expectations

Perceptions of Taiwanese college students toward human papillomavirus infection: A qualitative descriptive study

PURPOSE

The aim of this study was to explore college students' perceptions of human papillomavirus (HPV) infection and their thoughts on prevention measures.

DESIGN AND METHODS

A qualitative descriptive design was used. The study adopted purposive sampling at two universities in northern Taiwan and one in central Taiwan. Twenty-six college students participated, and data saturation was reached. Content analysis was undertaken.

RESULTS

Four main themes emerged from the data narratives: 1) having very little knowledge of HPV infection, 2) being concerned about outcomes of HPV infection, 3) taking measures to protect oneself, and 4) expecting to have HPV prevention resources.

CONCLUSIONS

The results indicated that college students needed a more complete understanding of HPV and prevention methods to protect themselves from infection. Schools were an ideal place to provide adequate information on HPV prevention.

PRACTICE IMPLICATIONS

The study suggested providing HPV-related information through school health centers and government health departments to resolve common questions and misunderstandings about HPV infection. Healthcare professionals should have a complete understanding of HPV-related knowledge in order to provide detailed information to young people.

HPV Opportunistic Vaccination: A Literature Review and a Single-Center Experience in Northern Italy through the COVID-19 Pandemic

The World Health Organization (WHO) set the goal of 90% HPV vaccination coverage in the population to eliminate cervical cancer. Opportunistic vaccination is performed outside the free vaccination or catch-up programs. Both free and opportunistic HPV vaccination programs experienced slowdowns during the COVID-19 pandemic. In this retrospective study, we aimed to identify the benefits and the obstacles of opportunistic vaccination among male and female individuals who took advantage of the "on-demand" service offered by San Raffaele Hospital in Milan from April 2018 to May 2023. The impact that the COVID-19 pandemic had on vaccination adherence was also analyzed. Data on a total of 527 subjects were collected from an in-house database and through personal interviews. Women in the cohort of older patients (over 25) adhered to the vaccination schedule more than younger women. Opportunistic vaccination request is influenced by the need of a gynecologist, a general practitioner, or public health clinic availability. Women also showed good adherence to screening, demonstrating awareness of the importance of cervical cancer secondary prevention despite vaccination. Opportunistic vaccination offers the possibility of including individuals excluded from the free vaccination campaigns, often already affected by lesions caused by HPV, providing increased viral clearance and faster lesion regression. The main limit remains the economic burden.

Human papillomavirus vaccination in low- and middle-income countries: progression, barriers, and future prospective

Human papillomavirus (HPV) is a viral infection that, if does not go away, can cause health problems like genital warts and cancer. The national immunization schedules for individuals before sexual debut, significantly decreased HPV-associated mortality and it will be affordable. However, immunization programs remain vulnerable to macroeconomic factors such as inflation, fiscal policy, employment levels, and national income. This review aims to investigate the association between national income in lower-middle-income countries to explore recent advances and potential issues, as well as how to deal with challenges.

Knowledge, attitudes and acceptance toward Human papillomavirus (HPV) vaccination: Perspectives of Muslim women and men

OBJECTIVES

Human papillomavirus (HPV) infection is the leading risk factor for the development of anogenital cancers. Most Arab countries lack both HPV education and national HPV vaccination programs. The objective of this study was to assess knowledge, attitudes, and acceptance toward HPV vaccination in men and women from Oman, a country in the Middle Eastern North Africa region.

METHODS

This cross-sectional quantitative study used convenience sampling to recruit male and female participants, aged 18 years and above from all 11 governorates of Oman to complete a validated self-administered questionnaire online in the Arabic language. The questionnaire comprised five sections, with a total of 32 questions. The questionnaire, including Arabic and English versions, was content validated and piloted.

RESULTS

A total of 1403 participants, including 952 parents and 369 healthcare providers, completed the survey. The results showed a lack of knowledge regarding HPV infection and vaccines, including among healthcare providers. Less than a quarter of the participants had heard of HPV infection, with digital sources of information being the most common. Factors such as being a woman or a healthcare provider or completing higher levels of education were independently and significantly positively association with HPV awareness (p < 0.001). The majority of the participants lacked vaccine safety knowledge, had concerns about the vaccine's side effects, and sought reassurance of its protection against HPV infection (62%, 71.5%, and 84.6%, respectively). Nevertheless, nearly two-thirds of the participants agreed to take the HPV vaccine, with support for both boys and girls being vaccinated. There was almost universal agreement among the participants regarding the need for parental and adolescent HPV educational programs.

CONCLUSION

Omani women and men showed a high level of acceptance and favorable attitude toward HPV vaccination. The study findings support future efforts to implement school and public-level HPV education and a national HPV vaccination program in Oman.

