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Khoja L, Torres HG, Hak L, Aljebori M, Phung MT, Sakleh A, Stiffler M, Tariq M, Pearce CL. Cervical cancer screening and vaccination acceptability and attitudes among Arab American women in Southeastern Michigan: a qualitative study. Sci Rep 2024; 14:13624. [PMID: 38871762 PMCID: PMC11176183 DOI: 10.1038/s41598-024-64462-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 06/10/2024] [Indexed: 06/15/2024] Open
Abstract
Among Arab-American women in Michigan, rates of cervical cancer screening are lower than those in non-Hispanic White and Black women in the state. A deep understanding of the Arab community's perspective on cervical cancer screening is needed to address the disparity in rates across populations in Michigan. Arab and Chaldean women across Michigan were invited to participate in Zoom-based focus groups to understand the attitudes, acceptability, and barriers of cervical cancer screening among this population. Four focus groups with a total of 19 women aged 30 to 61 were conducted. The focus groups were conducted in English, Arabic, or both languages. The guided discussion was focused on knowledge of cervical cancer and Human papillomavirus (HPV) and its transmission, attitudes towards HPV vaccination, and attitudes towards cervical cancer screening. HPV self-sampling as an alternative to traditional provider-based screening was specifically discussed as this has been proposed as a way to increase screening in hard-to-reach populations. The conversations revealed insights related to barriers at the individual and community levels for screening and vaccination, attitudes towards preventive health care including screening, a need for accessible women's health literature, and health education. The women also discussed vaccine hesitancy related to HPV and COVID-19, suggesting a need for targeted community interventions.
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Affiliation(s)
- Lilah Khoja
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Heidi G Torres
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Layla Hak
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Manar Aljebori
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Minh Tung Phung
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Andrea Sakleh
- Center for Arab Narratives at the Arab American National Museum, ACCESS, 6450 Maple St., Dearborn, MI, 48126, USA
| | - Matthew Stiffler
- Center for Arab Narratives at the Arab American National Museum, ACCESS, 6450 Maple St., Dearborn, MI, 48126, USA
| | - Madiha Tariq
- ACCESS Community Health and Research Center, 6450 Maple St., Dearborn, MI, 48126, USA
| | - Celeste Leigh Pearce
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
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Malagón T, Franco EL, Tejada R, Vaccarella S. Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination. Nat Rev Clin Oncol 2024:10.1038/s41571-024-00904-z. [PMID: 38760499 DOI: 10.1038/s41571-024-00904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.
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Affiliation(s)
- Talía Malagón
- Department of Oncology, McGill University, Montréal, Quebec, Canada.
- St Mary's Research Centre, Montréal West Island CIUSSS, Montréal, Quebec, Canada.
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada.
| | - Eduardo L Franco
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Romina Tejada
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
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Falcaro M, Soldan K, Ndlela B, Sasieni P. Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England: population based observational study. BMJ 2024; 385:e077341. [PMID: 38749552 PMCID: PMC11094700 DOI: 10.1136/bmj-2023-077341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES To replicate previous analyses on the effectiveness of the English human papillomavirus (HPV) vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia (CIN3) using 12 additional months of follow-up, and to investigate effectiveness across levels of socioeconomic deprivation. DESIGN Observational study. SETTING England, UK. PARTICIPANTS Women aged 20-64 years resident in England between January 2006 and June 2020 including 29 968 with a diagnosis of cervical cancer and 335 228 with a diagnosis of CIN3. In England, HPV vaccination was introduced nationally in 2008 and was offered routinely to girls aged 12-13 years, with catch-up campaigns during 2008-10 targeting older teenagers aged <19 years. MAIN OUTCOME MEASURES Incidence of invasive cervical cancer and CIN3. RESULTS In England, 29 968 women aged 20-64 years received a diagnosis of cervical cancer and 335 228 a diagnosis of CIN3 between 1 January 2006 and 30 June 2020. In the birth cohort of women offered vaccination routinely at age 12-13 years, adjusted age standardised incidence rates of cervical cancer and CIN3 in the additional 12 months of follow-up (1 July 2019 to 30 June 2020) were, respectively, 83.9% (95% confidence interval (CI) 63.8% to 92.8%) and 94.3% (92.6% to 95.7%) lower than in the reference cohort of women who were never offered HPV vaccination. By mid-2020, HPV vaccination had prevented an estimated 687 (95% CI 556 to 819) cervical cancers and 23 192 (22 163 to 24 220) CIN3s. The highest rates remained among women living in the most deprived areas, but the HPV vaccination programme had a large effect in all five levels of deprivation. In women offered catch-up vaccination, CIN3 rates decreased more in those from the least deprived areas than from the most deprived areas (reductions of 40.6% v 29.6% and 72.8% v 67.7% for women offered vaccination at age 16-18 and 14-16, respectively). The strong downward gradient in cervical cancer incidence from high to low deprivation in the reference unvaccinated group was no longer present among those offered the vaccine. CONCLUSIONS The high effectiveness of the national HPV vaccination programme previously seen in England continued during the additional 12 months of follow-up. HPV vaccination was associated with a substantially reduced incidence of cervical cancer and CIN3 across all five deprivation groups, especially in women offered routine vaccination.
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Affiliation(s)
- Milena Falcaro
- Centre for Cancer Screening, Prevention and Early Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, UK Health Security Agency (UKHSA), London, UK
| | - Busani Ndlela
- National Disease Registration Service (NDRS), NHS England, London, UK
| | - Peter Sasieni
- Centre for Cancer Screening, Prevention and Early Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK
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Checchi M, Mesher D, Panwar K, Anderson A, Beddows S, Soldan K. The impact of over ten years of HPV vaccination in England: Surveillance of type-specific HPV in young sexually active females. Vaccine 2023; 41:6734-6744. [PMID: 37821315 DOI: 10.1016/j.vaccine.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION The UK national human papillomavirus (HPV) vaccination programme was introduced in 2008 using the bivalent HPV16/18 vaccine, changing to the quadrivalent HPV6/11/16/18 vaccine from 2012. We provide an analysis of type-specific HPV prevalence in young sexually active females in England to end 2020 (when the first routinely HPV vaccinated females were reaching 25 years of age and entering the National Health Service Cervical Screening Programme), showing the impact of over ten years of high coverage HPV vaccination. METHODS Residual vulvovaginal swabs (VVS) were collected from 16 to 24 year old women attending for chlamydia screening between 2010 and 2020, anonymised and tested for type-specific HPV DNA. Trends in vaccine and non-vaccine HPV type prevalence were compared over time and association with vaccination coverage was evaluated within the post-vaccination period. RESULTS A total of 21,168 eligible VVS specimens were tested for HPV DNA. The prevalence of HPV16/18 in sexually active 16-18 year old females who were offered vaccination aged 12-13 years was <1% in the most recent years tested, compared to over 15% prior to the vaccination programme in 2008. The magnitude of these decreases also suggests reduced transmission is offering some herd protection to unvaccinated females. HPV31/33/45 prevalence also steadily decreased, providing evidence of cross-protection. HPV6/11 prevalence remained stable during the bivalent vaccine period, with more recent declines, as expected due to the use of the quadrivalent vaccine. There has been no substantive increase in the prevalence of other high-risk (HR) HPV types. DISCUSSION More than ten years of high coverage HPV vaccination in adolescent females in England has delivered dramatic declines in the prevalence of HPV vaccine-types and closely related HPV types in females in the vaccine eligible age group, and no indication of type replacement. These findings should enable confidence in planning for cervical screening of these females, and in predicting declines in HPV-related cancers.
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Affiliation(s)
- Marta Checchi
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK.
| | - David Mesher
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
| | - Kavita Panwar
- Virus Reference Department, UK Health Security Agency, London, UK
| | - Anja Anderson
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
| | - Simon Beddows
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK; Virus Reference Department, UK Health Security Agency, London, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
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van Eer K, Middeldorp M, Dzebisasjvili T, Lamkaraf N, de Melker HE, Steenbergen RDM, King AJ. Effects of 2 and 3 Vaccinations With the Bivalent Human Papillomavirus (HPV) Vaccine on the Prevalence and Load of HPV in Clearing and Persistent Infections in Young Women. J Infect Dis 2023; 228:1012-1022. [PMID: 36988110 DOI: 10.1093/infdis/jiad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) viral load (VL) is associated with persistence, which increases cervical cancer risk. The bivalent vaccine protects against oncogenic HPV-16/18 and cross-protects against several nonvaccine types. We examined the effect of 2-dose (2D) and 3-dose (3D) vaccination on HPV prevalence and VL in clearing infections and persistent infections, 6 years and 12 years postvaccination, respectively. METHODS Vaginal swabs collected from the "HPV Amongst Vaccinated and Non-vaccinated Adolescents" study (HAVANA, 3D-eligible) and HAVANA-2 (2D-eligble) participants were genotyped for HPV with the SPF10-DEIA-LiPA25 system. HPV VL was measured with type-specific quantitative polymerase chain reaction (qPCR). RESULTS HPV-16, -18, -31, -33, and -45 clearing and/or persistent infection prevalence and HPV-16, -18, and -31 VLs in clearing infections were significantly reduced in 3D-vaccinated women compared to unvaccinated women. Except for HPV-11 and -59 clearing infections, no significant VL differences were observed among vaccinated women, ≤6 and >6 years post-vaccination. Infection numbers were low in 2D-eligible women, with no HPV-16/18 in vaccinated women. No VL differences for the remaining types were found. CONCLUSIONS 3D vaccination reduces HPV prevalence in clearing infections and persistent infections and decreases HPV VLs in clearing infections, 12 years post-vaccination for vaccine and several nonvaccine types. 2D-eligible women had low infection numbers, with no HPV-16/18 among vaccinated women.
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Affiliation(s)
- Kahren van Eer
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
| | - Marit Middeldorp
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
| | - Tsira Dzebisasjvili
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
| | - Najima Lamkaraf
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
| | - Hester E de Melker
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
| | - Renske D M Steenbergen
- Pathology, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Audrey J King
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands
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Deng D, Shen Y, Li W, Zeng N, Huang Y, Nie X. Challenges of hesitancy in human papillomavirus vaccination: Bibliometric and visual analysis. Int J Health Plann Manage 2023; 38:1161-1183. [PMID: 37309072 DOI: 10.1002/hpm.3665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/30/2023] [Accepted: 05/15/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) vaccine has immense research value in the prevention of related tumours. A huge body of work has been published in this field, which may pose difficulties for researchers aiming to investigate all the available information. However, bibliometrics can provide deep insights into this research field. OBJECTIVE We aimed to study HPV vaccine development, visually analyse the development status, trends, research hotspots, and frontiers of this field, and provide a reference for research on it. METHODS Articles were acquired from the Web of Science Core Collection. VOS viewer and CiteSpace software were used to analyse publication growth, country/region, institution, journal distribution, author, reference, and keywords, and collected burst keyword words to display research hotspots. RESULTS A total of 4831 references were obtained, and the annual number of publications increased fluctuating over the past decade. The United States of America ranked at the top in terms of percentage of articles. The institution with the highest number of research publications in this field was the Centers for Disease Control and Prevention. The most productive and frequently cited authors was Lauri E Markowitz. The journal with the most publications in this field was Vaccine, and the most influential journal was Paediatrics. The most frequently cited reference was 'A 9-Valent HPV Vaccine against Infection and Intraepithelial Neoplasia in Women'. Burst detection analysis of top keywords showed that 'national immunisation survey', 'social media', and 'hesitancy' are the current research frontiers in this field. CONCLUSION This study provides useful information for acquiring knowledge on HPV vaccine. Research on solving the hesitation of HPV vaccination will become an academic trend in this field, which can offer guidance for more extensive and in-depth studies in the future.
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Affiliation(s)
- Disi Deng
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yifeng Shen
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wanjing Li
- Department of Gynaecology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Nan Zeng
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yefang Huang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaowei Nie
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
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Deng S, Welby S, Liu Z, Yang Y, Meng R, Sun Y, Yang J, Liu G, He Y, Jiang N, Wu Z, Liu K, Rosillon D, Cohet C, Borys D, Zhan S. MOnitoring human papillomavirus Vaccine effect on Infection and cErvical diseases (MOVIE): Protocol for a cohort study using electronic health records from Yinzhou, China. Hum Vaccin Immunother 2023; 19:2257989. [PMID: 37813849 PMCID: PMC10997301 DOI: 10.1080/21645515.2023.2257989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
Cervical cancer is the fourth most common cancer in women, with a high disease burden worldwide. Human papillomavirus (HPV) vaccination reduces HPV-related infection and associated cervical lesions and cancers. Few studies have explored HPV vaccination impact in real-world settings in China. This study aims to monitor HPV vaccine uptake and its effects on HPV-related diseases, evaluating vaccine effectiveness in a real-world context and complementing clinical trial results. Electronic health records (EHRs) from 2010 to 2020 from the Yinzhou Regional Health Information Platform (YRHIP) will be queried/extracted to identify and monitor HPV vaccine uptake in females aged 9-45 years, and HPV-related screening and prevalence (i.e., cervical HPV infection, cervical intraepithelial neoplasia [CIN] grades 1-3, and cervical cancer) in a cohort of females aged 9-70 years. Cervical cancer screening guidelines and expert consultation will be used for intra-database validation, to determine the best algorithm for identifying HPV-related disease. Pre-launch (2010-2016) and post-launch (2018-2020) periods are predefined. A time trend analysis will be performed to describe the vaccination impact on disease prevalence and, if prerequisite conditions are met, vaccine effectiveness will be computed using logistic regression, adjusting for age, calendar year, history of screening and HPV infection. Cohort study design, outcomes validation, data linkage, and multi-step statistical analyses could provide valuable experience for designing other real-world studies in the future. The study outcomes can help inform policy-makers about uptake and HPV vaccination policy in girls and women in Yinzhou District, and provide insights on progress toward achieving goals set by the World Health Organization.
