Human papilloma virus immunization in adolescent and young adults: a cohort study to illustrate what events might be mistaken for adverse reactions

Safety of Streptococcus pyogenes Vaccines: Anticipating and Overcoming Challenges for Clinical Trials and Post-Marketing Monitoring

Streptococcus pyogenes (Strep A) infections result in a vastly underestimated burden of acute and chronic disease globally. The Strep A Vaccine Global Consortium's (SAVAC's) mission is to accelerate the development of safe, effective, and affordable S. pyogenes vaccines. The safety of vaccine recipients is of paramount importance. A single S. pyogenes vaccine clinical trial conducted in the 1960s raised important safety concerns. A SAVAC Safety Working Group was established to review the safety assessment methodology and results of more recent early-phase clinical trials and to consider future challenges for vaccine safety assessments across all phases of vaccine development. No clinical or biological safety signals were detected in any of these early-phase trials in the modern era. Improvements in vaccine safety assessments need further consideration, particularly for pediatric clinical trials, large-scale efficacy trials, and preparation for post-marketing pharmacovigilance.

Background incidence rates of selected adverse events of special interest (AESI) to monitor the safety of COVID-19 vaccines

BACKGROUND

Determining background rates of medical conditions identified as adverse events of special interest (AESI) that may occur following COVID-19 vaccination is important for contextualising and investigating potential vaccine safety signals.

METHODS

We conducted a retrospective population-based cohort study using linked emergency department, hospitalisation and death data for 2017 and 2018 from Australia's most populous state, New South Wales. Incident cases of select neurological conditions, arterial or venous thromboembolic conditions, secondary thrombocytopenia, myocarditis/pericarditis, and unique events of anaphylaxis and generalised convulsions were identified using internationally agreed upon diagnostic (ICD-10) codes. State-specific rates per 100,000 person-years were calculated, with further stratification by age group and sex where clinically relevant to the condition, and the number of expected cases nationally in one and 6 weeks was estimated.

RESULTS

Background rates of selected neurological conditions were low with the exception of generalised convulsions for which 1,599-1,872 cases were estimated nationally in a 1-week period in the absence of vaccination. Using a narrow case definition, rates of Guillain-Barré Syndrome (3.9 per 100,000 person-years) were higher than international rates reported elsewhere. Thromboembolic and cerebral venous sinus thrombosis event rates increased with age. Myocarditis occurred more commonly in males, and was highest in males aged 18-24 years, with an estimated 1-4 cases expected nationally in a 1-week period.

CONCLUSIONS

Using routinely collected linked healthcare data provides localised estimates of background rates of new onset or periodic AESI which enables rapid estimation of observed-versus-expected rates of events reported following COVID-19 vaccination. This Australian-specific analysis contributes AESI background rates which can be compared with those from other countries to enhance understanding of geographic variability in the frequency of specific AESI in the absence of vaccination, and can be utilised for signal detection during program implementation.

Economic impact of vaccine safety incident in Ukraine: The economic case for safety system investment

BACKGROUND

Vaccine confidence and coverage decreased following a death temporally but not causally related to measles vaccination in Ukraine in 2008. Large measles outbreaks including international exportations followed. Herein we characterize this experience including associated costs.

METHODS

Mixed-methods were used to characterize this vaccine safety incident and quantify health and economic costs. Qualitative interviews illuminate the incident, social climate, and corruption that influenced vaccine confidence in Ukraine. A literature review explored attitudes toward vaccines in the USSR and post-independence Ukraine. Infectious disease incidence was examined before and after the vaccine safety incident. An economic analysis estimated associated healthcare costs, including prevention and outbreak control measures, additional vaccination activities due to failure of the 2008 campaign, treatment costs for new cases domestically and foreign exportation, and productivity loss from treatment time and mortality for new cases.

FINDINGS

Vaccine hesitancy and distrust in government and public health programs due to corruption existed in Ukraine before the vaccine safety incident. The mishandling of the 2008 incident catalyzed the decline of vaccine confidence and prompted poor procurement decisions, leading to a drop in infant vaccination coverage, increased domestic measles cases, and exportation of measles. The estimated cost of this incident was approximately $140 million from 2008 to 2018.

INTERPRETATION

Absent a rapid and credible vaccine safety response, a coincidental death following immunization resulted in major outbreaks of measles with substantial economic costs. Adequate investments in a post-licensure safety system may help avoid similar future incidents.