The association of Chlamydia trachomatis and human papillomavirus co-infection with abnormal cervical cytology among women in south of Morocco

PURPOSE

Evidence indicates that human papillomavirus (HPV) and Chlamydia trachomatis (CT) co-infection increases the risk of developing cervical pathogenesis. This study aims to assess the prevalence and possible risk factors of CT and HPV/CT co-infection in women from South of Morocco with normal and abnormal cytology.

METHODS

Participants were recruited after signing an informed consent. Cervical samples were collected and analysed for the presence of HPV or CT. Detection of genomic DNA of both pathogens was performed by nested polymerase chain reaction. HPV genotypes defined by Sanger sequencing method. The association between demographic features and co-infection status was determined using a logistic regression model. A possible association between the presence of HPV and CT and cytological abnormality patterns was also investigated.

RESULTS

We recruited n = 438 women, aged between 18 and 86 years. Around 59% of participants underwent a pap smear test for the first-time. Genomic DNA of HPV, CT and HPV/CT co-infection was detected in 32.3%, 17.7%, and 13.4% of the total samples, respectively. The identified risk factors associated with CT infection were history of sexually transmitted infections and marital status. By contrast, only smoking was found to be associated with HPV/CT co-infection. Evidence showed that co-infection was associated with an increased risk of developing cervical abnormalities (OR 3.18, 95% CI 0.96-9.21; p = 0.040).

CONCLUSION

HPV and CT rates were high among the studied population. Evidence suggests that HPV/CT co-infected women were more susceptible to developing abnormal cytology.

A review of data systems for assessing the impact of HPV vaccination in selected high-income countries

INTRODUCTION

The introduction of effective human papillomavirus (HPV) vaccination, screening, and treatment programs has led the World Health Organization to call for the global elimination of cervical cancer. Assessing progress toward this goal is supported through monitoring vaccination coverage and its impact.

AREAS COVERED

We performed a targeted review to assess the characteristics of HPV-related data systems from seven high-income countries (HICs) that represented varied approaches, including Australia, Canada, France, Italy, Scotland, Sweden, and the United States (US). Included data systems focused on preventive and early detection measures: HPV vaccination and cervical screening programs, as well as HPV-related disease outcomes. Differences were observed in approach to development of data systems, along with variation in geographical scope and methods of data collection.

EXPERT OPINION

A challenge exists in how to best follow-up the ongoing global-scale elimination efforts in a comprehensive manner. These sources provide a wealth of information regarding the strengths and limitations of, and notable variation among, current data systems used in HICs. This review can inform improvements to existing prevention programs and the implementation of new programs in other countries, and thus support optimization of cervical cancer prevention policy.

Real-world impact and effectiveness of the quadrivalent HPV vaccine: an updated systematic literature review

INTRODUCTION

Human papillomavirus (HPV) infection, which poses significant disease burden, is decreasing following implementation of vaccination programs. Synthesized evidence on HPV vaccine real-world benefit was published in 2016. However, long-term impact of vaccination, and how vaccination programs influence infection rates and disease outcomes, requires further examination.

AREAS COVERED

We systematically reviewed observational studies on HPV vaccination within MEDLINE, EMBASE, and Google Scholar from 2016 to 2020, involving 14 years of follow-up data. We identified 138 peer-reviewed publications reporting HPV vaccine impact or effectiveness. Outcomes of interest included rates of infection at different anatomical sites and incidence of several HPV-related disease endpoints.

EXPERT OPINION

The expansion of HPV vaccination programs worldwide has led to a reduction in genital infection and significant decreases in incidence of HPV-related disease outcomes. Therefore, the WHO has set goals for the elimination of cervical cancer as a public health concern. To track progress toward this requires an understanding of the effectiveness of different vaccination initiatives. However, the impact on males, and potential benefit of gender-neutral vaccination programs have not been fully explored. To present an accurate commentary on the current outlook of vaccination and to help shape policy therefore requires a systematic review of available data.

Acting on the call for cervical cancer elimination: Planning tools for low- and middle- income countries to increase the coverage and effectiveness of screening and treatment

Introduction

Accessible planning tools tailored for low-and middle-income countries can assist decision makers in comparing implementation of different cervical cancer screening approaches and treatment delivery scenarios in settings with high cervical cancer burden.

Methods

The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and compare the accuracy of screening approaches, what treatment equipment to procure, and how best to deploy treatment equipment in a given country. The CPPT compares four screening approaches: 1) visual inspection with acetic acid (VIA), 2) HPV testing, 3) HPV testing followed by a VIA triage, and 4) HPV testing followed by an enhanced triage test. Accuracy of screening outcomes (e.g., true positives, false positives) is based on published sensitivity and specificity of tests to detect cervical precancerous lesions. The CPPT compares five scenarios for deploying ablative treatment equipment: 1) cervical precancer equipment at every location a woman is screened (single visit approach), 2) equipment only at a hospital level, 3) a single unit of equipment in each district, 4) allowing two districts to share a single unit of equipment, and 5) equipment placed at select district hospitals paired with mobile outreach. Users can customize the CPPT by adjusting pre-populated baseline values and assumptions, including population estimates, screening age range, screening frequency, HPV and HIV prevalence, supply costs, and health facility details.