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Affiliation(s)
- Siwei Deng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Ministry of Education, Key Laboratory of Epidemiology of Major Diseases (Peking University), Beijing, China
| | | | - Zhike Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Ministry of Education, Key Laboratory of Epidemiology of Major Diseases (Peking University), Beijing, China
| | - Yu Yang
- National Institute of Health Data Science, Peking University, Beijing, China
| | - Ruogu Meng
- National Institute of Health Data Science, Peking University, Beijing, China
| | - Yixin Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Junting Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Ministry of Education, Key Laboratory of Epidemiology of Major Diseases (Peking University), Beijing, China
| | - Guangxu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | | | | | | | | | | | | | | | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Ministry of Education, Key Laboratory of Epidemiology of Major Diseases (Peking University), Beijing, China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
- Institute for Artificial Intelligence, Peking University, Beijing, China
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Chen M, Li C, Cui Q, Zhou C, Chen P, Yao S. The efficacy of human papillomavirus prophylactic vaccination after conization in preventing cervical intraepithelial neoplasia recurrence: A prospective observational study in China. Eur J Obstet Gynecol Reprod Biol 2023; 286:10-15. [PMID: 37159990 DOI: 10.1016/j.ejogrb.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/26/2023] [Accepted: 04/16/2023] [Indexed: 05/11/2023]
Abstract
High-risk human papillomavirus (hrHPV) infection is the cause of most cervical cancers. Since therapeutic vaccines are not yet available for clinical practice, the administration of HPV prophylactic vaccines in patients with cervical intraepithelial neoplasia (CIN) arouses great interest and its value after excisional treatment of CIN remains unclear. We conducted this prospective cohort study to evaluate the impact of HPV prophylactic vaccination on preventing women from subsequent infection and cervical lesions after excision treatment. 148 patients after loop electrosurgical excision procedure (LEEP) for CIN2+ disease received HPV prophylactic vaccination (6/11/16/18 vaccine, Gardasil®, Merck) after surgery (V-group) and 273 didn't get vaccination (NV-group). The HPV infection rates at the first and second year after LEEP were significantly lower in the V-group than that in NV-group (P = 0.049 and P = 0.026). CIN2+ recurrence was observed in 29 cases (10.62 %) in the NV-group and 2 cases (2.03 %) in the V-group. Logistic regression analysis showed that the HPV16/18 infection, the CIN3 pathology after LEEP and no vaccination after LEEP were significant risk factors of recurrence. Patients without HPV vaccination had a higher CIN2+ recurrence rate (OR = 12.35, 95 % CI 1.919-79.492, P = 0.008). Our study showed the quadrivalent prophylactic HPV vaccination after LEEP had a significantly protective role in the prevention of high-grade squamous intraepithelial lesion recurrence. Further randomized, controlled trials are required in elucidating the efficacy of the prophylactic HPV vaccines using shortly after LEEP in patients with CIN disease.
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Affiliation(s)
- Ming Chen
- Department of Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, China
| | - Cheng Li
- Department of Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, China
| | - Qiulin Cui
- Department of Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, China
| | - Chengli Zhou
- Department of Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, China
| | - Peisong Chen
- Department of Clinical Laboratory, Department of Laboratory Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shuzhong Yao
- Department of Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, China.
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Rickford R, Rogers M, Halliday A, Lamptey P, Kola-Palmer S. Attitudes to reducing cervical screening frequency among UK women: A qualitative analysis. Psychooncology 2023; 32:721-729. [PMID: 36855835 DOI: 10.1002/pon.6117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Cervical cancer remains a significant health threat amongst women globally despite most cervical cancers being preventable through screening and Human Papilloma Virus (HPV) vaccination. With the introduction of HPV testing and vaccination, evidence suggests that the frequency of cervical screening for women can be reduced. However, there is limited evidence on women's attitudes to possible changes to the cervical screening programme. This study explored attitudes, perceptions and beliefs of women in the United Kingdom (UK) regarding potential changes to the National Cervical Screening Programme. METHOD Forty-four women were interviewed between November 2018 and March 2019. Reflexive thematic analysis was used to identify key themes. RESULTS Most participants were opposed to any reduction in cervical screening frequency. Reasons included perceptions that disease would develop undetected, disempowerment, increased anxiety, reduced motivation to attend, and inefficient use of health care resources. Women perceived that they were ill-informed about the reasons for the proposed change, and that access to evidence for the basis of proposed changes may persuade them to accept reduced screening frequency. Women believed that cervical screening is a test for cancer and that HPV vaccination does not provide reliable protection against cervical cancer. These beliefs suggest that women's perception that they require more information about the basis for reduced screening frequency is correct. CONCLUSION Any changes to cervical screening frequency need to ensure public support and trust through a robust public health initiative clearly identifying the rationale for any changes.
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Affiliation(s)
- Rose Rickford
- Department of Sociology, University of York, York, UK
| | - Melanie Rogers
- Department of Nursing, University of Huddersfield, Huddersfield, UK
| | - Abigail Halliday
- Department of Psychology, University of Huddersfield, Huddersfield, UK
| | - Pearl Lamptey
- Department of Psychology, University of Huddersfield, Huddersfield, UK
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Hoes J, King AJ, Berkhof J, de Melker HE. High vaccine effectiveness persists for ten years after HPV16/18 vaccination among young Dutch women. Vaccine 2023; 41:285-289. [PMID: 36470686 DOI: 10.1016/j.vaccine.2022.11.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
The current study describes the long-term effectiveness of three-dose HPV16/18 vaccination among Dutch women who were eligible for vaccination during a catch-up campaign and were followed in an observational cohort study. Ten years post vaccination, vaccine effectiveness (VE) was estimated using generalized estimating equation models. VE against persistent infections with vaccine type infections (HPV16/18) was high at 95.8%. For cross protective type persistent infections (HPV31/33/45) this was 64.6%. There were no indications of waning of protection over time. This indicates solid long-term protection is provided by the vaccine and is promising with regard to the future clinical impact.
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Affiliation(s)
- Joske Hoes
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; Department of Epidemiology & Biostatistics, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands.
| | - Audrey J King
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Johannes Berkhof
- Department of Epidemiology & Biostatistics, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Hester E de Melker
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
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Ikiroma A, Santin O, Camanda J, Chocolate F, Pelinganga O, Jordao H, Tommasino M, Lohfeld L, Anderson L. Evaluation of human papillomavirus (HPV) knowledge among healthcare professionals: A study of conference attendees in Angola. Glob Public Health 2023; 18:2099931. [PMID: 35849621 DOI: 10.1080/17441692.2022.2099931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/06/2022] [Indexed: 11/04/2022]
Abstract
Human papillomavirus (HPV) plays an essential role in cervical cancer development. Angola has a high cervical cancer incidence rate (36.1 per 100,000); therefore, knowledge of HPV among clinicians is essential for the prevention of cervical cancer and educating at-risk individuals. This study aimed to evaluate knowledge of HPV among healthcare professionals in Angola. A 44-item questionnaire was distributed to 65 healthcare professionals who attended a conference on the cancer burden in Angola. Non-parametric and multiple regression analyses were conducted. Of the participants (55.6%) were male, and 33.3% were aged 31-40 years, 56.3% had an undergraduate degree, and 35.9% had a postgraduate degree. All participants worked in healthcare in academic and/or clinical settings, with 36.7% in joint contracts. Most (62.2%) knew that early sexual debut increases the risk of contracting HPV, and HPV vaccines are most effective if administered before sexual debut. However, there was limited knowledge regarding the virus transmission. The mean HPV knowledge score was 11.08 ± 8.76 and knowledge was higher among older healthcare workers (>50 years) with a postgraduate degree and working in a clinical role. Overall, HPV knowledge was limited among the respondents. Policymakers should consider promoting knowledge and targeted public health initiatives among healthcare professionals in Angola.
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Affiliation(s)
- Adalia Ikiroma
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
| | - Olinda Santin
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | | | | | - Osvaldo Pelinganga
- Department of Agriculture, Instituto Superior Politécnico do Cuanza Sul, Sumbe, Angola
| | - Haydee Jordao
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Massimo Tommasino
- Infections and Cancer Biology Group, International Agency for Research on Cancer, Lyon, France
| | - Lynne Lohfeld
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Lesley Anderson
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
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12
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Changes in genital Human Papillomavirus (HPV) prevalence among urban females a decade after the Malaysian HPV vaccination program. PLoS One 2022; 17:e0278477. [PMID: 36538522 PMCID: PMC9767374 DOI: 10.1371/journal.pone.0278477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022] Open
Abstract
To increase the coverage of HPV vaccination, Malaysia implemented a national school-based vaccination program for all 13-year-old girls in 2010. Two years later, a clinic-based catch-up program was started for 16 to 21-year-old girls. We assessed the prevalence of a range of HPV genotypes, among a sample of urban women within the age groups of 18-24 and 35-45 years in 2019-2020, a decade into the national vaccination program. The HPV prevalence was then compared to that reported in an unvaccinated population in 2013-2015. We sampled a total of 1134 participants, comprising of 277 women aged 18-24 years and 857 women aged 35-45 years, from several urban clinics in the state of Selangor. Participants provided a self-acquired vaginal sample for HPV genotyping. Comprehensive sociodemographic and vaccination history were collected. The HPV vaccination coverage among women in the younger age group increased from 9.3% in 2013-2015 to 75.5% in 2019-2020. The prevalence of vaccine-targeted HPV16/18 decreased 91% (CI: 14.5%-99.0%) among the younger women, from 4.0% in 2013-2015 to 0.4% in 2019-2020. There was also an 87% (CI: 27.5%-97.5%) reduction in HPV6/11/16/18. There was no difference in the prevalence of non-vaccine targeted HPV genotypes among younger women. The HPV prevalence among older women, for both vaccine targeted and non-vaccine targeted genotypes in 2019-2020, did not differ from 2013-2015. The observed decline in prevalence of vaccine-targeted HPV genotype among younger women a decade after the national HPV vaccination program is an early indication of its effectiveness in reducing the burden of cervical cancer.
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Kola‐Palmer S, Rogers M, Halliday A, Rickford R. "A lot can happen in five years": Women's attitudes to extending cervical screening intervals. Eur J Cancer Care (Engl) 2022; 31:e13655. [PMID: 35838304 PMCID: PMC9786642 DOI: 10.1111/ecc.13655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Evidence suggests that cervical screening intervals can be extended and lifetime cervical screening for human papillomavirus (HPV)-vaccinated women could be reduced. This study examines UK women's attitudes to extending screening intervals and assesses associations between knowledge, risk perception and HPV vaccination status, and acceptability of changes. METHODS Using a convenience sampling strategy, an anonymous mixed-methods online survey was used and data recorded from 647 women (mean age = 28.63, SD = 8.69). RESULTS Across the full sample, 46.1% of women indicated they would wait 5 years for their next cervical screening, while 60.2% of HPV-vaccinated women would be unwilling to have as few as three cervical screens in a lifetime. Multivariate analysis revealed those who are regular screened, those who intend to attend when invited, and those who perceive greater personal risk of cervical cancer are less likely to accept a 5-year screening interval. Qualitative findings relating to benefits of extending intervals included convenience of less tests, less physical discomfort, and psychological distress. Concerns identified included the likelihood of developing illness, increased psychological distress relating to what may be happening in the body, and worries about increased risk of cervical cancer. CONCLUSION Women need clear and specific information about HPV timelines, their relationship with cancer risk, and the rationale for extending screening intervals.
