Human Papillomavirus and Cervical Cancer in Australasia and Oceania: Risk-factors, Epidemiology and Prevention

Sustained Decline in Hospitalisations for Anogenital Warts in Australia: Analysis of National Hospital Morbidity Data 2003-2020

In Australia, school-based human papillomavirus (HPV) vaccination was introduced initially for girls in 2007, and then also for boys in 2013. While studies have shown declines in the incidence of anogenital warts, there is a paucity of recent data analysis assessing the impact of vaccination on more severe disease. The National Hospital Morbidity Database of the Australian Institute of Health and Welfare (AIHW) hospitalisation admission data that included ICD-10-AM code A63.0 ('anogenital warts') as the diagnoses, for the years 2003-2020, were analysed to estimate hospitalisation rates per 100,000 mid-year population. The annual average hospitalisation rates per 100,000 population for anogenital warts in both genders combined in the age groups 10-19 years, 20-29 years, and 30-39 years decreased, respectively, from 16.9, 49.6, and 23.6 in 2003-2007 (pre-vaccine period) to 2.6, 15.2, and 14.6 in 2008-2020 (post-vaccine period), equating to declines of 84.7%, 69.4%, and 38.2%, respectively. Following the introduction of the boy's vaccination, hospitalisation rates decreased further in the respective age bands from 4.3, 22.8, and 18.4 in 2008-2013 (early post-vaccine period) to 1.1, 9.3, and 11.7 in 2014-2020 (late post-vaccine period), equating to respective declines of 73.4%, 59.3%, and 36.4%. This analysis confirms that there is a substantial incremental decline in anogenital warts hospitalisations among Australians aged 10-39 years.

Incidence, trends, and survival of oropharyngeal squamous cell cancer in Aotearoa New Zealand, 2006-2020

BACKGROUND

An increasing trend of oropharyngeal cancer (OPC) has been reported in several countries with different demographic characteristics, and often attributed to increases in human papillomavirus (HPV) infection. The survival of patients with OPC has steadily improved, especially for those with positive HPV status. This study assessed the incidence, trends, and survival of OPC in Aotearoa New Zealand (NZ) by age at diagnosis, sex and ethnicity.

METHODS

The study included all 2109 patients resident in NZ with a primary diagnosis of oropharyngeal squamous cell carcinoma from 2006 to 2020, identified from the National Cancer Registry. We assessed age-standardised incidence rate (ASR), annual percent change (APC) and overall and relative survival rates.

RESULTS

The average annual incidence of OPC was 2.2 per 100,000 population. There was a steady increase of 4.9% per year over 15 years. Although the incidence rates were higher in males over the study period, the overall rate of increase was similar in males (4.9%) and in females (4.3%). The incidence was highest in the 50-69-year group (8.8/100,000 population). This age group had an incidence that increased by 7.5% per year to 2018, and then declined. The main increase in rates was seen between the birth cohort of 1946-50 and that of 1956-60. The increase in incidence was seen in Māori and Pākehā/European populations, but no increase was seen in Pacific or Asian populations. The 5-year overall relative survival rate improved from 69% in 2006-13 to 78% in 2014-20. Survival rates were lower in older patients, females, and Māori patients.

CONCLUSION

This study confirmed a substantial increase in OPC incidence in NZ, with some evidence to suggest a recent slowing in this increase. Māori and Pākehā/European had the highest incidence, while Pacific and Asian populations showed the lowest rates and no increase over the study period. Survival rates have improved over time, but remained lower in some demographic groups.

Risk of cervical pre-cancer and cancer in women with multiple sclerosis exposed to high efficacy disease modifying therapies

There is a growing need to better understand the risk of malignancy in the multiple sclerosis (MS) population, particularly given the relatively recent and widespread introduction of immunomodulating disease modifying therapies (DMTs). Multiple sclerosis disproportionately affects women, and the risk of gynecological malignancies, specifically cervical pre-cancer and cancer, are of particular concern. The causal relationship between persistent human papillomavirus (HPV) infection and cervical cancer has been definitively established. To date, there is limited data on the effect of MS DMTs on the risk of persistent HPV infection and subsequent progression to cervical pre-cancer and cancer. This review evaluates the risk of cervical pre-cancer and cancer in women with MS, including the risk conferred by DMTs. We examine additional factors, specific to the MS population, that alter the risk of developing cervical cancer including participation in HPV vaccination and cervical screening programs.