Results

The CPPT generates data tables and graphs that compare the results of implementing each of the four screening and five treatment scenarios disaggregated by HIV status. Outputs include the number and outcomes of women screened, cost of each screening approach, provider time and cost saved by implementing self-sampling for HPV testing, number of women treated, treatment equipment needed by type, and the financial and economic costs for each equipment deployment scenario.

Conclusion

The CPPT provides practical information and data to compare tradeoffs of patient access and screening accuracy as well as efficient utilization of equipment, skilled personnel, and financial resources. Country decision makers can use outputs from the CPPT to guide the scale-up of cervical cancer screening and treatment while optimizing limited resources.

Association between serum vitamin C and HPV infection in American women: a cross-sectional study

Background

Evidence regarding the relationship between serum vitamin C levels and human papillomavirus (HPV) infection is limited. Therefore, this study aimed to investigate whether serum vitamin C levels are independently associated with HPV infection.

Methods

Data for this cross-sectional study were obtained from the National Health and Nutrition Examination Survey 2003–2006. A total of 2174 women, 18–59 years of age, were enrolled in this study. The associations between serum vitamin C levels (continuous and categorical forms) and cervicovaginal HPV infection were estimated using weighted logistic regression.

Results

The adjusted binary logistic regression showed that serum vitamin C was not associated with the risk of HPV infection after adjusting for age, race, poverty income ratio, alcohol consumption, smoking, body mass index, education, and health condition (odds ratio [OR] 0.998, 95% confidence interval [CI] 0.994–1.001). Serum vitamin C levels were converted from a continuous variable to a categorical variable for the analysis. Compared with the vitamin C deficiency and hypovitaminosis groups, there was a negative correlation between vitamin C and HPV infection when vitamin C was adequate (OR 0.7, 95% CI: 0.52–0.94); however, when the serum vitamin C level was inadequate and saturated, this negative correlation was weaker or nonexistent (OR 0.76, 95% CI 0.56–1.03 and OR 0.76, 95% CI 0.55–1.04, respectively). A nonlinear relationship was detected between vitamin C level and HPV infection. Furthermore, we performed subgroup analysis of different models and found that serum vitamin C concentration was negatively associated with HPV infection in women ≥ 25 years of age; however, in women < 25 years of age, serum vitamin C levels were not associated with HPV infection.

Conclusion

The results from this United States nationally representative sample supported the hypothesis that there was a U-shaped relationship between serum vitamin C levels and HPV infection. Future studies are warranted to assess the association between vitamin C and HPV persistence and clarify the underlying mechanisms of these associations.

Modelling cervical cancer elimination using single-visit screening and treatment strategies in the context of high HIV prevalence: estimates for KwaZulu-Natal, South Africa

INTRODUCTION

In settings with high HIV prevalence, cervical cancer incidence rates are up to six-fold higher than the global average of 13.1 cases per 100,000 women-years. To inform strategies for global cervical cancer elimination, we used a dynamic transmission model to evaluate scalable screening and treatment strategies, accounting for HIV-associated cancer risks and weighing prevention gains against overtreatment.

METHODS

We developed a dynamic model of HIV-HPV co-infection and disease progression, which we calibrated to KwaZulu-Natal, South Africa. Our baseline scenario reflects the current practice of HPV vaccination with a multi-visit screening and treatment strategy involving cytology and colposcopy triage. We evaluated 13 comparator scenarios with increased vaccination coverage and one-time, two-time or repeat HIV-targeted cervical cancer screening with the following single-visit strategies: HPV DNA testing, HPV genotyping, automated visual evaluation (AVE) and HPV DNA with AVE triage. In all scenarios, HIV antiretroviral therapy, condom use and voluntary male medical circumcision continue at baseline levels. We simulated cancer incidence under each scenario from 2020 to 2120 using the 25 best-fitting parameter sets. We present the median and range of model output from these simulations to account for parameter uncertainty.

RESULTS

We estimate that cervical cancer incidence will decrease by 87% with the continuation of current cervical cancer and HIV prevention strategies, from an age-standardized rate per 100,000 women of 80.4 (range 58.2, 112.1) in 2020 to 10.7 (4.2, 29.9) in 2120. Scenarios scaling up vaccination and single-visit strategies resulted in near- and long-term gains. With repeat HIV-targeted screening, incidence rates were projected to be 29-34% lower in 2030 relative to the baseline scenario, and elimination (incidence <4/100,000) was achieved with HPV DNA testing in 2095 and with AVE in 2114. A strategy of HPV DNA with AVE triage optimized the tradeoff between cancer cases averted and overtreatment.