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Affiliation(s)
| | - Melanie Rogers
- Department of Nursing and MidwiferyUniversity of HuddersfieldHuddersfieldUK
| | - Abigail Halliday
- Department of PsychologyUniversity of HuddersfieldHuddersfieldUK
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Yu Y, Liu HL, He CF, Wang Y, Fu WJ, Gan GP, Qu HL, Zhou YN, Yao L. Prevalent characteristics of human papillomavirus infection in 29,508 women in Jinshan District, Shanghai. Taiwan J Obstet Gynecol 2022; 61:971-976. [DOI: 10.1016/j.tjog.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
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15
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Rebolj M, Pesola F, Mathews C, Mesher D, Soldan K, Kitchener H. The impact of catch-up bivalent human papillomavirus vaccination on cervical screening outcomes: an observational study from the English HPV primary screening pilot. Br J Cancer 2022; 127:278-287. [PMID: 35347326 PMCID: PMC9296648 DOI: 10.1038/s41416-022-01791-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 01/31/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In England, bivalent vaccination (Cervarix) against high-risk human papillomavirus (HR-HPV) genotypes 16/18 was offered in a population-based catch-up campaign in 2008-2010 to girls aged 14-17 years. These women are now entering the national cervical screening programme. We determined the impact of catch-up bivalent vaccination on their screening outcomes. METHODS We studied the overall and genotype-specific screening outcomes in 108,138 women aged 24-25 (offered vaccination) and 26-29 years (not offered vaccination) included in the English HPV screening pilot between 2013 and 2018. RESULTS At 24-25 years, the detection of high-grade cervical intraepithelial neoplasia (CIN2+) associated with HPV16/18 decreased from 3 to 1% (p < 0.001), with estimated vaccine effectiveness of 87% (95% CI: 82-91%). The detection of any CIN2+ halved from 6 to 3% (p < 0.001), with an estimated vaccine effectiveness of 72% (95% CI: 66-77%). The positive predictive value of a colposcopy for CIN2+ decreased for both low-grade (p < 0.001) and high-grade (p = 0.02) abnormalities on triage cytology. The decreases in screen-detected abnormalities at age 26-29 were of a substantially smaller magnitude. CONCLUSIONS These data confirm high effectiveness of bivalent HPV vaccination delivered through a population-based catch-up campaign in England. These findings add to the rationale for extending screening intervals for vaccinated cohorts.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK.
| | - Francesca Pesola
- Cancer Prevention Trials Unit, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK
- Health and Lifestyle Research Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Christopher Mathews
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK
| | - David Mesher
- Blood Safety, Hepatitis, STI and HIV (BSHSH) Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, STI and HIV (BSHSH) Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Henry Kitchener
- Division of Cancer Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Alzabibi MA, Alolabi H, Ali DA, Shibani M, Ismail H, Mohsen F, Armashi H, Sawaf B, Swed S, Bakr A, Nahas LD, Ghaith HS, Motawea KR. Oral cancer knowledge and practice among medical students: A cross-sectional study during the Syrian crisis. Ann Med Surg (Lond) 2022; 77:103504. [PMID: 35638081 PMCID: PMC9142404 DOI: 10.1016/j.amsu.2022.103504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/16/2022] [Accepted: 03/26/2022] [Indexed: 12/24/2022] Open
Abstract
Background lack of medical practitioners’ knowledge about oral cancer has contributed to delays in referral and treatment. Oral cancer is amenable to treatment when detected early, which leads to better prognosis and survival rates. In this study, we aimed to assess the knowledge of the Syrian medical students about the risk factors of oral cancer, oral cavity changes associated with oral cancer, and the relation between the relation with Human Papilloma Virus (HPV) and oral cancer. Methods This is a cross-sectional study conducted at the Syrian Private University. Data were collected through self-administered questionnaires, which targeted social demographic information, general knowledge, risk factors, oral changes and HPV knowledge associated with oral cancer. Data was categorized and analyzed to assess and compare the levels of knowledge between clinical and preclinical students. Results 301 out of 401 medical students responded to the questionnaires bringing the response rate to 75.25%. The study revealed adequate knowledge about oral cancer, general information, clinical features, risk factors and relation to HPV. Clinical students showed higher levels of awareness compared to pre-clinical students. No significance in knowledge was found between the genders. Conclusion The findings of the present study suggest that there is a need to reinforce the medical curriculum concerning oral cancer education, particularly in prevention and early detection to improve practices. In Syria, the incidence and mortality rates of OC and OPC were 2 and 0.8 per 100,000 annum, respectively. Awareness about OC was positively correlated with the year of study Low level of awareness about OC was found among medical students.
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Affiliation(s)
- Mhd Amin Alzabibi
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Homam Alolabi
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Dania Alsayed Ali
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Mosa Shibani
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Hlma Ismail
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Fatema Mohsen
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Humam Armashi
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Bisher Sawaf
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Sarya Swed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
- Corresponding author. Faculty of Human Medicine, Aleppo University, Aleppo, Syria.
| | - Aliaa Bakr
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
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17
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Frevert ML, Taran FA. Human papillomavirus vaccines: A great leap forward. Case Rep Womens Health 2022; 33:e00388. [PMID: 35145882 PMCID: PMC8802050 DOI: 10.1016/j.crwh.2022.e00388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Florin-Andrei Taran
- Corresponding author at: Department of Obstetrics and Gynecology, Medical-Center University Freiburg, University of Freiberg, Hugstetter Straße 55, 79106 Freiburg, Germany.
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18
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Falcaro M, Castañon A, Ndlela B, Checchi M, Soldan K, Lopez-Bernal J, Elliss-Brookes L, Sasieni P. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. Lancet 2021; 398:2084-2092. [PMID: 34741816 DOI: 10.1016/s0140-6736(21)02178-4] [Citation(s) in RCA: 247] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) immunisation with a bivalent vaccine (Cervarix) was introduced in England, UK, in Sept 1, 2008: routine vaccination was offered to girls aged 12-13 years with a catch-up programme for females aged 14-18 years in 2008-10. We quantified the early effect of this immunisation programme on cervical cancer and cervical carcinoma in situ, namely grade 3 cervical intraepithelial neoplasia (CIN3), registrations. METHODS In this observational study, we used an extension of the age-period-cohort Poisson model to estimate the relative risk of cervical cancer in three vaccinated cohorts compared with earlier cohorts that were not eligible for HPV vaccination. Data from a population-based cancer registry were extracted on Jan 26, 2021, and were assessed for diagnoses of cervical cancer and CIN3 from Jan 1, 2006 to June 30, 2019 in women aged 20-64 years and who were a resident in England. We used three vaccinated cohorts to account for differences in the school year in which the vaccine was offered and its national coverage. Adjustment for confounding was made using information on changes in cervical screening policy and historical events that affected cervical cancer incidence. Results were compared across models with different adjustments for confounders. FINDINGS We used data from a total of 13·7 million-years of follow-up of women aged 20 years to younger than 30 years. The estimated relative reduction in cervical cancer rates by age at vaccine offer were 34% (95% CI 25-41) for age 16-18 years (school year 12-13), 62% (52-71) for age 14-16 years (school year 10-11), and 87% (72-94) for age 12-13 years (school year 8), compared with the reference unvaccinated cohort. The corresponding risk reductions for CIN3 were 39% (95% CI 36-41) for those offered at age 16-18 years, 75% (72-77) for age 14-16 years, and 97% (96-98) for age 12-13 years. These results remained similar across models. We estimated that by June 30, 2019 there had been 448 (339-556) fewer than expected cervical cancers and 17 235 (15 919-18 552) fewer than expected cases of CIN3 in vaccinated cohorts in England. INTERPRETATION We observed a substantial reduction in cervical cancer and incidence of CIN3 in young women after the introduction of the HPV immunisation programme in England, especially in individuals who were offered the vaccine at age 12-13 years. The HPV immunisation programme has successfully almost eliminated cervical cancer in women born since Sept 1, 1995. FUNDING Cancer Research UK.
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Affiliation(s)
- Milena Falcaro
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Alejandra Castañon
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Busani Ndlela
- National Cancer Registration and Analysis Service, Public Health England, Manchester, UK
| | - Marta Checchi
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, National Infection Service, Public Health England, London, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, National Infection Service, Public Health England, London, UK
| | - Jamie Lopez-Bernal
- Immunisations and Countermeasures Division, Public Health England, London, UK
| | - Lucy Elliss-Brookes
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Peter Sasieni
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK; Innovation Hub, Guy's Cancer Centre, Guy's Hospital, London, UK.
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Gallant D, Tummers P, Weyers S, Merckx M. Single-Dose Human Papillomavirus Vaccination in Low- and Middle-Income Countries-Time for Implementation? J Pediatr Adolesc Gynecol 2021; 34:586-590. [PMID: 34144176 DOI: 10.1016/j.jpag.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023]
Abstract
Although cervical cancer is becoming a rare disease in high income regions, it is still a major health issue in low- and middle-income countries (LMICs). Cervical cancer develops after infection with a high-risk human papilloma virus (hrHPV), an infection against which vaccination has been possible since 2006. Large population immunization programs have been organized in many higher income countries, and yet they have not been implemented in most of the lower and middle-income nations. The cost of the vaccine, as well as the need for two doses impedes coverage in the most vulnerable groups. Studies are suggesting the efficacy of single dose vaccination, but so far only observational data are available while large, randomized, double-blind studies are still ongoing. In order to prevent and combat this disease, it is essential to inform the population of vaccination benefits and offer accessible programs in higher as well as low-and middle-income countries. In this commentary, we wish to focus our attention on the case for implementing single dose vaccination in lower- and middle-income nations.
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Affiliation(s)
- Delphine Gallant
- Department of Gynecology and Obstetrics, Universitair Ziekenhuis Gent, Ghent, Belgium.
| | - Philippe Tummers
- Department of Gynecology and Obstetrics, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Steven Weyers
- Department of Gynecology and Obstetrics, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Mireille Merckx
- Department of Gynecology and Obstetrics, Universitair Ziekenhuis Gent, Ghent, Belgium
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Lehtinen M, Apter D, Eriksson T, Harjula K, Hokkanen M, Natunen K, Nieminen P, Paavonen J, Palmroth J, Petäjä T, Pukkala E, Vänskä S, Cheuvart B, Soila M, Bi D, Struyf F. Effectiveness of various human papillomavirus vaccination strategies: A community randomized trial in Finland. Cancer Med 2021; 10:7759-7771. [PMID: 34581025 PMCID: PMC8559511 DOI: 10.1002/cam4.4299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION We conducted a community-randomized trial (NCTBLINDED) in Finland to assess gender-neutral and girls-only vaccination strategies with the AS04-adjuvanted human papillomavirus (HPV)-16/18 (AS04-HPV-16/18)vaccine. METHODS Girls and boys (12-15 years) were invited. We randomized 33 communities (1:1:1 ratio): Arm A: 90% of randomly selected girls and boys received AS04-HPV-16/18 vaccine and 10% received hepatitis B vaccine (HBV); Arm B: 90% of randomly selected girls received AS04-HPV-16/18 vaccine, 10% of girls received HBV, and all boys received HBV; Arm C: all participants received HBV. Effectiveness measurements against prevalence of HPV-16/18 cervical infection were estimated in girls at 18.5 years. The main measures were: (1) overall effectiveness comparing Arms A or B, regardless of vaccination status, vs Arm C; (2) total effectiveness comparing AS04-HPV-16/18 vaccinated girls in pooled Arms A/B vs Arm C; (3) indirect effectiveness (herd effect) comparing girls receiving HBV or unvaccinated in Arm A vs Arm C. Co-primary objectives were overall effectiveness following gender-neutral or girls-only vaccination. RESULTS Of 80,272 adolescents invited, 34,412 were enrolled. Overall effectiveness was 23.8% (95% confidence interval: -19.0, 51.1; P = 0.232) with gender-neutral vaccination. Following girls-only vaccination, overall effectiveness was 49.6% (20.1, 68.2; P = 0.004). Total effectiveness was over 90% regardless of vaccination strategy. No herd effect was found. Immunogenicity of the AS04-HPV-16/18 vaccine was high in both sexes. CONCLUSIONS This study illustrates the difficulty in conducting community randomized trials. It is not plausible that vaccinating boys would reduce overall effectiveness, and the apparent lack of herd effect was unexpected given findings from other studies. This analysis was likely confounded by several factors but confirms the vaccine's high total effectiveness as in clinical trials.
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Affiliation(s)
- Matti Lehtinen
- Department of Vaccines, National Institute for Health & Welfare, Helsinki, Finland.,Department of Laboratory Medicine, Karolinska Institute, Huddinge, Sweden
| | - Dan Apter
- VL-Medi Clinical Research Center, Helsinki, Finland
| | - Tiina Eriksson
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Katja Harjula
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Mari Hokkanen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Kari Natunen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Pekka Nieminen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
| | - Johanna Palmroth
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Tiina Petäjä
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Pukkala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Simopekka Vänskä
- Finnish Institute for Health and Welfare, Helsinki and Oulu, Finland
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21
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Gradissimo A, Shankar V, Wiek F, St. Peter L, Studentsov Y, Nucci-Sack A, Diaz A, Pickering S, Schlecht NF, Burk RD. Anti-HPV16 Antibody Titers Prior to an Incident Cervical HPV16/31 Infection. Viruses 2021; 13:v13081548. [PMID: 34452413 PMCID: PMC8402915 DOI: 10.3390/v13081548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 12/16/2022] Open
Abstract
The goal of this study was to investigate the serological titers of circulating antibodies against human papillomavirus (HPV) type 16 (anti-HPV16) prior to the detection of an incident HPV16 or HPV31 infection amongst vaccinated participants. Patients were selected from a prospective post-HPV vaccine longitudinal cohort at Mount Sinai Adolescent Health Center in Manhattan, NY. We performed a nested case-control study of 43 cases with incident detection of cervical HPV16 (n = 26) or HPV31 (n = 17) DNA who had completed the full set of immunizations of the quadrivalent HPV vaccine (4vHPV). Two control individuals whom had received three doses of the vaccine (HPV16/31-negative) were selected per case, matched on age at the first dose of vaccination and follow-up time in the study: a random control, and a high-risk control that was in the upper quartile of a sexual risk behavior score. We conducted an enzyme-linked immunosorbent assay (ELISA) for the detection of immunoglobulin G (IgG) antibodies specific to anti-HPV16 virus-like particles (VLPs). The results suggest that the average log antibody titers were higher among high-risk controls than the HPV16/31 incident cases and the randomly selected controls. We show a prospective association between anti-HPV16 VLP titers and the acquisition of an HPV16/31 incident infection post-receiving three doses of 4vHPV vaccine.