Global pattern and trend of cervical cancer incidence from 1993 to 2012: Joinpoint regression and age-period-cohort analysis

Background

Cervical cancer ranks fourth in global cancer incidence and mortality among women. A comparison of the global trends in cervical cancer would help us to identify high focus regions and serves an opportunity to evaluate the impact of the screening programs. Hence, the current study was done to assess the global trend in the incidence of cervical cancer from 1993 to 2012 among individuals aged between 30 and 79 years.

Methods

This secondary data analysis was conducted using the World Health Organization (WHO) Cancer Incidence data of five continents plus database (America, Asia, Europe, and Oceania) on the incidence of cervical cancer. Joinpoint regression was performed to determine the average annual percent change (AAPC) in cervical cancer incidence. We performed an age-period-cohort analysis to obtain age, period, and cohort-specific deviations and rate ratio (RR).

Results

Out of the four regions studied, all the regions showed a declining trend in cervical cancer incidence. The maximum decline was found in Oceania (AAPC = -3.3%) followed by America (AAPC = -2.0%). There was a consistent rise in cervical cancer incidence across the age groups in all the four continents with the maximum burden among the elderly. All the regions showed a steady decline in the rate of cervical cancer through the periods 1998-2002 to 2007-2012. There was also a steady decline in cervical cancer incidence across the cohorts from 1923-1927 to 1978-1982 in all the regions except America.

Conclusion

To summarize, cervical cancer incidence showed a declining trend globally, with the maximum decline in the Oceania region from 1993 to 2012.

Modeling the relative risk of incidence and mortality of select vaccine-preventable diseases by wealth group and geographic region in Ethiopia

Immunization is one of the most effective public health interventions, saving millions of lives every year. Ethiopia has seen gradual improvements in immunization coverage and access to child health care services; however, inequalities in child mortality across wealth quintiles and regions remain persistent. We model the relative distributional incidence and mortality of four vaccine-preventable diseases (VPDs) (rotavirus diarrhea, human papillomavirus, measles, and pneumonia) by wealth quintile and geographic region in Ethiopia. Our approach significantly extends an earlier methodology, which utilizes the population attributable fraction and differences in the prevalence of risk and prognostic factors by population subgroup to estimate the relative distribution of VPD incidence and mortality. We use a linear system of equations to estimate the joint distribution of risk and prognostic factors in population subgroups, treating each possible combination of risk or prognostic factors as computationally distinct, thereby allowing us to account for individuals with multiple risk factors. Across all modeling scenarios, our analysis found that the poor and those living in rural and primarily pastoralist or agrarian regions have a greater risk than the rich and those living in urban regions of becoming infected with or dying from a VPD. While in absolute terms all population subgroups benefit from health interventions (e.g., vaccination and treatment), current unequal levels and pro-rich gradients of vaccination and treatment-seeking patterns should be redressed so to significantly improve health equity across wealth quintiles and geographic regions in Ethiopia.

The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent?

Background: A National human papilloma virus (HPV) Vaccination Programme for the prevention of HPV infection and associated disease using the quadrivalent HPV vaccine (4vHPV) has been funded and implemented in Australia since 2007, initially for girls only and extended to boys in 2013, with uptake rates among the highest observed worldwide. Aim: We report on the impact of this national programme on HPV prevalence and associated disease burden and estimate the potential impact of adopting a nonavalent HPV (9vHPV) vaccine. Methods: We performed a non-systematic literature review of studies measuring the burden of HPV-associated disease and infection in Australia before and after introduction of HPV vaccination. We also included key national reports with estimates of HPV-related disease burden. Results: Substantial declines in high-grade cervical disease and genital warts among vaccine-eligible women have been observed. Reductions in genital warts incidence and HPV prevalence among heterosexual men of similar age were observed before introduction of the male vaccination programme, indicating a substantial herd effect. 9vHPV vaccine is expected to prevent up to 90% of cervical and 96% of anal cancers. Of an estimated 1,544 HPV-associated cancers in 2012, 1,242 would have been preventable by the 4vHPV vaccine and an additional 187 anogenital cancers by the 9vHPV vaccine. Conclusions: Vaccination using 4vHPV vaccine has had a large demonstrable impact on HPV-related disease in Australia. A switch to 9vHPV could further reduce the HPV-associated cancer burden. With continued high coverage among both males and females, elimination of vaccine-type HPV disease seems achievable in Australia.