CONCLUSIONS

Single-visit screening strategies could avert a substantial burden of cervical cancer and accelerate progress towards elimination in settings with a high burden of HIV. Increasing the screening frequency among women with HIV and reducing loss-to-follow-up for treatment will be key components of a successful elimination strategy.

Distribution of human papillomavirus genotypes by severity of cervical lesions in HPV screened positive women from the ESTAMPA study in Latin America

The proportion of HPV16 and 18-associated cervical cancer (CC) appears rather constant worldwide (≥70%), but the relative importance of the other HR-HPV differs slightly by geographical region. Here, we studied the HPV genotype distribution of HPV positive Latin American (LA) women by histological grade, in a sub-cohort from the ESTAMPA study; we also explored the association of age-specific HPV genotypes in severe lesions. Cervical samples from 1,252 participants (854 ≤CIN1, 121 CIN2, 194 CIN3 and 83 CC) were genotyped by two PCRs-Reverse Blotting Hybridization strategies: i) Broad-Spectrum General Primers 5+/6+ and ii) PGMY9/11 PCRs. HPV16 was the most frequently found genotype in all histological grades, and increased with the severity of lesions from 14.5% in ≤ CIN1, 19.8% in CIN2, 51.5% in CIN3 to 65.1% in CC (p < 0.001). For the remaining HR-HPVs their frequency in CC did not increase when compared to less severe categories. The nonavalent vaccine HR-types ranked at the top in CC, the dominant ones being HPV16 and HPV45. HR-HPV single infection occurs, respectively, in 57.1% and 57.0% of ≤CIN1 and CIN2, increasing to 72.2% and 91.6% in CIN3 and CC (p<0.001). No association between age and HPV type was observed in CC, although the risk of HPV16 infection in CIN3 cases increased with age. Results confirm the relevance of HPV16 in the whole clinical spectrum, with a strong rise of its proportion in CIN3 and cancer. This information will be relevant in evaluating the impact of HPV vaccination, as a baseline against which to compare genotype changes in HPV type-specific distribution as vaccinated women participate in screening in LA region. Likewise, these data may help select the best HPV testing system for HPV-based efficient, affordable, and sustainable screening programmes.

Knowledge and Awareness of Parents Towards Human Papillomavirus (HPV) and HPV Vaccines, and Vaccine Acceptability in Northern Cyprus

The human papillomavirus (HPV) vaccine is one of the most cost-effective public health measures for preventing cervical cancer and other HPV-related diseases. However, the vaccine uptake in many countries remains suboptimal. This cross-sectional study aimed to assess the knowledge and awareness of parents towards HPV, related diseases, and HPV vaccines, as well as to examine the effect of brief educational information on parents' vaccine acceptability. We used a structured interviewer-administered questionnaire to collect information from 227 outpatient visitors to a healthcare center who had children under the age of 19 years. We asked parents again about their acceptance of HPV vaccines after being provided brief educational information. Of all the parents, 43% were aware of HPV and related diseases, and 59% of those had sufficient knowledge regarding HPV while 45% of them reported that they were aware of HPV vaccines. Being Northern Cypriot was a predictor of having good knowledge, whilst being a female, having a higher education level, being 35 years or older, and being employed were the significant predictors of having greater awareness of HPV and related diseases. The HPV vaccine acceptance of the parents increased substantially in all sociodemographic groups after the provision of the educational information. The findings demonstrated that the vaccination rates of children of parents who have insufficient knowledge and awareness of HPV and vaccines are also very low. Effective educational interventions based on the specific sociodemographic characteristics of the patients should be given a stronger focus to improve vaccine acceptability among this population.

High human papillomavirus (HPV)-35 prevalence among South African women with cervical intraepithelial neoplasia warrants attention

Human papillomavirus (HPV) prevalence and genotype distribution data is important for HPV vaccine monitoring. This study investigated the prevalence and distribution of HPV genotypes in cervical lesions of unvaccinated women referred to Nelson Mandela Academic Hospital Gynaecology Department due to different abnormal cervical conditions. A total of 459 women referred to the Nelson Mandela Academic Hospital Gynaecology department were recruited. When the cervical biopsy was collected for histopathology, an adjacent biopsy was provided for HPV detection. Roche Linear Array HPV genotyping assay that detects 37 HPV genotypes was used to detect HPV infection in cervical biopsies. HPV infection was detected in 84.2% (383/455) of participants. The six most dominant HPV types were HPV-16 (34.7%), followed by HPV-35 (17.4%), HPV-58 (12.1%), HPV-45 (11.6%), HPV-18 (11.4%) and HPV-52 (9.7%). HPV-35 was the third most dominant type among women with cervical intraepithelial lesion (CIN)-2 (12.6%; single infection: 5.7% and multiple infection: 6.9%), the second most dominant type among women with CIN3 (22.2%; single infection: 8.0% and multiple infection: 14.2%); and the fourth most dominant type among women with cervical cancer (12.5%; single infection: 7.1% and multiple infection: 5.4%). A proportion of 41.1% (187/455) was positive for HPV types targeted by the Cervarix®, 42.4% (193/455) by Gardasil®4, and 66.6% (303/455) by Gardasil®9. There was a statistically significant increase when the prevalence of women infected with HPV-35 only or with other HPV types other than Gardasil®9 types was included to those infected with Gardasil®9 HPV types (66.6%, 303/455 increase to 76.0%, 346/455, p = 0.002). High HPV-35 prevalence in this population, especially among women with CIN3 warrants attention since it is not included in current commercially available HPV vaccines.