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Affiliation(s)
- Ana Gradissimo
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (A.G.); (F.W.); (L.S.P.); (Y.S.)
| | - Viswanathan Shankar
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (V.S.); (N.F.S.)
| | - Fanua Wiek
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (A.G.); (F.W.); (L.S.P.); (Y.S.)
| | - Lauren St. Peter
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (A.G.); (F.W.); (L.S.P.); (Y.S.)
| | - Yevgeniy Studentsov
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (A.G.); (F.W.); (L.S.P.); (Y.S.)
| | - Anne Nucci-Sack
- Department of Pediatrics, Icahn School of Medicine, Mount Sinai Adolescent Health Center, Manhattan, NY 10128, USA; (A.N.-S.); (A.D.); (S.P.)
| | - Angela Diaz
- Department of Pediatrics, Icahn School of Medicine, Mount Sinai Adolescent Health Center, Manhattan, NY 10128, USA; (A.N.-S.); (A.D.); (S.P.)
| | - Sarah Pickering
- Department of Pediatrics, Icahn School of Medicine, Mount Sinai Adolescent Health Center, Manhattan, NY 10128, USA; (A.N.-S.); (A.D.); (S.P.)
| | - Nicolas F. Schlecht
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (V.S.); (N.F.S.)
- Department of Pediatrics, Icahn School of Medicine, Mount Sinai Adolescent Health Center, Manhattan, NY 10128, USA; (A.N.-S.); (A.D.); (S.P.)
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA
| | - Robert D. Burk
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (A.G.); (F.W.); (L.S.P.); (Y.S.)
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (V.S.); (N.F.S.)
- Departments of Microbiology & Immunology, and Obstetrics, Gynecology & Women’s Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA
- Correspondence: ; Tel.: +1-718-430-3720
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22
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Mesher D, Thomas SL, Linley E, Edmundson C, Checchi M, Waterboer T, Bender N, Müller M, Beddows S, Borrow R, Soldan K. Post-vaccination HPV seroprevalence among female sexual health clinic attenders in England. Vaccine 2021; 39:4210-4218. [PMID: 34127297 DOI: 10.1016/j.vaccine.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 03/26/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The National HPV Immunisation Programme was introduced in England in September 2008 using the HPV16/18 bivalent vaccine. We conducted serological surveillance to explore vaccination coverage levels. We also conducted a case-control study to investigate a hypothesised cross-protective effect of the HPV16/18 vaccine against genital warts. METHODS Residual serum specimens from 16 to 20 year-old women attending six specialist sexual health services (SSHS) between 2011 and 2015 in England were tested for antibodies against HPV16 and HPV18 using a virus-like particle (VLP)-based multiplex serology assay. Patients were classified as having vaccine-induced seropositivity if they were seropositive for both HPV types and either had high antibody levels for at least one HPV type, or moderately high levels for both HPV types. Differences in vaccine-induced seropositivity by patient characteristics were investigated using logistic regression. Vaccine-induced seropositivity was then compared for patients with genital warts (cases) and matched patients without (controls). RESULTS Of 3,973 serum specimens collected, 3,870 (97.4%) had a valid result. The proportion of women with vaccine-induced seropositivity decreased with age (from 78.1% in 16-year-olds to 52.6% in 20-year-olds). Vaccine-induced seropositivity was lower among women born outside the UK, from more deprived areas and with a history of chlamydia diagnosis. A difference in uptake by ethnic group was also seen but this was largely confounded by differences in deprivation and country of birth. Among 537 cases and 1,515 controls, there was little evidence of a protective effect of the bivalent HPV vaccine against genital warts (adjusted odds ratio 0.93; 95% CI: 0.74-1.18). DISCUSSION Vaccine-induced seropositivity in this high-risk population was in line with vaccination coverage in the general population although was lower in some at-risk sub-groups. This study does not provide evidence to support a cross-protective effect of the HPV16/18 vaccine against genital warts.
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Affiliation(s)
- David Mesher
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Sara L Thomas
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ezra Linley
- Vaccine Evaluation Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Claire Edmundson
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK
| | - Marta Checchi
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK
| | - Tim Waterboer
- Program Infection, Inflammation & Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Noemi Bender
- Program Infection, Inflammation & Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Müller
- Program Infection, Inflammation & Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Simon Beddows
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK; Virus Reference Department, Public Health England, London, UK
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK
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23
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Hoes J, Woestenberg PJ, Bogaards JA, King AJ, de Melker HE, Berkhof J, Hoebe CJPA, van der Sande MAB, van Benthem BHB. Population Impact of Girls-Only Human Papillomavirus 16/18 Vaccination in The Netherlands: Cross-Protective and Second-Order Herd Effects. Clin Infect Dis 2021; 72:e103-e111. [PMID: 33249475 PMCID: PMC7935392 DOI: 10.1093/cid/ciaa1770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/23/2020] [Indexed: 01/08/2023] Open
Abstract
Background Human papillomavirus (HPV) vaccination programs achieve substantial population-level impact, with effects extending beyond protection of vaccinated individuals. We assessed trends in HPV prevalence up to 8 years postvaccination among men and women in the Netherlands, where bivalent HPV vaccination, targeting HPV types 16/18, has been offered to (pre)adolescent girls since 2009 with moderate vaccination coverage. Methods We used data from the PASSYON study, a survey initiated in 2009 (prevaccination) and repeated biennially among 16- to 24-year-old visitors of sexual health centers. We studied genital HPV positivity from 2009 to 2017 among women, heterosexual men, and unvaccinated women using Poisson generalized estimating equation models, adjusted for individual- and population-level confounders. Trends were studied for 25 HPV types detected by the SPF10-LiPA25 platform. Results A total of 6354 women (64.7% self-reported unvaccinated) and 2414 heterosexual men were included. Percentual declines in vaccine types HPV-16/18 were observed for all women (12.6% per year [95% confidence interval {CI}, 10.6–14.5]), heterosexual men (13.0% per year [95% CI, 8.3–17.5]), and unvaccinated women (5.4% per year [95% CI, 2.9–7.8]). We observed significant declines in HPV-31 (all women and heterosexual men), HPV-45 (all women), and in all high-risk HPV types pooled (all women and heterosexual men). Significant increases were observed for HPV-56 (all women) and HPV-52 (unvaccinated women). Conclusions Our results provide evidence for first-order herd effects among heterosexual men against HPV-16/18 and cross-protective types. Additionally, we show second-order herd effects against vaccine types among unvaccinated women. These results are promising regarding population-level and clinical impact of girls-only bivalent HPV vaccination in a country with moderate vaccine uptake.
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Affiliation(s)
- Joske Hoes
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.,Department of Epidemiology and Data Science, Amsterdam University Medical Center, location VUmc, Amsterdam, The Netherlands
| | - Petra J Woestenberg
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johannes A Bogaards
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.,Department of Epidemiology and Data Science, Amsterdam University Medical Center, location VUmc, Amsterdam, The Netherlands
| | - Audrey J King
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Hester E de Melker
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, location VUmc, Amsterdam, The Netherlands
| | - Christian J P A Hoebe
- Department of Social Medicine, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Sexual Health, Infectious Diseases and Environment, South Limburg Public Health Service, Heerlen, The Netherlands
| | - Marianne A B van der Sande
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgit H B van Benthem
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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24
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Systematic literature review of cross-protective effect of HPV vaccines based on data from randomized clinical trials and real-world evidence. Vaccine 2021; 39:2224-2236. [PMID: 33744051 DOI: 10.1016/j.vaccine.2020.11.076] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/07/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The extent of cross-protection provided by currently licensed bivalent and quadrivalent HPV vaccines versus direct protection against HPV 31-, 33-, 45-, 52-, and 58-related disease is debated. A systematic literature review was conducted to establish the duration and magnitude of cross-protection in interventional and observational studies. METHODS PubMed and Embase databases were searched to identify randomized controlled trials (RCT) and observational studies published between 2008 and 2019 reporting on efficacy and effectiveness of HPV vaccines in women against non-vaccine types 31, 33, 45, 52, 58, and 6 and 11 (non-bivalent types). Key outcomes of interest were vaccine efficacy against 6- and 12-month persistent infection or genital lesions, and type-specific genital HPV prevalence or incidence. RCT data were analyzed for the according-to-protocol (bivalent vaccine) or negative-for-14-HPV-types (quadrivalent vaccine) efficacy cohorts. RESULTS Data from 23 RCTs and 33 observational studies evaluating cross-protection were extracted. RCTs assessed cross-protection in post-hoc analyses of small size subgroups. Among fully vaccinated, baseline HPV-naïve women, the bivalent vaccine showed statistically significant cross-protective efficacy, although with wide confidence intervals, against 6-month and 12-month persistent cervical infections and CIN2+ only consistently for HPV 31 and 45, with the highest effect observed for HPV 31 (range 64.6% [95% CI: 27.6 to 83.9] to 79.1% [97.7% CI: 27.6 to 95.9] for 6-month persistent infection; maximal follow-up 4.7 years). No cross-protection was shown in extended follow-up. The quadrivalent vaccine efficacy reached statistical significance for HPV 31 (46.2% [15.3-66.4]; follow-up: 3.6 years). Similarly, observational studies found consistently significant effectiveness only against HPV 31 and 45 with both vaccines. CONCLUSIONS RCTs and observational studies show that cross-protection is inconsistent across non-vaccine HPV types and is largely driven by HPV 31 and 45. Furthermore, existing data suggest that it wanes over time; its long-term durability has not been established.
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25
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Brotherton JML, Wheeler C, Clifford GM, Elfström M, Saville M, Kaldor J, Machalek DA. Surveillance systems for monitoring cervical cancer elimination efforts: Focus on HPV infection, cervical dysplasia, cervical screening and treatment. Prev Med 2021; 144:106293. [PMID: 33075352 PMCID: PMC8403014 DOI: 10.1016/j.ypmed.2020.106293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
In order to achieve the global elimination of cervical cancer as a public health problem, close surveillance of progress in public health and clinical activities and outcomes across the three pillars of vaccination, screening and treatment will be required. Surveillance should ideally occur within an integrated system that is planned, funded, and regularly evaluated to ensure it is providing timely, accurate and relevant feedback for action. In this paper, we conceptualise the main public health surveillance objectives as process and outcome measures in each of the three pillars. Process measures include coverage/participation measures for vaccination, screening and treatment alongside the ongoing assessment of the quality and reach of these programs and activities. Outcome measures related to the natural history of human papillomavirus (HPV) infection include HPV infection prevalence, precursor cervical lesions and cervical cancers (including stage at diagnosis, cancer incidence and mortality). These outcome measures can be used for monitoring the effectiveness of the three core activities in the short, medium and long term to assess whether these interventions are effectively reducing their occurrence. We discuss possible methods for the surveillance of these measures in the context of country capacity, drawing from examples in Australia, the USA and in low and middle income countries.
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Affiliation(s)
- Julia M L Brotherton
- VCS Population Health, VCS Foundation, Level 6, 176 Wellington Parade, East Melbourne, Victoria 3002, Australia; Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton 3053, Victoria, Australia.
| | - Cosette Wheeler
- Department of Pathology and Obstetrics & Gynecology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
| | - Gary M Clifford
- International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon, Cedex 08, France
| | - Miriam Elfström
- Department of Laboratory Medicine, Karolinska Institutet, Alfred Nobels Allé 8, 8th floor, 141 52 Huddinge, Stockholm, Sweden
| | - Marion Saville
- VCS Population Health, VCS Foundation, Level 6, 176 Wellington Parade, East Melbourne, Victoria 3002, Australia; University Department of Obstetrics and Gynaecology, University of Melbourne, The Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - John Kaldor
- Kirby Institute, Level 6, Wallace Wurth Building, University of New South Wales, High Street, Kensington, NSW 2052, Australia
| | - Dorothy A Machalek
- Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton 3053, Victoria, Australia; Kirby Institute, Level 6, Wallace Wurth Building, University of New South Wales, High Street, Kensington, NSW 2052, Australia; Centre for Women's Infectious Diseases, The Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC 3052, Australia
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26
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Oliveira CR, Niccolai LM. Monitoring HPV vaccine impact on cervical disease: Status and future directions for the era of cervical cancer elimination. Prev Med 2021; 144:106363. [PMID: 33678234 PMCID: PMC8582276 DOI: 10.1016/j.ypmed.2020.106363] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022]
Abstract
Post-licensure monitoring of the impact of HPV vaccines is critical to track the progress being made toward cervical cancer elimination and to identify areas where further progress can accelerate the achievement of this important public health goal. Over the past decade, a large body of evidence has revealed convincing benefits of HPV vaccination in preventing cervical infections and precancers at the individual-level (i.e., direct effectiveness) as well as in reducing the population-level burden of disease (i.e., overall effectiveness). At this time, effectiveness of the vaccines on preventing cervical cancer is just beginning to emerge given that there is a prolonged latency period for invasive disease. As we enter the era of cervical cancer elimination, these early and promising results may be expected in other countries in the near future. Thus, monitoring the direct and overall effectiveness for cervical cancer is an urgent research priority. In this article, we summarize what is known about the effectiveness of HPV vaccines on precancerous outcomes, and we highlight considerations for continuing these important public health activities going forward to monitor progress toward cervical cancer elimination.