Performance of clinical screening algorithms comprising point-of-care HPV-DNA testing using self-collected vaginal specimens, and visual inspection of the cervix with acetic acid, for the detection of underlying high-grade squamous intraepithelial lesions in Papua New Guinea

The performance of different clinical screening algorithms comprising point-of-care HPV-DNA testing using self-collected vaginal (‘V’) specimens, and visual inspection of the cervix with acetic acid (VIA) was evaluated in Papua New Guinea.

Women aged 30–59 years provided V specimens that were tested at point-of-care using the Xpert HPV Test (Cepheid, Sunnyvale, CA). A clinician-collected cervical (‘C’) specimen was then collected for point-of-care Xpert testing, and liquid-based cytology (LBC). Following this, VIA examination was conducted, blind to HPV test results, and ablative cervical cryotherapy provided if indicated. Detection of high-grade squamous intraepithelial lesion (HSIL) by LBC was the reference standard used to evaluate clinical screening algorithms.

Of 1005 women, 36 had HSIL+. Xpert HPV Test performance using V specimens (sensitivity 91.7%, specificity 87.0%, PPV 34.0%, NPV 99.3%) was superior to VIA examination alone (51.5%, 81.4%, 17.5%, 95.6% respectively) in predicting underlying HSIL+. A screening algorithm comprising V specimen HPV testing followed by VIA examination had low sensitivity (45.5%) but comparable specificity, PPV and NPV to HPV testing alone (96.3%, 45.5%, 96.3% respectively).

A ‘test-and-treat’ screening algorithm based on point-of-care HPV testing of V specimens had superior performance compared with either VIA examination alone, or a combined screening algorithm comprising HPV testing plus VIA.

Mapping HPV Vaccination and Cervical Cancer Screening Practice in the Pacific Region-Strengthening National and Regional Cervical Cancer Prevention

OBJECTIVE

To provide background information for strengthening cervical cancer prevention in the Pacific by mapping current human papillomavirus (HPV) vaccination and cervical cancer screening practices, as well as intent and barriers to the introduction and maintenance of national HPV vaccination programmes in the region.

MATERIALS AND METHODS

A cross-sectional questionnaire-based survey among ministry of health officials from 21 Pacific Island countries and territories (n=21).

RESULTS

Cervical cancer prevention was rated as highly important, but implementation of prevention programs were insufficient, with only two of 21 countries and territories having achieved coverage of cervical cancer screening above 40%. Ten of 21 countries and territories had included HPV vaccination in their immunization schedule, but only two countries reported coverage of HPV vaccination above 60% among the targeted population. Key barriers to the introduction and continuation of HPV vaccination were reported to be: (i) Lack of sustainable financing for HPV vaccine programs; (ii) Lack of visible government endorsement; (iii) Critical public perception of the value and safety of the HPV vaccine; and (iv) Lack of clear guidelines and policies for HPV vaccination.

CONCLUSION

Current practices to prevent cervical cancer in the Pacific Region do not match the high burden of disease from cervical cancer. A regional approach, including reducing vaccine prices by bulk purchase of vaccine, technical support for implementation of prevention programs, operational research and advocacy could strengthen political momentum for cervical cancer prevention and avoid risking the lives of many women in the Pacific.

HPV vaccination in women aged 27 to 45 years: what do general practitioners think?

Background

Although the Human Papillomavirus (HPV) vaccine is registered in Australia for females aged 9 to 45 years, females aged 27 to 45 years have shown limited vaccine uptake. Our study explored general practitioners’ (GPs) views concerning HPV vaccination of females in this age group, with particular focus on the barriers and the facilitators to the delivery of the HPV vaccine.

Methods

Semi-structured telephone interviews were conducted with 24 randomly selected general practitioners from metropolitan Melbourne. Questions were based on a theoretical framework that explained the barriers and facilitators to professional behaviour change.

Results

According to the GPs, the major barriers to the uptake of the HPV vaccine included the cost of the vaccine, time constraints, and the three-dose schedule. Other barriers that were identified included GPs’ and patients’ beliefs that females in this age group were at low risk of contracting HPV, lack of awareness about the vaccine, and uncertainty about the benefits of this vaccine for females in this age group. In contrast, the facilitators that were identified included the availability of the vaccine on site, the availability of vaccine clinics or nurses for administering the vaccine, the availability of information related to the vaccine either on site or online, and positive opinions from experts in the field.

Conclusions

Our study has identified some of the barriers and facilitators to the delivery and uptake of the HPV vaccine in females aged 27 to 45 years, as perceived by GPs. Further studies should be conducted to determine which of these should be targeted or prioritised for intervention. The views of women in this age group should also be considered as these would also be influential in designing effective intervention strategies for improving the delivery and uptake of the HPV vaccine.