Protamine Sulfate Is a Potent Inhibitor of Human Papillomavirus Infection In Vitro and In Vivo

Human papillomavirus (HPV) infections are transmitted through sexual or other close contact and are etiologically associated with epithelial warts, papillomas, and intraepithelial lesions that may progress to cancer. Indeed, 4.8% of the global cancer burden is linked to HPV infection. Highly effective vaccines protect against two to nine of the most medically important HPV genotypes, yet vaccine uptake is inadequate and/or cost prohibitive in many settings. With HPV-related cancer incidence expected to rise over the coming decades, there is a need for effective HPV microbicides. Herein, we demonstrate the strong inhibitory activity of the heparin-neutralizing drug protamine sulfate (PS) against HPV infection. Pretreatment of cells with PS greatly reduced infection, regardless of HPV genotype or virus source. Vaginal application of PS prevented infection of the murine genital tract by HPV pseudovirions. Time-of-addition assays where PS was added to cells before infection, during infection, or after viral attachment demonstrated strong inhibitory activities on early infection steps. No effect on virus infection was found for cell lines deficient in heparan sulfate expression, suggesting that PS binds to heparan sulfate on the cell surface. Consistent with this, prophylactic PS exposure prevented viral attachment, including under low-pH conditions akin to the human vaginal tract. Our findings suggest PS acts dually to prevent HPV infection: prophylactic treatment prevents HPV attachment to host cells, and postattachment administration alters viral entry. Clinical trials are warranted to determine whether protamine-based products are effective as topical microbicides against genital HPVs.

Clinicopathological and prognostic significance of immunophenotypic characterization of endocervical adenocarcinoma using CLDN18, CDH17, and PAX8 in association with HPV status

In 2020, the WHO published a new system for classifying invasive endocervical adenocarcinoma based on histological features and high-risk human papillomavirus (HPV) infection. However, immunophenotypes of each histological subtype require further investigation. We immunohistochemically analyzed 66 invasive endocervical adenocarcinomas using three cell-lineage-specific markers: claudin 18 (CLDN18) for gastric, cadherin 17 (CDH17) for intestinal, and PAX8 for Müllerian epithelial cells. We identified five immunophenotypes of endocervical adenocarcinoma: gastric (21%); intestinal (14%); gastrointestinal (11%); Müllerian (35%); and not otherwise specified (NOS) (20%). Adenocarcinomas with gastric immunophenotype, characterized by aging (p = 0.0050), infrequent HPV infection (p < 0.0001), concurrent lobular endocervical glandular hyperplasia (p = 0.0060), lymphovascular invasion (p = 0.0073), advanced clinical stage (p = 0.0001), and the poorest progression-free (p < 0.0001) and overall (p = 0.0023) survivals, were morphologically compatible with gastric-type adenocarcinoma of the WHO 2020 classification. Conversely, most adenocarcinomas with Müllerian (91%) and intestinal (89%) immunophenotypes were HPV associated and morphologically compatible with usual- or intestinal-type adenocarcinomas of the WHO 2020 classification. The morphology of adenocarcinomas with gastrointestinal immunophenotype was intermediate or mixed between those of gastric and intestinal immunophenotypes; 57% were HPV associated. Adenocarcinomas with NOS immunophenotype were mainly HPV associated (85%) and histologically poorly differentiated. Multivariate analysis revealed that gastric (p = 0.008), intestinal + gastrointestinal (p = 0.0103), and NOS (p = 0.009) immunophenotypes were independent predictors of progression-free survival. Immunophenotypes characterized by CLDN18, CDH17, and PAX8 exhibited clinicopathological relevance and may improve the diagnostic accuracy and prognostic value of conventional histological classification.