Information systems for vaccine safety surveillance

Immunization implementation in the community relies upon post-licensure vaccine safety surveillance to maintain safe vaccination programs and to detect rare AEFI not observed in clinical trials. The increasing availability of electronic health-care related data and correspondence from both health-related providers and internet-based media has revolutionized health-care information. Many and varied forms of health information related to adverse event following immunization (AEFI) are potentially suitable for vaccine safety surveillance. The utilization of these media ranges from more efficient use of electronic spontaneous reporting, automated solicited surveillance methods, screening various electronic health record types, and the utilization of natural language processing techniques to scan enormous amounts of internet-based data for AEFI mentions. Each of these surveillance types have advantages and disadvantages and are often complementary to each other. Most are "hypothesis generating," detecting potential safety signals, where some, such as vaccine safety datalinking, may also serve as "hypothesis testing" to help verify and investigate those potential signals.

Assessment of thyroiditis risk associated with HPV vaccination among girls aged 9-18 years: A time-varying cohort study

BACKGROUND

Previous studies have suggested a relationship between human papillomavirus vaccine and autoimmune diseases, including thyroiditis. Thus, we aimed to evaluate the risk of thyroiditis associated with HPV vaccination among girls using the Primary Care Database For Pharmacoepidemiological Research (BIFAP) in Spain.

METHODS

In this retrospective cohort study, girls in BIFAP aged 9-18 years from 2007 to 2016, free of past thyroiditis and HPV vaccination, were included. Hazard Ratios (HRs; 95% CI) of thyroiditis were calculated within exposed periods (up to 2 years of vaccination) and post-exposed periods (from 2 years after vaccination onwards) compared with non-exposed periods, overall, by dose and by type of vaccine, adjusted for potential confounders collected at different times. In a post-hoc analysis, we moved back the thyroiditis date (30 days) as a theoretical delay in diagnosis.

RESULTS

Out of the 388,411 girls included in the cohort, 153,924 were vaccinated against HPV and 480 thyroiditis (253 autoimmune) cases were identified (334 non-exposed; 103 exposed; 43 post-exposed). Adjusted HR was 1.18 [95% CI: 0.79-1.76] for exposed (1.25 [0.77-2.04] for bi- and 1.15 [0.76-1.76] for quadri-valent vaccines) and 1.26 [0.74-2.14] for post-exposed periods. HR was 1.50 [0.87-2.59] for the 1^st dose, 1.13 [0.66-1.91] for the 2^nd and 1.11 [0.71-1.72] for the 3^rd one. When the diagnosis date was moved back, the risk was 1.14 [0.76-1.70] for exposed period, being 1.80 [0.86-3.76] and 1.40 [0.74-2.66] after 1^st dose of bi- and quadri-valent, respectively.

CONCLUSIONS

We did not observe an increased risk of thyroiditis following HPV vaccination (whether bi- or quadri-valent). Even though the point estimate was higher after 1^st HPV vaccination dose than after subsequent doses, a dose-effect was not confirmed. Results remained similar after applying a lag time.

Vaccine safety issues at the turn of the 21st century

Global gains in vaccination coverage during the early 21st century have been threatened by the emergence of antivaccination groups that have questioned the effectiveness of vaccines to generate public distrust of vaccines and immunisation programmes. This manuscript summarises six key topics that have been at the centre of global discussions on vaccine safety during the early 21st century: thiomersal in multi-dose non-live vaccines, aluminium adjuvants used with several non-live vaccines, autism and auto-immune conditions as possible consequences of vaccination, a risk of immune overload with increasing numbers of vaccinations, and detrimental non-specific effects (NSEs) of vaccination. For each topic, we describe the hypothesis behind the public concern, the evidence reviewed by the WHO’s Global Advisory Committee for Vaccine Safety (GACVS) during 1999–2019, and any significant new data that has emerged since GACVS conclusions were made. Although the scientific evidence on these issues overwhelmingly supports the safety of vaccines, communication messages to caregivers and providers need to condense and convey scientific information in an appropriate way to address concerns contributing to vaccine distrust. In addition, there is need for further studies specifically designed to address both positive and negative NSE of vaccination. The role of GACVS will be increasingly important in evaluating the evidence and engaging the global community in promoting and assuring the safety of vaccines in the decades to come as we move into an era in which we use new vaccination platforms, antigens and formulations.

18F-FDG-PET brain imaging may highlight brain metabolic alterations in dysautonomic syndrome after human papilloma virus vaccination

AIM

The aim of this study was to evaluate brain glucose metabolism by means of [18F]-fluoro-deoxygluycose (F-FDG) PET in a group of patients presenting dysautonomic syndrome after human papilloma virus (HPV) immunization.