The high burden of cervical cancer in Fiji, 2004-07

BACKGROUND

There are few population-based data on the disease burden of cervical cancer from developing countries, especially South Pacific islands. This study aimed to determine the incidence and mortality associated with cervical cancer and the coverage of Papanicolaou (Pap) cervical cytology in 20- to 69-year-old women in Fiji from 2004 to 2007.

METHODS

National data on the incident cases of histologically confirmed cervical cancer and the associated deaths, and on Pap smear results were collected from all pathology laboratories, and cancer and death registries in Fiji from 2004 to 2007.

RESULTS

There were 413 incident cases of cervical cancer and 215 related deaths during the study timeframe. The annualised incidence and mortality rates in 20- to 69-year-old Melanesian Fijian women, at 49.7 per 100?000 (95% confidence interval (CI): 43.7-56.4) and 32.3 per 100?000 (95% CI: 26.9-38.4) respectively, were significantly higher than among 20- to 69-year-old Indo-Fijian women at 35.2 per 100?000 (P<0.001, 95% CI: 29.5-41.7) and 19.8 per 100?000 (P=0.002, 95% CI: 15.1-25.5) respectively. Of 330 cases diagnosed between 2004 and 2006, 186 (56%) had died by 31 December 2006. Pap smear coverage for this period was 8.0% (95% CI: 7.9-8.1) of the target population.

CONCLUSIONS

The incidence and mortality related to cervical cancer in Fiji is high, whereas Pap smear coverage is very low. Greater investment in alternative screening strategies and preventive measures should be integrated into a comprehensive, strategic cervical cancer control program in Fiji.

Findings and implications of the Global Burden of Disease 2010 Study for the Pacific Islands

The Global Burden of Disease 2010 Study is the largest study of its kind. It provides a large volume of information about the global burden of disease and associated risk factors. It estimates that lower respiratory infections, diabetes, diarrhea, and tuberculosis cause the greatest burden in the Pacific, and noncommunicable diseases caused a substantially greater burden in 2010 compared with 1990. Although the Pacific is considered to be a region rich in data, very little of these data has been analyzed, synthesized, and made publically available. Consequently, burden estimates for the Pacific are derived from models built with very limited data, and it is difficult to know how accurate they are. Health information in the Pacific needs strengthening, particularly in relation to data collection, analysis, use, and sharing. This will improve the reliability and comparability of burden of disease estimates.

High prevalence and incidence of HIV, sexually transmissible infections and penile foreskin cutting among sexual health clinic attendees in Papua New Guinea

Background Papua New Guinea (PNG) has one of the highest prevalences of HIV and sexually transmissible infections (STIs) in the Asia-Pacific region, and one of the highest burdens of maternal syphilis and cervical cancer globally. Despite this disease burden, only limited clinical research in sexual and reproductive health has been conducted in PNG.

METHODS

A longitudinal clinical cohort study was conducted at two sexual health clinics. Participants completed a behavioural interview, clinical assessment and genital examination at baseline, and at 12, 24 and 50 weeks, including specimen collection for STI diagnostics.

RESULTS

In total, 154 people attended a screening visit. Reattendance at 12, 24 and 50-weeks was 87%, 78% and 80% respectively. At baseline, HIV prevalence was 3.3%; chlamydia (Chlamydia trachomatis), 29.2%; gonorrhoea (Neisseria gonorrhoeae), 22.1%; Trichomonas vaginalis 15.6%; herpes simplex type-2 (HSV-2), 46.1%; active syphilis, 11.7%. Multiple infections were common particularly among women. The incidence of chlamydia was 27 per 100 person-years (PY); gonorrhoea, 15 out of 100 PY; T. vaginalis, 29 out of 100 PY; HSV-2, 12 out of 100 PY; syphilis, 8 out of 100 PY. No incident HIV cases were recorded. At baseline, 39% of men in Mt Hagen and 65% in Port Moresby had a penile foreskin cut, with a dorsal slit being the most common. Two men underwent penile cutting during the follow-up period.

CONCLUSIONS

The prevalence and incidence of STIs, HIV and penile cutting were high among sexual health clinic attendees. High retention figures suggest that this population may be suitable for future interventions research and clinical trials.