Human papillomaviruses: diversity, infection and host interactions

Human papillomaviruses (HPVs) are an ancient and highly successful group of viruses that have co-evolved with their host to replicate in specific anatomical niches of the stratified epithelia. They replicate persistently in dividing cells, hijack key host cellular processes to manipulate the cellular environment and escape immune detection, and produce virions in terminally differentiated cells that are shed from the host. Some HPVs cause benign, proliferative lesions on the skin and mucosa, and others are associated with the development of cancer. However, most HPVs cause infections that are asymptomatic and inapparent unless the immune system becomes compromised. To date, the genomes of almost 450 distinct HPV types have been isolated and sequenced. In this Review, I explore the diversity, evolution, infectious cycle, host interactions and disease association of HPVs.

Sociodemographic Correlates of Human Papillomavirus Vaccine Uptake: Opportunistic and Catch-Up Vaccination in Norway

Simple Summary

HPV vaccination protects against virus that may cause cervical cancer. Opportunistic HPV vaccination (i.e., vaccination at a citizens’ own initiative and cost) has been available in Norway since the first HPV vaccine was licensed in 2006. A routine HPV vaccination program targeting 12-year-old girls was introduced in 2009. A delayed catch-up vaccination program was initiated in 2016, offering HPV vaccination free-of-charge to women born in 1991 and later who had not previously been vaccinated in the routine program. The aim of this study was to assess sociodemographic correlates of opportunistic and catch-up HPV vaccine uptake among women in Norway. We found inequalities in both self-paid opportunistic and free-of-charge catch-up HPV vaccine uptake among adolescents and adult women, with particularly low uptake among women with two immigrant parents and among women with a low household income.

Abstract

Achieving equity in human papillomavirus (HPV) vaccination has high priority. In this nationwide registry-based study, we aimed to investigate sociodemographic correlates of HPV vaccine uptake among women who were vaccinated opportunistically at their own initiative and cost during October 2006–June 2018, and among women who were vaccinated free-of-charge in a catch-up vaccination program during November 2016–June 2018. For 840,328 female residents born in Norway between 1975 and 1996, we retrieved HPV vaccination and sociodemographic data from national registries. We used separate models to analyze the sociodemographic correlates of the initiation and completion of HPV vaccination in opportunistic and catch-up vaccination settings. Overall initiation rate for opportunistic HPV vaccination was 2.2%. Uptake increased consistently with birth year, maternal education level, and household income. Having two immigrant parents or a mother working in a lower prestige occupation was strongly associated with low opportunistic vaccination uptake. Similar but weaker inequities were observed in catch-up HPV vaccination. Initiation rate during the first 20 months of the catch-up program was 46.2%. Completion rate was 72.1% and 73.0% for opportunistic or catch-up vaccination, respectively, with small inequities. In conclusion, HPV vaccine uptake was strongly associated with sociodemographic background both in opportunistic and catch-up vaccination settings, with particularly low uptake associated with having two immigrant parents and low household income.

Provider communication and HPV vaccine uptake: A meta-analysis and systematic review

Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6-13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3-24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication.

High human papillomavirus prevalence among females attending high school in the Eastern Cape Province of South Africa

As part of the human papillomavirus (HPV) vaccination strategy in South Africa, it is essential to have information on HPV prevalence, and HPV types distribution among the unvaccinated population. Information on the prevalence of HPV and the distribution of HPV types in adolescents and young women in South Africa’s Eastern Cape Province is minimal. Therefore, this study investigates the prevalence, distribution of HPV types, and factors associated with HPV infection amongst unvaccinated female learners. A sample composed of 213 sexually active female learners attending high schools in the Eastern Cape Province of South Africa; median age 18 years, who provided self-collected vaginal specimens. Roche Linear Array HPV genotyping assay that detects 37 HPV genotypes was used to detect HPV infection. HPV infection was detected in 76.06% (162/213) of participants. Of these 14.55% (31/213) were positive for HPV types targeted by the Cervarix® HPV vaccine (HPV-16 and/or 18), 20.66% (44/213) by Gardasil®4 (HPV-6, -11, -16 and/or -18) and 37.09% (79/213) by Gardasil®9 (HPV-6, -11, -16, -18, -31, -33, -45, -52 and/or -58). HPV-35, commonly detected in cervical cancer cases among women of African ancestry, was frequently detected (9.40%). Participants who reported to have ever consumed alcohol had a significantly higher risk of HPV infection (OR: 2.91, 95% CI: 1.38–6.11, p = 0.005). High HPV prevalence was observed among participants. The high prevalence of HPV types targeted by the Gardasil®9 vaccine encourages the introduction of the Gardasil®9 vaccine. Data from this study will inform both vaccination campaigns and monitor the impact on HPV types after vaccination.

Respective prevalence of high-risk HPVgenotypes in cervical neoplasia in Senegal

OBJECTIVES

With the perspective of prophylactic vaccination against high-risk human papillomavirus (HPV), we analyzed the viral epidemiology of cervical neoplasia in Senegal.