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Affiliation(s)
| | - Linda M Niccolai
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, USA.
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27
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King EM, Mesher D, Sonnenberg P, Linley E, Panwar K, Beddows S, Soldan K, Borrow R, Jit M, Gilson R. HPV16 and HPV18 seropositivity and DNA detection among men who have sex with men: a cross-sectional study conducted in a sexual health clinic in London. Sex Transm Infect 2020; 97:382-386. [PMID: 33361466 PMCID: PMC8311088 DOI: 10.1136/sextrans-2020-054726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 01/07/2023] Open
Abstract
Objectives Men who have sex with men (MSM) have an increased risk of human papillomavirus (HPV) infection and related diseases compared with men who have sex exclusively with women. From April 2018, there has been a phased roll-out of HPV vaccination offered to MSM aged up to 45 years old who are attending sexual health clinics and HIV clinics in England. The vaccine is most effective if delivered prior to HPV infection. We estimated the proportion of MSM with no current vaccine-type infection and no serological evidence of prior infection, in a study undertaken prior to vaccine introduction. Methods We conducted a cross-sectional study among 484 MSM aged 18–40 years old who attended a sexual health clinic in London between 2010 and 2012. We estimated the prevalence of current and past infection by testing for HPV DNA in anogenital samples and for serum antibodies to HPV16 and HPV18. Results The median age was 30 years (IQR 25–35). The prevalence of HPV16 and HPV18 DNA was 13.2% and 6.2%, respectively. Seropositivity for HPV16 and HPV18 was 28.5% and 17.1%, respectively, with 11.4% seropositive for both types. Seropositivity for the same HPV type was strongly associated with anogenital DNA detection. 279 MSM (57.6%) tested negative for both HPV16 and HPV18 serology and were DNA negative for these two types; only 5 MSM (1.0%) were seropositive and DNA positive for both HPV types. Conclusions This is the first study to determine both the prevalence of HPV DNA in anogenital samples and HPV seroprevalence among MSM attending a sexual health clinic in the UK. Over half of MSM in this study had no evidence of a previous or current infection with either of the high-risk HPV types included in the quadrivalent vaccine, which supports the rationale for opportunistic HPV vaccination of MSM attending sexual health clinics.
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Affiliation(s)
- Eleanor M King
- Institute for Global Health, University College London, London, UK
| | - David Mesher
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK
| | - Pam Sonnenberg
- Institute for Global Health, University College London, London, UK
| | - Ezra Linley
- Vaccine Evaluation Unit, Public Health England, Manchester, UK
| | - Kavita Panwar
- Virus Reference Department, Public Health England, London, UK
| | - Simon Beddows
- Virus Reference Department, Public Health England, London, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, Public Health England, London, UK
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester, UK
| | - Mark Jit
- Modelling and Economics Unit, Public Health England, London, UK.,Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London, London, UK .,The Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
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28
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Nugent D, Stirrup O, Pett S, Panwar K, Checchi M, Mesher D, Soldan K, Beddows S, Gilson R. Performance of human papillomavirus DNA detection in residual specimens taken for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid amplification testing in men who have sex with men. Sex Transm Infect 2020; 97:541-546. [PMID: 33328194 DOI: 10.1136/sextrans-2020-054702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/06/2020] [Accepted: 11/15/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Rectal swab specimens, either alone or pooled with first-void urine (FVU) and pharyngeal swab specimens, are used to test for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection in men who have sex with men (MSM). Following introduction of human papillomavirus (HPV) vaccination for MSM attending UK sexual health services (SHSs), HPV testing of residual CT/NG test specimens has been proposed to monitor HPV prevalence in this population. Performance of HPV detection in such specimens has not been evaluated previously. METHODS MSM attending a UK SHS provided three specimens: (1) rectal swab for CT/NG, (2) pooled rectal/pharyngeal/FVU specimen for CT/NG and (3) dedicated anal swab for HPV. Specimen 3 and residual material from specimens 1 and 2 were tested for type-specific HPV DNA. HPV detection was by an in-house multiplex PCR and luminex-based genotyping assay. RESULTS A total of 129 MSM were recruited with a mean age of 38.1 years; 24% were HIV-positive. Of the 129 MSM, 92 (71%) had any type-specific HPV DNA in ≥1 specimen; 80 (62%) had high risk (HR) HPV. Of 123 participants with sufficient residual pooled and dedicated specimens, 70 (56.9%) had detectable HPV on both, and 40 (32.5%) were negative on both; overall concordance was 89% (95% CI 83% to 94%), and kappa statistic was 0.78 (95% CI 0.66 to 0.89). Pooled samples had a 4.1% (95% CI -1.9% to 10.0%) higher test positivity rate than dedicated samples.Of 125 participants with sufficient residual rectal and specimens, 74 (59.2%) had detectable HPV on both, and 36 (28.8%) were negative on both; overall concordance was 88% (95% CI 81% to 93%), and kappa statistic was 0.74 (95% CI 0.61 to 0.86). Residual rectal samples had 5.6% (95%CI -0.6% to 11.8%) higher test positivity than dedicated samples. CONCLUSIONS We observed high concordance between the dedicated and residual STI test specimens. Our data support the strategy of testing residual specimens for HPV prevalence monitoring in MSM to evaluate the impact of the targeted vaccination programme.
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Affiliation(s)
- Diarmuid Nugent
- Centre for Clinical Research in Infection and Sexual Health, University College London, London, UK .,The Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Oliver Stirrup
- Centre for Clinical Research in Infection and Sexual Health, University College London, London, UK
| | - Sarah Pett
- Centre for Clinical Research in Infection and Sexual Health, University College London, London, UK.,The Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Kavita Panwar
- National Infection Service, Public Health England, London, UK
| | - Marta Checchi
- National Infection Service, Public Health England, London, UK
| | - David Mesher
- National Infection Service, Public Health England, London, UK
| | - Kate Soldan
- National Infection Service, Public Health England, London, UK
| | - Simon Beddows
- National Infection Service, Public Health England, London, UK
| | - Richard Gilson
- Centre for Clinical Research in Infection and Sexual Health, University College London, London, UK.,The Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
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29
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González JV, Deluca GD, Correa RM, Liotta DJ, Basiletti JA, Fellner MD, Colucci MC, Alzogaray OG, Katz N, Carmona JJ, Tappari NF, Berner E, Cramer V, Real P, López Kaufman CV, Kosoy GJ, Katabian L, Severino MS, Aboslaiman RE, Chami C, Totaro ME, Rogoski C, Giurgiovich AJ, Martínez GL, Plana LM, Vizzotti C, Picconi MA. 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. ACTA ACUST UNITED AC 2020; 10:100208. [PMID: 33161174 PMCID: PMC7683272 DOI: 10.1016/j.pvr.2020.100208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/07/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
HPV16/18 decreased by >93% in vaccinated sexually active Argentine girls. Detected reduction of HPV31 and 45 would add to the success of immunization. No genotype replacement was observed. First HPV vaccination monitoring data reported from a Latin American country.
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Affiliation(s)
- Joaquín Víctor González
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
| | - Gerardo Daniel Deluca
- Facultad de Medicina, Universidad Nacional Del Nordeste, Mariano Moreno 1240, W3400ACX, Corrientes, Argentina.
| | - Rita Mariel Correa
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
| | - Domingo Javier Liotta
- Laboratorio de Biología Molecular Aplicada, Facultad de Ciencias Exactas, Quimicas y Naturales, Universidad Nacional de Misiones, Av. Mariano Moreno 1375, N3300, Posadas, Misiones, Argentina; Instituto Nacional de Medicina Tropical- ANLIS "Dr. Malbrán", Neuquén y Jujuy S/n, N3370, Puerto Iguazú, Misiones, Argentina.
| | - Jorge Alejandro Basiletti
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
| | - María Dolores Fellner
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
| | - María Celeste Colucci
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
| | - Olga Gabriela Alzogaray
- Centro Integral de Salud La Banda, Av. San Martín 449, G4300, La Banda, Santiago Del Estero, Argentina.
| | - Nathalia Katz
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de La Nación, Rivadavia 875, C1002AAG, Buenos Aires, Argentina.
| | - Juan José Carmona
- Servicio Ginecología, Hospital Escuela de Agudos "Ramón Madariaga", Av. Marconi 3736, N3300, Posadas, Misiones, Argentina.
| | - Néstor Fabián Tappari
- Servicio Ginecología, Hospital Escuela de Agudos "Ramón Madariaga", Av. Marconi 3736, N3300, Posadas, Misiones, Argentina.
| | - Enrique Berner
- Servicio de Adolescencia, Hospital General de Agudos "Dr. Cosme Argerich", Gral. Urquiza 609, C1221 ADC, Buenos Aires, Argentina.
| | - Viviana Cramer
- Servicio de Adolescencia, Hospital General de Agudos "Dr. Cosme Argerich", Gral. Urquiza 609, C1221 ADC, Buenos Aires, Argentina.
| | - Paula Real
- Servicio de Adolescencia, Hospital General de Agudos "Dr. Cosme Argerich", Gral. Urquiza 609, C1221 ADC, Buenos Aires, Argentina.
| | - Carlota Viviana López Kaufman
- Sección Adolescencia, Hospital General de Agudos "Bernardino Rivadavia", Av. Gral. Las Heras 2670, C1425ASQ, Buenos Aires, Argentina.
| | - Gabriela Judit Kosoy
- Sección Adolescencia, Hospital General de Agudos "Bernardino Rivadavia", Av. Gral. Las Heras 2670, C1425ASQ, Buenos Aires, Argentina.
| | - Lucía Katabian
- Sección Adolescencia, Hospital General de Agudos "Bernardino Rivadavia", Av. Gral. Las Heras 2670, C1425ASQ, Buenos Aires, Argentina.
| | - María Silvia Severino
- Servicio Adolescencia, Hospital General de Agudos "Carlos Durand", Av. Díaz Vélez 5044, C1405DCS, Buenos Aires, Argentina.
| | | | - Cecilia Chami
- Sub Programa Salud Integral Del Adolescente, Ministerio de Salud de Santiago Del Estero, Av. Belgrano Sur 2050, Santiago Del Estero, G4200, Argentina.
| | - María Elina Totaro
- Laboratorio de Biología Molecular Aplicada, Facultad de Ciencias Exactas, Quimicas y Naturales, Universidad Nacional de Misiones, Av. Mariano Moreno 1375, N3300, Posadas, Misiones, Argentina.
| | - Carolina Rogoski
- Servicio Ginecología, Hospital Escuela de Agudos "Ramón Madariaga", Av. Marconi 3736, N3300, Posadas, Misiones, Argentina.
| | - Alejandra Julia Giurgiovich
- Consultorio de Adolescencia, Hospital Zonal General de Agudos "Evita Pueblo", Calle 136 3008, B1884, Berazategui, Provincia de Buenos Aires, Argentina.
| | - Gloria Lilian Martínez
- Consultorio de Adolescencia, Hospital Zonal General de Agudos "Evita Pueblo", Calle 136 3008, B1884, Berazategui, Provincia de Buenos Aires, Argentina.
| | - Liliana Marisol Plana
- Consultorio de Adolescencia, Hospital Zonal General de Agudos "Evita Pueblo", Calle 136 3008, B1884, Berazategui, Provincia de Buenos Aires, Argentina.
| | - Carla Vizzotti
- Secretaría de Acceso a La Salud, Ministerio de Salud de La Nación, Av. 9 de Julio 1925, C1073ABA, Buenos Aires, Argentina.
| | - María Alejandra Picconi
- Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia para HPV, Instituto Nacional de Enfermedades Infecciosas -ANLIS "Dr. Malbrán", Av. Velez Sársfield 563, C1282AFF, Buenos Aires, Argentina.