Human papillomavirus in adolescents: lessons learned from decades of evaluation

Knowledge regarding the natural history of human papillomavirus (HPV) infection and its clinical sequelae in adolescents has increased significantly over the last decade; as a result, there have been world-wide recommendations for less aggressive Pap screening and management of cervical dysplasias in young women. It is important that adolescent health providers understand these issues, as knowledge of HPV and its sequelae in the Australian community is limited, despite the introduction of a national immunisation programme. Parents and young women have expressed a desire for further information to make informed choices. This paper reviews the natural history of HPV infection in adolescents and the evidence behind new conservative guidelines for cervical screening, plus prophylactic vaccination in young women.

Cervical cancer burden and prevention strategies: Asia Oceania perspective

The Asia Oceania region contributes to more than 50% of cervical cancer cases worldwide. Yet cervical cancer is one of few cancers that can be prevented through comprehensive screening for precancerous lesions, with their subsequent treatment. Screening with cervical cytology, a very old technology, has reduced cervical cancer mortality and incidence when applied in comprehensive programs with high coverage and high quality assurance. However, of those countries within this region that have set up such programs, many have been opportunistic, had poor coverage, or inadequate treatment facilities for lesions found. Consequently, they have not seen large reductions in cancer incidence or mortality. Some have therefore adopted visual inspection by acetic acid (VIA) and Lugol's iodine (VILI) or human papillomavirus (HPV) DNA assays for screening. With two safe, immunogenic and efficacious prophylactic vaccines licensed, the way forward to reduction of cervical cancer to becoming uncommon is within reach. Where governments have supported high coverage public-health vaccination programs, reductions in disease burden with shortest incubation (genital warts, high-grade abnormalities) are already being reported. One of the biggest impediments is the cost of vaccines that are affordable to resource-poor countries. Other challenges include, infrastructure for delivery of vaccines, plus general acceptance of vaccination by the community.

A qualitative study investigating knowledge and attitudes regarding human papillomavirus (HPV) and the HPV vaccine among parents of immunosuppressed children

Barriers influencing the willingness of parents to vaccinate immunocompetent children include a lack of knowledge about human papillomavirus (HPV) and low perception of risk regarding their child's acquisition of HPV infection. However, it cannot be assumed that the facilitators and barriers of HPV vaccination are the same for parents/guardians of children who are immunocompromised, or who have chronic medical conditions. This study aimed to document the knowledge and attitudes of parents/guardians of immunosuppressed children and adolescents towards HPV infection and the vaccine. A study using qualitative methods which incorporated 27 semi-structured interviews was undertaken with parents/guardians of immunosuppressed children vaccinated against HPV at three hospitals in two states of Australia. Thematic analysis revealed that while participants acknowledged that they had heard of HPV, they did not have a strong sense of what it actually was. The level of concern held about their child acquiring an HPV infection (prior to vaccination) ranged from 'not at all' to 'extremely'. Some believed that their child was at increased risk of developing a severe HPV-related illness because of their underlying condition. The participants supported their child receiving the HPV vaccine, as they did not want to take a risk with a disease that may cause their child to return to hospital for treatment. The majority had little apprehension about the use of the HPV vaccine but expressed some concern that potential adverse effects would be more severe for immunosuppressed children. However, they stressed their belief in the safety of the vaccine and their trust in the child's health team. Our study results show that parents of children with impaired immunity would benefit from further information about the safety of the vaccine and about the important role of the vaccine for boys as well as girls.

Acceptability of school requirements for human papillomavirus vaccine

We characterized parental attitudes regarding school HPV vaccination requirements for adolescent girls. Study participants were 866 parents of 10–18 y-old girls in areas of North Carolina with elevated cervical cancer incidence. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) by logistic regression. Approximately half (47%) of parents agreed that laws requiring HPV immunization for school attendance "are a good idea" when opt-out provisions were not mentioned. Far more agreed that "these laws are okay only if parents can opt out if they want to" (84%). Predictors of supporting requirements included believing HPV vaccine is highly effective against cervical cancer (OR = 2.5, 95% CI:1.7–.0) or is more beneficial if provided at an earlier age (OR = 16.1, 95% CI:8.4–1.0). Parents were less likely to agree with vaccine requirements being a good idea if they expressed concerns related to HPV vaccine safety (OR = 0.3, 95% CI:0.1–.5), its recent introduction (OR = 0.3, 95% CI:0.2–.6). Parental acceptance of school requirements appears to depend on perceived HPV vaccine safety and efficacy, understanding of the optimal age for vaccine administration, and inclusion of opt-out provisions.