METHODS

All patients were treated at the Institut Joliot Curie du Cancer in Dakar. HPV genotypes were characterized using a real-time polymerase chain reaction-based approach and sequencing.

RESULTS

Histologically, there were 224 invasive carcinomas, 17 high-grade intraepithelial neoplasia (CIN), and five undetermined histologies. Molecular analysis was conclusive in 241 cases. HPV DNA was found in 207/241 (85.9%) cases while 34/241 (14.1%) remained HPV negative. There was one single genotype in 127/207 (61.4%) cases and several in 80/207 (38.6%) corresponding to 308 genotypes identified. Viral genotyping found HPV16 in 175 (56.8%) cases, HPV18 in 45 (14.6%), HPV45 in 40 (13.0%), HPV58 in 35 (11.4%), HPV33 in 6 (2.0%), HPV35 in 3 (1.0%), HPV31 in 2 (0.6%), HPV39 and HPV56 in one (0.3% each).

CONCLUSION

Our analysis showed that 98.4% of the HPV-positive cases were associated with viral genotypes covered by the 9-valent HPV vaccine. However, 14.1% of cases remained HPV negative. Therefore, prophylactic vaccination using a 9-valent vaccine should dramatically reduce the incidence of HPV-associated neoplasia but the detection and treatment of CIN remain necessary for the optimal prevention of cervical cancer.

National implementation of HPV vaccination programs in low-resource countries: Lessons, challenges, and future prospects

More than 90% of cervical cancer deaths occur in low- and middle-income countries (LMICs), which have limited capacity to mount the comprehensive national screening and precancer treatment programs that could prevent most of these deaths. The development of vaccines against the human papillomavirus (HPV) has dramatically altered the landscape of cervical cancer prevention. As of mid-2020, 56 LMICs (41% of all LMICs) have initiated national HPV vaccination programs. This paper reviews the experience of LMICs that have introduced HPV vaccine into their national programs, key lessons learned, HPV vaccination sustainability and scale-up challenges, and future mitigation measures. As international guidance evolved and countries accumulated experience, strategies for national introduction shifted with regard to target groups, delivery site and timing, preparation and planning, communications and social mobilization, and ultimately monitoring, supervision and evaluation. Despite the successes that LMICs have been able to achieve in reaching large proportions of eligible girls, there are still considerable challenges countries encounter in overcoming rumors, reaching out-of-school girls, completing the vaccine series, estimating target populations, monitoring program performance, and assuring vaccination sustainability. New opportunities, such as the entry of additional vaccine manufacturers and ongoing studies to evaluate one-dose delivery, could help overcome the outstanding barriers to higher coverage and financial sustainability. Effective use of the experience to date and advances on the horizon could enable all LMICs to move towards the coverage levels that are needed to achieve eventual elimination.

An Introduction to Virus Infections and Human Cancer

Approximately, 1.4 million virus-induced cancers occur annually, representing roughly 10% of the worldwide cancer burden, with the majority (> 85%) occurring in the lower- and middle-income countries. The viruses associated with the greatest number of cancer cases are human papillomaviruses (HPVs), which cause cervical cancer and several other epithelial malignancies, and hepatitis viruses HBV and HCV, which are responsible for the majority of hepatocellular cancer. Other oncoviruses include Epstein-Barr virus (EBV), Kaposi's sarcoma herpesvirus (KSHV), human T-cell leukemia virus (HTLV-I), and Merkel cell polyoma virus (MCPyV). These oncoviruses include various classes of DNA and RNA viruses and induce cancer by a variety of mechanisms. However, cancers develop in a minority of infected individuals and almost always after chronic infection of many year's duration. Identification of the oncoviruses has provided critical insights in human carcinogenesis and led to several interventions that may reduce the risk of developing the tumors they induce. These interventions include preventive vaccines against HBV and HPV, screening for persistent HPV and HCV infections, antivirals for the treatment of chronic HBV and HCV infection, and screening the blood supply for the presence of HBV and HCV. Further efforts to identify additional oncogenic viruses in human cancers and new insights into etiology and pathogenesis of virally induced cancers would likely lead to new approaches for prophylactic and therapeutic interventions.

Strong reduction in prevalence of HPV16/18 and closely related HPV types in sexually active adolescent women following the introduction of HPV vaccination in Argentina

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HPV16/18 decreased by >93% in vaccinated sexually active Argentine girls.

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Detected reduction of HPV31 and 45 would add to the success of immunization.

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No genotype replacement was observed.

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First HPV vaccination monitoring data reported from a Latin American country.