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Guid M, Bruno A, Tagliaferro L, Aprile V, Tinelli A, Fedele A, Lobreglio G, Menegazzi P, Pasanisi G, Tassi V, Forcina B, Fortunato F, Lupo LI, Zizza A. Universal Human Papillomavirus Vaccination and its Impact on the Southern Italian Region. Curr Pharm Des 2020; 26:343-357. [PMID: 32048956 DOI: 10.2174/1381612826666200212115840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/03/2020] [Indexed: 01/04/2023]
Abstract
HPV is still the most common sexually transmitted infection, leading to the onset of many disorders while causing an increase in direct and indirect health costs. High Risk (HR) HPV is the primary cause of invasive cervical cancer and contributes significantly to the development of anogenital and oropharyngeal cancers. The introduction of universal HPV vaccination has led to a significant reduction in vaccine-targeted HPV infections, cross-protective genotypes, precancerous lesions and anogenital warts. Despite the several limitations of HPV vaccination programs, including vaccine type specificity, different schedules, target age-groups and poor communication, the impact has become increasingly evident, especially in countries with high vaccine uptake. We carried out a review of the most recent literature to evaluate the effects of HPV vaccination on vaccinetargeted HPV genotypes and to assess the level of cross-protection provided against non-vaccine HPV types. Subsequently, to assess the rates of HPV infection in a southeast Italian region, we performed an epidemiological investigation on the impact of vaccination on genotypes and on the prevalence and distribution of HPV infection during the twelve-year period 2006-2017 in the Local Health Unit (LHU) of Lecce. The vaccination coverage of about 70% among girls in the LHU led to an initial reduction in vaccine-targeted HPV types and cross-protective genotypes. However, the results on this population should be interpreted cautiously because the period since the start of vaccination is too short and the coverage rate is not yet optimal to evaluate the efficacy of vaccination in lowering the prevalence of non-vaccine HR HPV types in the vaccinated cohort and in older subjects. Nevertheless, it is expected that direct effects will increase further and that herd immunity will begin to emerge as vaccination coverage increases.
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Affiliation(s)
- Marcello Guid
- Laboratory of Hygiene, Department of Biological and Environmental Sciences and Technologies, Faculty of Sciences, University of Salento, Lecce, Italy.,Inter-University Centre of Research on Influenza and other Transmissible Infections (CIRI-IT), Genoa, Italy
| | - Annarita Bruno
- Laboratory of Molecular Virology, "S. Caterina Novella" Hospital, Galatina, Italy
| | - Luigi Tagliaferro
- Anatomical Pathology Unit, "Sacro cuore di Gesù" Hospital, Gallipoli, Italy
| | - Valerio Aprile
- Prevention Dept, Hygiene and Public Health Service, Local Health Agency, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, "Veris delli Ponti" Hospital, Scorrano, Lecce, Italy
| | - Alberto Fedele
- Prevention Dept, Hygiene and Public Health Service, Local Health Agency, Lecce, Italy
| | | | | | | | - Vittorio Tassi
- Clinical Pathology and Microbiology Laboratory, Vito Fazzi Hospital, Lecce, Italy
| | | | - Francesca Fortunato
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Laura Isabella Lupo
- Clinical Pathology and Microbiology Laboratory, Vito Fazzi Hospital, Lecce, Italy
| | - Antonella Zizza
- Institute of Clinical Physiology, National Research Council, Lecce, Italy
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Evidence for Missing Positive Results for Human Papilloma Virus 45 (HPV-45) and HPV-59 with the SPF 10-DEIA-LiPA 25 (Version 1) Platform Compared to Type-Specific Real-Time Quantitative PCR Assays and Impact on Vaccine Effectiveness Estimates. J Clin Microbiol 2020; 58:JCM.01626-20. [PMID: 32907991 PMCID: PMC7587105 DOI: 10.1128/jcm.01626-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/01/2020] [Indexed: 11/29/2022] Open
Abstract
Human papillomavirus (HPV) epidemiological and vaccine studies require highly sensitive HPV detection systems. The widely used broad-spectrum SPF10-DEIA-LiPA25 (SPF10 method) has reduced sensitivity toward HPV-45 and -59. Therefore, anogenital samples from the PASSYON study were retrospectively analyzed with type-specific (TS) HPV-45 and -59 real-time quantitative PCR (qPCR) assays. The SPF10 method missed 51.1% of HPV-45 and 76.1% of HPV-59 infections that were detected by the TS qPCR assays. Human papillomavirus (HPV) epidemiological and vaccine studies require highly sensitive HPV detection systems. The widely used broad-spectrum SPF10-DEIA-LiPA25 (SPF10 method) has reduced sensitivity toward HPV-45 and -59. Therefore, anogenital samples from the PASSYON study were retrospectively analyzed with type-specific (TS) HPV-45 and -59 real-time quantitative PCR (qPCR) assays. The SPF10 method missed 51.1% of HPV-45 and 76.1% of HPV-59 infections that were detected by the TS qPCR assays. The viral copy number (VCn) of SPF10-missed HPV-45 and -59 was significantly lower than SPF10-detected HPV-45 and -59 (P < 0.0001 for both HPV types). Sanger sequencing showed no phylogenetic distinction between SPF10-missed and SPF10-detected HPV-59 variants, but variants bearing the A6562G single-nucleotide polymorphism (SNP) in the SPF10 target region were more likely to be missed (P = 0.0392). HPV cooccurrence slightly influenced the detection probability of HPV-45 and -59 with the SPF10 method. Moreover, HPV-59 detection with the SPF10 method was hampered more in nonvaccinated women than vaccinated women, likely due to a stronger masking effect by increased HPV cooccurrence in the former group. Consequently, the SPF10 method led to a strong negative vaccine effectiveness (VE) of –84.6% against HPV-59, while the VE based on TS qPCR was 3.1%. For HPV-45, the relative increase in detection in nonvaccinated women compared vaccinated women was more similar, resulting in comparable VE estimates. In conclusion, this study shows that HPV-45 and -59 detection with the SPF10 method is dependent on factors including VCn, HPV cooccurrence, and vaccination, thereby showing that knowledge of the limitations of the HPV detection method used is of great importance.
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Mehanna H, Bryant TS, Babrah J, Louie K, Bryant JL, Spruce RJ, Batis N, Olaleye O, Jones J, Struijk L, Molijn A, Vorsters A, Rosillon D, Taylor S, D'Souza G. Human Papillomavirus (HPV) Vaccine Effectiveness and Potential Herd Immunity for Reducing Oncogenic Oropharyngeal HPV-16 Prevalence in the United Kingdom: A Cross-sectional Study. Clin Infect Dis 2020; 69:1296-1302. [PMID: 30590469 PMCID: PMC6763631 DOI: 10.1093/cid/ciy1081] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/21/2018] [Indexed: 01/08/2023] Open
Abstract
Background Oropharyngeal cancer incidence is rapidly rising due to human papillomavirus (HPV) type 16 infection. The dearth of data on effectiveness of national female-only vaccination programs in preventing oral HPV infection and potential herd immunity in unvaccinated males has resulted in considerable controversy regarding the need to vaccinate males, especially in countries with high female vaccination coverage. Methods Subjects aged 0–65 years undergoing tonsillectomy for nonmalignant indications were recruited in 6 hospitals in the United Kingdom. Oral samples were collected as follows: oral rinse, tongue base, and pharyngeal wall brushes, then tonsil tissue (tonsillectomy). Vaccination data were obtained from regional health authorities. All samples were centrally tested for HPV DNA by polymerase chain reaction. Results Of 940 subjects, 243 females and 69 males were aged 12–24 years (median age, 18.6 years), with 189 (78%) females and no males vaccinated against HPV. Overall, oropharyngeal HPV-16 prevalence was significantly lower in vaccinated versus unvaccinated females (0.5% vs 5.6%, P = .04). In contrast, prevalence of any oropharyngeal HPV type was similar in vaccinated and unvaccinated females (19% vs 20%, P = .76). Oropharyngeal HPV-16 prevalence in unvaccinated males was similar to vaccinated females (0% vs 0.5%, P > .99), and lower than unvaccinated females (0% vs 5.6%, P = .08). Conclusions Our findings indicate that the UK female-only vaccination program is associated with significant reductions in oropharyngeal HPV-16 infections. These are also the first data to suggest potential herd immunity from female-only vaccination against oropharyngeal HPV infection in contemporaneously aged males.
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Affiliation(s)
- Hisham Mehanna
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Tyler S Bryant
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jaspreet Babrah
- Cancer Research UK Clinical Trials Unit, University of Birmingham, United Kingdom
| | - Karly Louie
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom
| | - Jennifer L Bryant
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Rachel J Spruce
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Nikolaos Batis
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Oladejo Olaleye
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - June Jones
- Institute of Head and Neck Studies and Education, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Linda Struijk
- DDL Diagnostic Laboratory, Rijswijk, The Netherlands
| | - Anco Molijn
- DDL Diagnostic Laboratory, Rijswijk, The Netherlands
| | - Alex Vorsters
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, GlaxoSmithKline, Wavre, Belgium
| | - Dominique Rosillon
- Clinical and Epidemiology Research Development, GlaxoSmithKline, Wavre, Belgium
| | - Sylvia Taylor
- Clinical and Epidemiology Research Development, GlaxoSmithKline, Wavre, Belgium
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Bogani G, Chiappa V, Pinelli C, Lopez S, Signorelli M, Taverna F, Lombardo C, Ditto A, Raspagliesi F. Trends in prevalence in human papillomavirus types and their association with cervical dysplasia: an analysis on 15 138 women over 20 years. Eur J Cancer Prev 2020; 29:452-457. [PMID: 32740171 DOI: 10.1097/cej.0000000000000565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To investigate trends in prevalence of various human papillomavirus types in order to assess the unmet clinical needs for women affected by human papillomavirus-related disease. Data of consecutive 15 138 patients undergoing human papillomavirus DNA testing from 1998 to 2018 were retrospectively identified. Human papillomavirus types were classified at high-risk according to the classification of the International Agency for Research on Cancer. The International Agency for Research on Cancer included seven human papillomavirus types covered by nine-valent vaccine and five not yet covered by any available vaccines. Overall, 4159 (65.3%), 1500 (23.5%) and 714 (11.2%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. At least one high-risk human papillomavirus type(s) was detected in 1241 patients with genital dysplasia: 832 (67.1%), 291 (23.4%) and 118 (9.5%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. Over the twenty-year study period, the number of human papillomavirus types not covered by nine-valent vaccine increased dramatically (from 4 to 16%; P < 0.001, P for trend). Similarly, looking at patients with genital dysplasia, high-risk human papillomavirus types not covered by nine-valent vaccine increased from 3 to 13% (P < 0.001, P for trend). Our data highlight that human papillomavirus types covered by nine-valent vaccine represent are the main types associated with genital dysplasia. However, over the study period, we observed an increasing prevalence of confections and high-risk human papillomavirus types not covered by the nine-valent vaccine, thus suggesting the need of developing more complete vaccines against human papillomavirus.
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Affiliation(s)
- Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Impact of a High Coverage Vaccination Rate on Human Papillomavirus Infection Prevalence in Young Women: A Cross-sectional Study. J Low Genit Tract Dis 2020; 24:363-366. [PMID: 32796265 DOI: 10.1097/lgt.0000000000000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to compare the rate of high-risk human papillomavirus (HR-HPV) genotypes in vaccinated (Gardasil [quadrivalent]) and unvaccinated cohorts of young women. MATERIALS AND METHODS This is a retrospective, cross-sectional study, consisting of the comparison of the prevalence of HPV 16, 18, and other HR genotypes in 2183 women younger than 25 years, according to their birth year (born >1994 [mostly vaccinated <13 years]; born 1992-1994 [vaccinated at 17 years]; born <1992 [not vaccinated/vaccinated >17 years]), in a private laboratory. RESULTS The rates of HPV 16, 18, 16/18, and others in the cohort born before 1992 (n = 331) were 6.3%, 1.5%, 7.9%, and 31.7%. In those born 1992-1994 (n = 901), the rates were 3.3%, 0.4%, 3.6%, and 32.5%; in the ones born after 1994 (n = 951), the rates were 0.7%, 0.2%, 0.9%, and 33.2%, respectively.There were no changes in the relative risk (RR) of HR-HPV infection by genotypes other than HPV 16/18 in any cohort.The RR was significantly reduced in the cohort born after 1994 for HPV 16 (0.12 [0.050-0.270], p < .0001), HPV 18 (0.14 [0.027-0.714], p = .02), and HPV 16/18 (0.12 [0.057-0.254], p < .0001).In those born 1992-1994, there was a nearly significant reduction in the RR of HPV 18 infection (0.29 [0.079-1.09], p = .07); the reduction was significant for HPV 16 (0.52 [0.305-0.904], p = .02) and HPV 16/18 (0.45 [0.274-0.747], p = .0018). CONCLUSIONS Young women vaccinated before 13 years had a nearly 90% risk reduction of HPV 16/18, whereas if vaccinated at 17 years, the decrease was of 50%. There was no impact in the nonvaccine genotypes.Our data highlight the importance of vaccinating at young age and of introducing vaccines covering more HR genotypes.