The relationship of knowledge, health value and health self-efficacy with men's intentions to receive the human papillomavirus (HPV) vaccine

The aim of the present study was to determine whether it was possible to predict Human Papillomavirus (HPV) vaccination intentions an Australian male sample. One hundred and twenty one males aged 18 to 26 (M = 22.3, SD = 2.06), completed an online survey assessing HPV-related knowledge, health beliefs and health self-efficacy. HPV knowledge and health self-efficacy were significant independent predictors of vaccine acceptance. A moderating effect was found between HPV knowledge and health self-efficacy. It was concluded that the results of previous research into the predictors of HPV vaccination intentions can largely be applied to an Australian male population.

Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control

This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.

Scaling up human papillomavirus vaccination: a conceptual framework of vaccine adherence

This review article provides a conceptual framework for human papillomavirus (HPV) vaccine acceptance and adherence, with a focus on improving understanding of the sociocultural factors impacting vaccine adherence behaviour. We include a systematic review of the slowly expanding literature on HPV vaccine acceptability and uptake in developed nations, as well as the relatively few publications from poorer nations, where more than 80% of global cervical cancer related deaths occur and where the vaccine will probably have the largest impact. We suggest that this conceptual framework will not only improve our understanding of HPV vaccine uptake and adherence, but it may also guide future sociobehavioural research geared towards improving adherence to the HPV vaccine and other multi-step vaccines in a young population at risk for sexually transmissible infections.

Cancers attributable to human papillomavirus infection

Although the human papillomavirus (HPV) vaccine was introduced primarily as a cervical cancer prevention vaccine, HPV has a causal role in several types of cancer. This article reviews the epidemiological evidence for the role of HPV in human cancer, and describes Australian trends in these cancers. HPV is a necessary cause of cervical cancer. The currently vaccine-preventable subtypes of HPV 16 and 18 are responsible for ~70% of cervical cancer. The introduction of an organised Pap smear program in Australia led to a steep decline in incidence over the past decades. HPV can be detected in ~40% and 70% of vulval and vaginal cancers respectively. Rates of these cancers have been stable over the past 20 years. The prevalence of HPV in penile cancer is ~50% and incidence has not recently changed. For anal cancer, ~85% of cases are HPV positive, and incidence has increased significantly in both men and women over the past 20 years. In the oral cavity, ~35% of oropharyngeal cancers and ~25% of other oral cavity cancers are HPV positive. The incidence of HPV-related oral cavity and oropharyngeal cancers is increasing, whereas incidence at HPV-unrelated sites is decreasing. Overall, 1154 HPV-related cancer cases were potentially preventable by vaccination. If HPV-related cancers at non-cervical sites are prevented by vaccination, then a similar number of cancer cases will be prevented as in the cervix. However, almost one-quarter of the potentially preventable cancer cases are in men, who are not included in the current national immunisation program.

Evaluation of a cervical cancer screening program based on HPV testing and LLETZ excision in a low resource setting

We conducted studies in Vanuatu to evaluate potential screening and treatment strategies to assist with control of cervical cancer. In a pilot study of 496 women, visual inspection and cytology were evaluated as screening tests for detection of CIN 2 or worse (CIN2+), observed in 21 of 206 subjects biopsied on the basis of abnormal visual inspection or cytology. Sensitivity of visual inspection with Lugol's Iodine for detection of CIN2+ on biopsy was 0.63, specificity was 0.32, and the positive predictive value was 0.09. For HSIL cytology, sensitivity was 0.99, specificity was 0.77, and the positive predictive value was 0.88. HSIL cytology was significantly more sensitive and had a significantly higher PPV for CIN 2+ than visual inspection (p<0.01). In a further study of 514 women, we compared testing for HR HPV and cytology as predictors of biopsy proven CIN 2+. Sensitivity of HSIL cytology for CIN2+ as established by loop excision of the cervix was 0.81, specificity was 0.94, and positive predictive value was 0.48. Sensitivity of a positive test for HR HPV for detection of CIN2+ was non-significantly different from cytology at 0.81, specificity was 0.94, and positive predictive value was 0.42. Combining the two tests gave a significantly lower sensitivity of 0.63, a specificity of 0.98, and a positive predictive value of 0.68. For women over 30 in a low resource setting without access to cytology, a single locally conducted test for high risk HPV with effective intervention could reduce cervical cancer risk as effectively as intervention based on cytology conducted in an accredited laboratory.