Burden and Prevention of HPV. Knowledge, Practices and Attitude Assessment Among Pre-Adolescents and their Parents in Italy

Despite infections due to HPV nowadays represent the most common sexually transmitted diseases worldwide with recognized effective and safe preventive strategies, knowledge, attitudes; however, awareness on HPV is considerably low. The present study has two main objectives: 1. To conduct a literature review to analyze the evolution of preventive tools, the complexity of the vaccine choice process, and the challenges posed by HPV vaccine hesitancy and refusal among pre-adolescents and their parents; 2. To assess knowledge, practices and attitudes toward HPV infection and vaccination in a sample of Italian pre-adolescents and their parents. The observational study was carried out through the use of two anonymous and self-administered pre- and post-intervention questionnaires dedicated to the target populations. Between the administrations of the pre- and post-intervention questionnaires, an educational intervention on HPV infection and related diseases, and prevention strategies was conducted. All participants demonstrated suboptimal knowledge and positive attitudes in the pre-intervention questionnaire. Higher levels of knowledge and attitudes were observed among pre-adolescents thatused social networks and had heard of sexually transmitted diseases at home/school/physician and from parents and also who had heard of HPV from General Practitioners, Gynecologists, family members and newspapers. A significant increase in HPV vaccination awareness was observed among pre-adolescents after the educational sessions. Health education programs aimed at increasing knowledge, attitudes and awareness on HPV are needed to implement the outcomes of HPV immunization programs, especially if supported by the physicians involved in counselling and recommendation processes.

Human papillomavirus prevalence and distribution in self-collected samples from female university students in Maputo

OBJECTIVE

To characterize human papillomavirus (HPV) prevalence and distribution among female university students in Maputo, Mozambique, and evaluate the determinants of HPV infection.

METHODS

A cross-sectional study among 504 female university students between February and April 2017. Cervicovaginal self-collected samples were analyzed for HPV genotypes by polymerase chain reaction-restriction fragment length polymorphism and Anyplex^TM II HPV28 Detection kit (Seegene^® ).

RESULTS

The prevalence of any HPV genotype was 28.6% (144/504). Single and multiple HPV infections were detected in 76 (15.1%) and 68 (13.5%) participants, respectively. Prevalence of high-risk HPV was significantly higher than that of low-risk HPV (P<0.001). HPV16 was the most frequent genotype, followed by HPV58, HPV66, HPV52, HPV18, HPV56, HPV61, and HPV70. The prevalence of genotypes covered by the bivalent, quadrivalent, and nonavalent vaccine was 14.3%, 15.9%, and 23.4%, respectively. Number of sexual partners over lifetime and in the past 12 months was associated with HPV infection (P<0.001 and P=0.039, respectively).

CONCLUSIONS

Knowledge of HPV genotype-specific prevalence among young women is important to set up strategies for HPV vaccination. The findings suggest that introduction of the nonavalent HPV vaccine might be the way forward in the present low-resource setting. In addition, self-sampling was useful for HPV detection and genotyping.

Key steps in vaccine development

OBJECTIVE

The goal of a vaccine is to prime the immune response so the immune memory can facilitate a rapid response to adequately control the pathogen on natural infection and prevent disease manifestation. This article reviews the main elements that provide for the development of safe and effective vaccines.

DATA SOURCES

Literature covering target pathogen epidemiology, the key aspects of the functioning immune response underwriting target antigen selection, optimal vaccine formulation, preclinical and clinical trial studies necessary to deliver safe and efficacious immunization.

STUDY SELECTIONS

Whole live, inactivated, attenuated, or partial fractionated organism-based vaccines are discussed in respect of the balance of reactogenicity and immunogenicity. The use of adjuvants to compensate for reduced immunogenicity is described. The requirements from preclinical studies, including establishing a proof of principle in animal models, the design of clinical trials with healthy volunteers that lead to licensure and beyond are reviewed.

RESULTS

The 3 vaccine development phases, preclinical, clinical, and post-licensure, integrate the requirements to ensure safety, immunogenicity, and efficacy in the final licensed product. Continuing monitoring of efficacy and safety in the immunized populations is essential to sustain confidence in vaccination programs.

CONCLUSION

In an era of increasing vaccine hesitancy, the need for a better and widespread understanding of how immunization acts to counteract the continuing and changing risks from the pathogenic world is required. This demands a societal responsibility for obligate education on the benefits of vaccination, which as a medical intervention has saved more lives than any other procedure.

The contribution of Latin American research to HPV epidemiology and natural history knowledge

Our aim was to review the major contributions of studies conducted in different Latin American (LA) countries to the field of human papillomavirus (HPV) epidemiology, natural history, risk of disease, and prevention strategies, mainly in the uterine cervix. Although cytological screening is established in several countries in LA, incidence and mortality rates from cervical cancer (CC) are still extremely high. Finally, data from large cohort studies conducted in LA countries provided seminal data to propose primary and secondary prevention modalities: the HPV vaccine has been introduced in the national immunization programs of several LA countries and multiple screening experiences using HPV testing are under evaluation in the region.