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Kyrgiou M, Arbyn M, Bergeron C, Bosch FX, Dillner J, Jit M, Kim J, Poljak M, Nieminen P, Sasieni P, Kesic V, Cuzick J, Gultekin M. Cervical screening: ESGO-EFC position paper of the European Society of Gynaecologic Oncology (ESGO) and the European Federation of Colposcopy (EFC). Br J Cancer 2020; 123:510-517. [PMID: 32507855 PMCID: PMC7434873 DOI: 10.1038/s41416-020-0920-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/21/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
This paper summarises the position of ESGO and EFC on cervical screening based on existing guidelines and opinions of a team of lead experts. HPV test is replacing cytology as this offers greater protection against cervical cancer and allows longer screening intervals. Only a dozen of HPV tests are considered as clinically validated for screening. The lower specificity of HPV test dictates the use of triage tests that can select women for colposcopy. Reflex cytology is currently the only well validated triage test; HPV genotyping and p16 immunostaining may be used in the future, although methylation assays and viral load also look promising. A summary of quality assurance benchmarks is provided, and the importance to audit the screening histories of women who developed cancer is noted as a key objective. HPV-based screening is more cost-effective than cytology or cotesting. HPV-based screening should continue in the post-vaccination era. Only a fraction of the female population is vaccinated, and this varies across countries. A major challenge will be to personalise screening frequency according to vaccination status. Still the most important factor for successful prevention by screening is high population coverage and organised screening. Screening with self-sampling to reach under-screened women is promising.
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Affiliation(s)
- Maria Kyrgiou
- Department of Surgery and Cancer - Gut, Metabolism and Reproduction IRDB, Faculty of Medicine, Imperial College London, London, W12 0NN, UK.
- West London Gynaecological Cancer Centre, Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, W12 0HS, UK.
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
| | - Christine Bergeron
- Department of Pathology, Laboratoire Cerba, 95066, Cergy Pontoise, Cedex 9, France
| | - F Xavier Bosch
- Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Universitat Oberta de Catalunya, Barcelona, Spain
| | - Joakim Dillner
- Department of Laboratory Medicine, Karolinska Institut, Stockholm, Sweden
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- Modelling and Economics Unit, National Infections Service, Public Health England, London, NW9 5EQ, UK
- School of Public Health, University of Hong Kong, Hong Kong, SAR, China
| | - Jane Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA, 02115, USA
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Peter Sasieni
- King's Clinical Trials Unit, King's University, London, UK
| | - Vesna Kesic
- Medical Faculty, University of Belgrade; Clinic of Obstetrics and Gynecology, Clinical center of Serbia, Beograd, Serbia
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine - Barts and The London, Queen's Mary University, Charterhouse Square, EC1M 6BQ, London, UK
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Sasieni P, Castanon A. Evidence of HPV vaccination efficacy comes from more than clinical trials. Vaccine 2020; 38:5569-5571. [PMID: 32654905 DOI: 10.1016/j.vaccine.2020.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Peter Sasieni
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Cancer Prevention Group, Innovation Hub, Guys Cancer Centre, Guys Hospital, Great Maze Pond, London SE1 9RT, United Kingdom
| | - Alejandra Castanon
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Cancer Prevention Group, Innovation Hub, Guys Cancer Centre, Guys Hospital, Great Maze Pond, London SE1 9RT, United Kingdom.
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HPV vaccination and cancer prevention. Best Pract Res Clin Obstet Gynaecol 2020; 65:109-124. [DOI: 10.1016/j.bpobgyn.2020.02.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
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Yang W, Kehm RD, Terry MB. Survival model methods for analyses of cancer incidence trends in young adults. Stat Med 2020; 39:1011-1024. [PMID: 32022306 DOI: 10.1002/sim.8458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 11/09/2022]
Abstract
Recent studies have reported increases in cancer incidence in adults under 50 years. However, there remains uncertainty about whether these are true increases or a result of incidental findings from increased medical imaging. To evaluate these trends, we propose an alternative method to age-period-cohort analyses based on survival modeling. Simulations show that our method is capable of quantifying cohort effects within various backgrounds including increasing medical imaging. We applied the method to analyze the changes in cancer incidence rates for 44 anatomic sites, stratified by sex, by birth cohort for individuals born from 1945 to 1969 in the US based on incidence data from the Surveillance, Epidemiology, and End Results (SEER) program, and tested the validity of our models using later birth cohorts (1970-1974 and 1975-1979). We found that cancer risks have increased significantly in 15 sites (9 in men and 11 in women) for 25-49 year-olds. These results were consistent with previous findings from age-period-cohort analyses. Furthermore, based on our simulations, these increases were independent of increased medical imaging and support substantial, increased extrinsic risks in the identified cancers. Although our approach has several limitations including the restriction to the younger age range and requirement of complete data for all ages of interest, we demonstrate many advantages of our approach including the ease in implementation and interpretation of cohort effects, robustness to various period backgrounds, and ability to make predictions. Our approach should help epidemiologists evaluate cohort effects using incidence data for cancer or other diseases.
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Affiliation(s)
- Wan Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Rebecca D Kehm
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
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Folschweiller N, Behre U, Dionne M, Durando P, Esposito S, Ferguson L, Ferguson M, Hillemanns P, McNeil SA, Peters K, Ramjattan B, Schwarz TF, Supparatpinyo K, Suryakirian PV, Janssens M, Moris P, Decreux A, Poncelet S, Struyf F. Long-term Cross-reactivity Against Nonvaccine Human Papillomavirus Types 31 and 45 After 2- or 3-Dose Schedules of the AS04-Adjuvanted Human HPV-16/18 Vaccine. J Infect Dis 2020; 219:1799-1803. [PMID: 30715452 PMCID: PMC6500548 DOI: 10.1093/infdis/jiy743] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/08/2019] [Indexed: 01/28/2023] Open
Abstract
This analysis focused on long-term cross-reactive immunogenicity against nonvaccine human papillomavirus (HPV) types 31 and 45 following 2 doses of AS04-adjuvanted HPV-16/18 vaccine in girls aged 9-14 years or following 3 doses in women aged 15-25 years, for up to 3 years (HPV-070 study) and up to 5 years (HPV-048 study) after the first vaccination. Both schedules elicited antibodies against HPV-31 and HPV-45 up to 5 years after first dose. The antibody concentration was similar in young girls as compared to women. Specific CD4+ T-cell and B-cell responses to HPV-31 and HPV-45 at month 36 were similar across groups. Clinical trials registration: NCT01381575 and NCT00541970.
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Affiliation(s)
| | | | | | - Paolo Durando
- Department of Health Sciences, University of Genoa.,IRCCS Ospedale Policlinico AOU San Martino-IST, Genoa
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | | | | | | | - Shelly A McNeil
- Canadian Center for Vaccinology, IWK Health Centre and Nova Scotia Health Authority, Dalhousie University, Halifax
| | | | | | - Tino F Schwarz
- Institute of Laboratory Medicine and Vaccination Centre, Klinikum Würzburg Mitte, Standort Juliusspital, Würzburg, Germany
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Li Y, Zhu P, Wu M, Zhang Y, Li L. Immunogenicity and safety of human papillomavirus vaccine coadministered with other vaccines in individuals aged 9-25 years: A systematic review and meta-analysis. Vaccine 2020; 38:119-134. [PMID: 31831220 DOI: 10.1016/j.vaccine.2019.10.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/09/2019] [Accepted: 10/28/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Adolescents and young adults are at a high risk of developing human papillomavirus (HPV) infections, which can be prevented with the use of vaccines. Moreover, a combined immunization strategy for administration of HPV vaccines with other routine vaccines may lead to better compliance. We aim to comprehensively evaluate immunogenicity and safety in the case of concomitantly administered HPV vaccine in individuals aged 9-25 years. METHODS Relevant studies, published up to December 27, 2018, were identified through searches of Medline/PubMed, EMBASE, Web of Knowledge. The pooled relative risk (RR) of immunogenicity and safety information pertaining to the concomitant administration of HPV vaccines with other routine vaccines in healthy participants aged 9-25 years were evaluated. RESULTS A total of 13 papers (11,657 participants) were included in this meta-analysis. The analyses showed that, between the concomitant and nonconcomitant administration groups, the seroconversion rate for the specific antibodies against all HPV types (type 16-, 18-, 6-, 11-, 31-, 33-, 45-, 52-, and 58) were the same (the pooled RR = 1.00, 95% confidence interval (CI) of 1.00-1.00); for the bivalent HPV (2vHPV) vaccine, the risks of local adverse events showed no significant difference (the pooled RR = 1.00, 95%CI: 0.97-1.04), and the risks of systemic adverse events were almost similar (the pooled RR = 1.10, 95% CI: 1.03-1.18); for the non-bivalent HPV (4vHPV and 9vHPV) vaccines, the risks of local adverse events were slightly higher in the concomitant administration groups (the pooled RR = 1.31, 95%CI: 1.17-1.47), and the risks of systemic adverse events were higher in the concomitant administration groups (the pooled RR = 2.09, 95% CI: 1.69-2.59). CONCLUSIONS We believe that the concomitant administration of other vaccines along with HPV vaccine is acceptable and there is no interference with the immune response to HPV vaccine. Concomitant vaccine administration has the potential to minimize the number of vaccination visits, leading to increased compliance, hence more effective disease prevention.
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Affiliation(s)
- Yaowei Li
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Guangxi Medical University, Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor, Ministry of Education, Nanning, Guangxi, China; Department of Gynecology and Obstetrics, Shangyu People's Hospital, Shangyu, Zhejiang, China
| | - Pengfei Zhu
- Department of Gynecology and Obstetrics, Shangyu People's Hospital, Shangyu, Zhejiang, China
| | - Meifen Wu
- Department of Gynecology and Obstetrics, Shangyu People's Hospital, Shangyu, Zhejiang, China
| | - Yiqing Zhang
- Department of Gynecology and Obstetrics, Shangyu People's Hospital, Shangyu, Zhejiang, China
| | - Li Li
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Guangxi Medical University, Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor, Ministry of Education, Nanning, Guangxi, China.
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Latsuzbaia A, Arbyn M, Tapp J, Fischer M, Weyers S, Pesch P, Mossong J. Effectiveness of bivalent and quadrivalent human papillomavirus vaccination in Luxembourg. Cancer Epidemiol 2019; 63:101593. [DOI: 10.1016/j.canep.2019.101593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 01/17/2023]
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Su YY, Lin BZ, Zhao H, Li J, Lin ZJ, Qiao YL, Wei LH, Hu YM, Li RC, Zhuang SJ, Sun G, Zheng ZZ, Huang SJ, Wu T, Zhang J, Pan HR, Li CG. Lot-to-lot consistency study of an Escherichia coli-produced bivalent human papillomavirus vaccine in adult women: a randomized trial. Hum Vaccin Immunother 2019; 16:1636-1644. [PMID: 31770068 DOI: 10.1080/21645515.2019.1691413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
An Escherichia. coli-produced HPV-16/18 bivalent vaccine has been proved to be well-tolerated and highly efficacious against diseases associated with vaccine HPV types. As a part of the multi-center, randomized, double-blind phase III clinical trial, this lot-to-lot consistency study aimed to assess the safety and immunogenicity consistency of this novel HPV vaccine, which is also one of the objectives of the phase III trial. A total of 3689 healthy women aged 18-45 years were enrolled and randomly assigned 1:1:1 to three lots of the HPV vaccine groups. The primary outcomes were the IgG antibody level at 1 month after the last dose (month 7). In the immunogenicity per-protocol set (PPS), almost all of the participants seroconverted at month 7 and remained seropositive at month 42. For each paired comparison of the three lot groups, the two-sides of 90% CIs of GMC ratios for both IgG and neutralizing antibodies for HPV-16 and HPV-18 at month 7 were within the equivalence interval [0.5, 2]. Lot consistency was also demonstrated at month 42. The majority of recorded solicited reactions were mild or moderate. The incidences of solicited reactions of Lot 2 and Lot 3 were slightly higher than Lot 1. However, the incidences of solicited reactions of ≥ grade 3 and solicited reactions by symptoms were all similar among the three lot groups. None of the SAEs was considered related to vaccination by the investigator. In conclusion, this study demonstrates lot-to-lot consistency of the 3 consecutive lots of the E. coli-produced HPV-16/18 bivalent vaccine.