Human papillomavirus vaccines: current status and future prospects

Worldwide, cervical cancer is the second most common cancer of women. Less-developed countries bear the greatest burden in terms of morbidity and mortality, largely due to the lack of organized screening programmes. Cervical cancer is the first cancer shown to be caused solely by virological agents: oncogenic genotypes of human papillomavirus (HPV). Two recently developed prophylactic cervical cancer vaccines, which are based on viral-like particle (VLP) technology of HPV, have the capacity to diminish a large proportion of cervical cancer cases worldwide. However, to be successful public health tools, they need to be widely implemented to the appropriate target population, preferably prior to first sexual intercourse. To increase vaccination coverage, national programmes in some countries have also included catch-up vaccination, for a limited time period, to young adult women aged up to 26 years. Despite the excellent efficacy for high-grade dysplasia due to vaccine-related HPV types (near to 100%) and immunogenicity induced against the HPV types 16 and 18 in females naive to those HPV types pre-vaccination, some form of cervical precancer screening will still be necessary. Immunity to HPV is primarily type specific, and thus protection induced by the current generation of vaccines, based on a limited number of HPV VLP types, cannot provide complete protection against all oncogenic HPV types. Both these vaccines translate to protection of cervical cancer in the order of 70-75%, which represents the percentage of invasive cancers attributable to HPV-16 and -18. Challenges to ensuring the successful control of this largely preventable disease include endorsement by governments and policy makers, affordable prices, education at all levels, overcoming barriers to vaccination and continued adherence to screening programmes.

"Is cancer contagious?": Australian adolescent girls and their parents: making the most of limited information about HPV and HPV vaccination

INTRODUCTION

Australia has implemented a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies that explore knowledge about HPV and HPV vaccine post-implementation of the national school-based HPV vaccination program.

METHODS

A purposive sample of schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and different school types (Catholic, Independent or Government). Semi-structured focus groups and interviews were conducted with girls and their parents respectively, until saturation was reached. Transcripts were analysed, letting themes emerge from the data.

RESULTS

A core theme from both girls and parents was lack of knowledge. Supporting themes were lack of knowledge of HPV, lack of knowledge of vaccine, and realisation of their lack of knowledge. Their lack of knowledge was common in three areas: what HPV is, how HPV is transmitted, and the HPV and cervical cancer connection. The lack of knowledge about HPV vaccination was reflected in what the vaccine protects against, how the vaccine works, HPV vaccination recommendations, the vaccine and Pap smear connection, and myths about HPV vaccination. Both girls and parents wanted more information, had a tendency to defer responsibility, and parents expressed judgment of themselves as parents.

DISCUSSION

Low levels of knowledge and understanding about HPV vaccination among adolescents and parents have implications for adolescents' future health practices, including sexual risk behaviour, condom usage, and cervical screening. Reasons for the low levels of knowledge are explored, as are implications for school-based educational interventions.

Monitoring the control of human papillomavirus (HPV) infection and related diseases in Australia: towards a national HPV surveillance strategy

This paper describes a possible multifaceted approach to human papillomavirus (HPV) related surveillance in Australia following implementation of a national HPV vaccination program. We describe eight main components: monitoring of vaccine coverage, vaccine safety, type-specific HPV infection surveillance, cervical cytology (Pap screening) coverage and screen detected lesion prevalence, cervical cancer incidence and mortality, genital wart incidence, incidence of recurrent respiratory papillomatosis, and knowledge, attitudes and beliefs about HPV and HPV vaccination. Australia is well placed to monitor the impact of its HPV vaccination program as well as to measure vaccine effectiveness with existing HPV vaccines, cervical screening and cancer registries.

Global reduction of cervical cancer with human papillomavirus vaccines: insights from the hepatitis B virus vaccine experience

Background: Worldwide, prophylactic vaccines against two major human cancers are now commercially available: hepatitis B virus (HBV) vaccines (first licensed in 1982) against primary hepatocellular carcinoma and human papillomavirus (HPV) vaccines (first licensed 2006) against cervical cancer. Initial implementation strategies for HBV vaccination were not successful in preventing disease in the community: it took 15 years for significant global reduction in the burden of this disease. Methods: We compare and contrast HBV vaccine experiences to challenges for successful global HPV vaccination strategies, and make recommendations accordingly. Results: Lessons from HBV immunisation for successful outcomes with HPV immunisation showed that several factors need to be met: (i) the engagement of key stakeholders in all aspects of planning and delivery of HPV vaccine strategies; (ii) understanding the specific characteristics of targeted population groups; (iii) global cooperation and support with WHO recommendations; (iv) Government supported mass immunization programs and cooperation between public and private entities; (v) affordable HPV vaccines for some regions; (vi) culturally appropriate and diverse public education programs in targeted health promotion strategies; (vii) pro-active health providers and parents in encouraging adolescents to undertake HPV vaccination; and (vii) eventual immunisation of infants. Conclusions: The key to success will be affordable, readily deliverable HPV vaccines to young girls as universal campaigns.

National survey of general practitioners' experience of delivering the National Human Papillomavirus Vaccination Program

Background: Between 2007 and 2009, Australian general practitioners (GPs) were involved in implementing a population-based human papillomavirus (HPV) vaccination program. We investigated GPs’ experiences of delivering the HPV vaccine to women aged 18–26. Methods: We posted a survey to 1000 GPs. The survey was informed by 12 domains incorporating constructs from psychological theories that focus on individual and environmental barriers and facilitators to effective implementation of evidence-based practice by health professionals. Results: The response rate was 32%. The 298 vaccinating GPs were positive about HPV vaccine implementation as part of their professional role as a worthwhile initiative within existing general practice infrastructure. They had more negative views about some aspects of program organisation, such as the timelines and potential adverse impacts on cervical screening rates. Vaccine safety was not a key concern. Actual levels of knowledge about HPV were moderate (mean score 3.41 out of 6 (s.d. 0.99)) and contrasted with self-rated knowledge, which was high (93% perceived their knowledge to be adequate). Notably, there were unrealistic expectations about the likely reduction in Pap abnormalities due to vaccination, which is important to clarify to avoid loss of confidence in the vaccine when this reduction does not eventuate. Conclusions: Australian GPs viewed HPV vaccination of women aged 18–26 years as an integrated part of their routine practice, with positive attitudes regarding its benefits and achievability. GPs are well placed to implement mass immunisation programs as long as they are supported by effective and timely communication strategies and resources.

Control of cervical cancer: women's options and rights

Cervical cancer takes the lives of more than 250,000 women each year globally, particularly in under-resourced areas of low-, middle-, and high-income countries. Options for cancer control and treatment have reached a point that there are interventions for control that could be adopted for virtually every resource and demographic situation. Women die despite the availability of attractive control options, which means that educating policy makers, women's health professionals, as well as women themselves, must become a major focus for ongoing control of this disease. The human right to life, to prevention of suffering, and to education are all key rights linked to improving the control of cervical cancer and saving the lives of women, particularly in resource-poor parts of the world.

Early experience with human papillomavirus vaccine introduction in the United States, Canada and Australia

Successful incorporation of a new vaccine into a nation's vaccination program requires addressing a number of issues, including: 1) establishing national recommendations; 2) assuring education of and acceptance by the public and medical community; 3) establishing and maintaining an appropriate infrastructure for vaccine delivery; 4) financing the vaccine and the program, in addition to political will. This article reviews the early experience with implementation of human papillomavirus (HPV) vaccination programs. It focuses on the United States of America and Canada and provides a brief report on Australia, where introduction is underway.

Recommendations for cervical cancer prevention in Asia Pacific

Asia Oceania includes countries from both the Asia Pacific region and Australasia, which cover very diverse geographical areas and populations as well as bearing 52% of the cervical cancer burden in the world. Human papillomavirus (HPV) genotype distribution in women with normal cytology varies between countries in this region, as well as with the distribution typically observed in worldwide estimates or in Western countries. HPV-16 remains the predominant oncogenic type for high-grade cervical dysplasia and cervical cancer across the region, and HPV-18 is generally among the five most common types. HPV-58 is commonly found in cervical cancer as well as in women with normal cytology, and HPV-31, 33 and 35 are relatively less frequent in these regions compared to the West. While screening programmes have been proposed and implemented in several populations, successful programmes are rather limited and the majority of countries still have no or minimal screening services. Prophylactic HPV vaccination will only be feasible when it becomes affordable, thus the current priority and the short-term goal for cervical cancer control is to identify feasible and effective screening measures, and to find the most effective way to combine vaccination with sustainable screening programmes. This Regional Report has carefully described the disease burden of HPV and cervical cancer and the current situations in cervical cancer prevention for many countries in the Asia Oceania region. These data identify the many challenges and opportunities to be considered for policy decisions for cervical cancer control. Furthermore, this report presents the results of advanced decision analytic models calibrated to countries in the region that provide early insight into what strategies are most promising and those likely to be cost-effective and affordable. It thus provides a synthesis of the available evidence-based scientific information, in the context of a significant and systematic international review, that is likely to be useful to governments and public health providers.