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Affiliation(s)
- Ying-Ying Su
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Bi-Zhen Lin
- Vaccine R&D Department, Xiamen Innovax Biotech Company , Xiamen, Fujian, China
| | - Hui Zhao
- National Institute for Food and Drug Control, Division of Respiratory Virus Vaccines , Beijing, China
| | - Juan Li
- National Institute for Food and Drug Control, Division of Respiratory Virus Vaccines , Beijing, China
| | - Zhi-Jie Lin
- Vaccine R&D Department, Xiamen Innovax Biotech Company , Xiamen, Fujian, China
| | - You-Lin Qiao
- National Cancer Center, National Center for Cancer Clinical Research, the Cancer Institute, Chinese Academy of Medical Sciences/Peking Union Medical College , Beijing, China
| | - Li-Hui Wei
- Department of Obstetrics and Gynecology, Peking University People's Hospital , Beijing, China
| | - Yue-Mei Hu
- Department of Vaccine Evaluation, Jiangsu Provincial Center for Disease Control and Prevention , Nanjing, Jiangsu, China
| | - Rong-Cheng Li
- Center for Vaccine Clinical Research, Guangxi Center for Disease Control and Prevention , Nanning, Guangxi, China
| | - Si-Jie Zhuang
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Guang Sun
- Vaccine R&D Department, Xiamen Innovax Biotech Company , Xiamen, Fujian, China
| | - Zi-Zheng Zheng
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Shou-Jie Huang
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Ting Wu
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Jun Zhang
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Collaborative Innovation Center of Biologic Products, School of Public Health, Xiamen University , Xiamen, Fujian, China
| | - Hui-Rong Pan
- Vaccine R&D Department, Xiamen Innovax Biotech Company , Xiamen, Fujian, China
| | - Chang-Gui Li
- National Institute for Food and Drug Control, Division of Respiratory Virus Vaccines , Beijing, China
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Monitoring human papillomavirus prevalence among young Australian women undergoing routine chlamydia screening. Vaccine 2019; 38:1186-1193. [PMID: 31767467 DOI: 10.1016/j.vaccine.2019.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/21/2019] [Accepted: 11/08/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Australia has recently implemented major changes in cervical cancer prevention policies including introduction of primary human papillomavirus (HPV) screening starting at age 25, and replacement of the quadrivalent HPV vaccine with the nonavalent vaccine in the national school-based program. We assessed the feasibility and utility of conducting HPV testing in residual clinical specimens submitted for routine Chlamydia trachomatis screening, as a means of tracking HPV vaccine program impact among young sexually active women. METHODS De-identified residual specimens from women aged 16-24 years submitted for chlamydia testing were collected from three pathology laboratories in Victoria and New South Wales. Limited demographic information, and chlamydia test results were also collected. Patient identifiers were sent directly from the laboratories to the National HPV Vaccination Program Register, to obtain HPV vaccination histories. Samples underwent HPV genotyping using Seegene Anyplex II HPV 28 assay. RESULTS Between April and July 2018, 362 residual samples were collected, the majority (60.2%) of which were cervical swabs. Demographic data and vaccination histories were received for 357 (98.6%) women (mean age 21.8, SD 2.0). Overall, 65.6% of women were fully vaccinated, 9.8% partially, and 24.7% unvaccinated. The majority (86.0%) resided in a major city, 35.9% were classified in the upper quintile of socioeconomic advantage and chlamydia positivity was 7.8%.The prevalence of quadrivalent vaccine-targeted types (HPV6/11/16/18) was 2.8% (1.5-5.1%) overall with no differences by vaccination status (p = 0.729). The prevalence of additional nonavalent vaccine-targeted types (HPV31/33/45/52/58) was 19.3% (15.6-23.8%). One or more oncogenic HPV types were detected in 46.8% (95% CI 41.6-52.0%) of women. CONCLUSIONS HPV testing of residual chlamydia specimens provides a simple, feasible method for monitoring circulating genotypes. Applied on a larger scale this method can be utilised to obtain a timely assessment of nonavalent vaccine impact among young women not yet eligible for cervical screening.
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Checchi M, Mesher D, Mohammed H, Soldan K. Response to Berlaimont and Welby. Br J Vener Dis 2019; 95:553. [DOI: 10.1136/sextrans-2019-054148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/07/2019] [Indexed: 11/04/2022]
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Patel C, Brotherton JM, Pillsbury A, Jayasinghe S, Donovan B, Macartney K, Marshall H. The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent? ACTA ACUST UNITED AC 2019; 23. [PMID: 30326995 PMCID: PMC6194907 DOI: 10.2807/1560-7917.es.2018.23.41.1700737] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Cyra Patel
- National Centre for Immunisation Research and Surveillance, Westmead, Australia
| | - Julia Ml Brotherton
- School of Population and Global Health, University of Melbourne, Parkville, Australia.,VCS Population Health, VCS Foundation, East Melbourne, Australia
| | - Alexis Pillsbury
- National Centre for Immunisation Research and Surveillance, Westmead, Australia
| | - Sanjay Jayasinghe
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,National Centre for Immunisation Research and Surveillance, Westmead, Australia
| | - Basil Donovan
- Sydney Sexual Health Centre, Sydney Hospital, Sydney, Australia.,The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Kristine Macartney
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,National Centre for Immunisation Research and Surveillance, Westmead, Australia
| | - Helen Marshall
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide, Australia.,Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, North Adelaide, Australia
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Drolet M, Bénard É, Pérez N, Brisson M. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019; 394:497-509. [PMID: 31255301 PMCID: PMC7316527 DOI: 10.1016/s0140-6736(19)30298-3] [Citation(s) in RCA: 531] [Impact Index Per Article: 106.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination. METHODS In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks. FINDINGS We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5-8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11-0·25) among girls aged 13-19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23-0·49) among women aged 20-24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33-0·66) among girls aged 13-19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24-0·46) among girls aged 15-19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36-0.60) among women aged 20-24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53-0·89) among women aged 25-29 years. Among boys aged 15-19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37-0·75) and among men aged 20-24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47-0·98). After 5-9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42-0·58) among screened girls aged 15-19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57-0·84) among women aged 20-24 years. INTERPRETATION This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects. FUNDING WHO, Canadian Institutes of Health Research, Fonds de recherche du Québec - Santé.
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Affiliation(s)
- Mélanie Drolet
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Élodie Bénard
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada; Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Norma Pérez
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Marc Brisson
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada; Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada; Department of Infectious Disease Epidemiology, Imperial College, London, UK.
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Sonnenberg P, Tanton C, Mesher D, King E, Beddows S, Field N, Mercer CH, Soldan K, Johnson AM. Epidemiology of genital warts in the British population: implications for HPV vaccination programmes. Sex Transm Infect 2019; 95:386-390. [PMID: 30723185 PMCID: PMC6678036 DOI: 10.1136/sextrans-2018-053786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/06/2018] [Accepted: 11/25/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the prevalence of, and describe risk factors for, genital warts (GWs) in the British population, following the introduction of the bivalent (human papillomavirus (HPV)-16/18) vaccination programme in girls, and prior to the switch to quadrivalent (HPV-6/11/16/18) vaccine (offering direct protection against GWs) and compare this with GW diagnoses in the prevaccination era. METHODS Natsal-3, a probability sample survey in Britain, conducted in 2010-2012, interviewed 9902 men and women aged 16-44. Natsal-2, conducted in 1999-2001, surveyed 11 161 men and women aged 16-44. Both surveys collected data on sexual behaviour and sexually transmitted infection diagnoses using computer-assisted interview methods. RESULTS In Natsal-3, 3.8% and 4.6% of sexually experienced men and women reported ever having a diagnosis of GWs, with 1.3% of men and 1.7% of woman reporting a GWs diagnosis in the past 5 years. GWs were strongly associated with increasing partner numbers and condomless sex. Diagnoses were more frequent in men who have sex with men (MSM) (11.6% ever, 3.3% past 5 years) and in women reporting sex with women (10.8% ever, 3.6% past 5 years). In the age group who were eligible for vaccination at the time of Natsal-3 (16-20 years), a similar proportion of same-aged women reported a history of GWs in Natsal-2 (1.9%, 1.1-3.4) and Natsal-3 (2.6%, 1.5-4.4). CONCLUSIONS These data provide essential parameters for mathematical models that inform cost-effectiveness analyses of HPV vaccination programmes. There was no evidence of population protection against GWs conferred by the bivalent vaccine. Even with vaccination of adolescent boys, vaccination should be offered to MSM attending sexual health clinics.
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Affiliation(s)
- Pam Sonnenberg
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
| | - Clare Tanton
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - David Mesher
- Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - Eleanor King
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
| | - Simon Beddows
- Virus Reference Department, Public Health England, London, UK
| | - Nigel Field
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
| | - Catherine H Mercer
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
| | - Kate Soldan
- Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - Anne M Johnson
- Mortimer Market Centre, Institute for Global Health, University College London, London, UK
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Chernyshov PV, Humenna I. Human papillomavirus: vaccination, related cancer awareness, and risk of transmission among female medical students. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2019. [DOI: 10.15570/actaapa.2019.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Joura EA, Kyrgiou M, Bosch FX, Kesic V, Niemenen P, Redman CW, Gultekin M. Human papillomavirus vaccination: The ESGO-EFC position paper of the European society of Gynaecologic Oncology and the European Federation for colposcopy. Eur J Cancer 2019; 116:21-26. [PMID: 31163338 DOI: 10.1016/j.ejca.2019.04.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/31/2019] [Accepted: 04/10/2019] [Indexed: 10/26/2022]
Abstract
Vaccines against human papillomavirus (HPV) are available in Europe since 2006. They have been highly effective in preventing infection and disease caused by the vaccine types. Clinical efficacy data are available for cervical, vulvovaginal and anal precancer and invasive cervical cancer. Disease reduction is best with early vaccination and a coverage of more than 70%. Gender-neutral vaccination provides direct protection for all men and improves the coverage. A good coverage is followed by herd protection of the unvaccinated men and women. School-based programs appear to be most effective; under the age of 15 years, two doses with an interval of 6-12 months are sufficient. From the age of 15 years, the standard regimen with three doses is recommended. A broad catch-up program for young adult women and men improves the effectiveness. The vaccines are also effective in sexually active women and men with previous but cleared infections. Vaccination in addition to local treatment of HPV-related disease appears to reduce recurrent or subsequent HPV-related disease. Combination of HPV vaccination and screening with HPV testing is the most effective approach to prevention of cervical cancer. The screening intervals may increase in the vaccinated cohorts. The upper age limit for vaccination remains to be evaluated, is country specific and depends on cost-effectiveness. The European Society of Gynaecologic Oncology and the European Federation for Colposcopy strongly support gender-neutral vaccination programs for children and young adolescents, with a catch-up program for young adults.
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Affiliation(s)
- Elmar A Joura
- Medical University of Vienna, Department of Gynecology and Gynecologic Oncology, Austria; Comprehensive Cancer Center (CCC) Vienna, Austria
| | - Maria Kyrgiou
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, W12 0NN, UK; West London Gynaecological Cancer Centre, Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, W12 0HS, UK.
| | - Francisco X Bosch
- Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO), Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Vesna Kesic
- Clinic of Obstetrics and Gynecology, University of Belgrade, Serbia
| | - Pekka Niemenen
- Department Obstetrics & Gynecology, Helsinki University Hospital and Helsinki University, Finland
| | - Charles We Redman
- University Hospitals of North Midlands NHS Trust, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Markowitz LE, Naleway AL, Lewis RM, Crane B, Querec TD, Weinmann S, Steinau M, Unger ER. Declines in HPV vaccine type prevalence in women screened for cervical cancer in the United States: Evidence of direct and herd effects of vaccination. Vaccine 2019; 37:3918-3924. [PMID: 31160099 DOI: 10.1016/j.vaccine.2019.04.099] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Human papillomavirus (HPV) vaccine has been recommended in the United States since 2006 for routine vaccination of girls at age 11-12 years and through age 26 years for women not previously vaccinated. Changes in vaccine-type HPV (VT) prevalence can be used to evaluate vaccine impact, including herd effects. METHODS We determined type-specific HPV in cytology specimens from women aged 20-29 years screened for cervical cancer at Kaiser Permanente Northwest in 2007 and in two vaccine era periods: 2012-2013 and 2015-2016. Detection and typing used L1 consensus PCR with hybridization for 37 types, including quadrivalent vaccine types (HPV 6/11/16/18). RESULTS Among 20-24 year-olds in 2012-2013 and 2015-2016, 44% and 64% had a history of ≥1-dose vaccination. VT prevalence decreased from 13.1% in 2007 to 2.9% in 2015-2016 (prevalence ratio [PR] = 0.22; 95% confidence interval [CI] 0.17-0.29). HPV 31 prevalence was also lower in the vaccine periods compared with 2007. VT prevalence in 2015-2016 among 20-24 year-olds was lower in both vaccinated, 1.3% (PR = 0.10; 95% CI 0.06-0.16), and unvaccinated women, 5.8% (PR = 0.45; 95% CI 0.33-0.61). Among 25-29 year-olds, 21% and 32% had a history of ≥1-dose vaccination. VT prevalence decreased from 8.1% in 2007 to 5.0% in 2015-2016 (PR = 0.62; 95% CI 0.50-0.78). Non-VT high risk prevalence was higher in the vaccine periods compared with the pre-vaccine era in both age groups, however, not in 2015-2016 compared with 2012-2013. CONCLUSION Within 9-10 years of vaccine introduction, VT prevalence decreased 78% among 20-24 year-olds and 38% in 25-29 year-olds. There were declines in both vaccinated and unvaccinated women, showing evidence of direct and herd protection.
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Affiliation(s)
- Lauri E Markowitz
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Allison L Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Rayleen M Lewis
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; Synergy America, Inc., Duluth, GA 30097, USA
| | - Bradley Crane
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Troy D Querec
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Martin Steinau
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
| | - Elizabeth R Unger
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
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