METHODS

Medical records of patients, referred to the 'Second Opinion Medical Consulting Network' Medical Centre (Modena, Italy) diagnosed with dysautonomic syndrome were searched. Inclusion criteria were presence in the medical history of adverse drug reactions following HPV vaccine; a Montreal Cognitive Assessment score <25 and good quality of a F-FDG-PET brain scan performed within 12 months from the diagnosis of dysautonomic syndrome. F-FDG-PET images of patients (HPV-group) were compared to a control group, matched for age and sex, using statistical parametric mapping (SPM).

RESULTS

The F-FDG-PET study was available for five female patients. The SPM-group analysis revealed significant hypometabolism (P < 0.05 false discovery rate corrected) in the right superior and medial temporal gyrus (Brodmann areas 22, 21) and insula (Brodmann area 13). At a threshold of P < 0.001 (uncorrected), further hypometabolic regions were revealed in the right superior temporal gyrus (Brodmann area 42) and caudate head and in the left superior temporal gyrus (Brodmann area 22), frontal subcallosal gyrus (Brodmann area 47) and insula (Brodmann area 13). Relative hypermetabolism (P = 0.001) was revealed in the right premotor cortex (Brodmann area 6).

CONCLUSION

This study revealed the possibility of altered brain glucose metabolism in subjects with dysautonomic syndrome post-immunization with HPV vaccine. These results could reinforce the hypothesis of a causal relationship between HPV vaccine, or some component included in the vaccine and the development of clinical manifestations.

Assessing the Safety of COVID-19 Vaccines: A Primer

Vaccines against COVID-19 are being developed at speeds not previously achieved. With this unprecedented effort comes challenges for post-marketing safety monitoring and challenges for vaccine safety communication. To deploy these new vaccines fast across diverse populations, it is vital that robust pharmacovigilance and active surveillance systems are in place. Not all countries have the capability or resources to undertake adequate surveillance and will rely on data from those who can. The tools exist to assess COVID-19 vaccines as they are deployed such as surveillance systems, administrative data and case definitions for adverse events of special interest. However, stitching these all together and using them effectively requires investment and collaboration. This paper provides a high-level overview of some of the facets of modern vaccine safety assessment and how they are, or can be, applied to COVID-19 vaccines.

Spread of vaccine hesitancy in France: What about YouTube™?

OBJECTIVES

This work characterises the information about vaccination available on YouTube™ in France.

METHODS

YouTube™ (www.YouTube.com) was searched using "vaccines" as a keyword. Videos in French with at least 10,000 views were identified. For each video, specific descriptive information including the opinion on vaccination was identified. To study the anti-vaccine reaction linked to a change in French policy on vaccination, the main arguments used in videos with negative opinions on vaccination uploaded in 2017 and 2018 were also collected.

RESULTS

We identified 166 videos: 120 (72.2%) were considered anti-vaccine videos and 46 (27.8%) were pro-vaccine; 92 (55%) were uploaded between 2017 and 2018. The anti-vaccine videos had been viewed 5,129,215 times and the pro-vaccine videos 2,371,048 times. The three most widely used anti-vaccination arguments were in regard to side effects (75.8%), pharmaceutical lobbying (61.3%), and the presence of adjuvants (51.6%).

CONCLUSION

Health professionals should be aware of the widely disseminated vaccination misinformation available on the Internet. Health professionals and health authorities must invest in these platforms, perhaps in collaboration with popular channels, to inform users accurately and to refute arguments put forward by anti-vaccine videos. Increasing and maintaining vaccination use is vital for vaccines to achieve success, particularly in France where vaccine hesitancy is strong.

Meta-analysis of the risk of autoimmune thyroiditis, Guillain-Barré syndrome, and inflammatory bowel disease following vaccination with AS04-adjuvanted human papillomavirus 16/18 vaccine

Purpose

To assess the risk of three autoimmune diseases ‐ autoimmune thyroiditis (AIT), Guillain‐Barré syndrome (GBS), and inflammatory bowel disease (IBD) ‐ in females following AS04‐HPV‐16/18 vaccination.

Methods

This meta‐analysis included data from 18 randomized controlled trials, one cluster‐randomized trial, two large observational retrospective cohort studies, and one case‐control study. Following vaccination, a risk window of 2 years was defined for AIT and IBD and 42 days for GBS. Odds ratios (ORs) were estimated using three methods: meta‐analysis inverse‐variance with continuity correction (primary analysis), pooled estimate, and beta‐binomial regression.

Results

In all studies apart from the case‐control study, 154 398 exposed and 1 504 322 non‐exposed subjects were included, among whom there were 141 and 1972 cases of (autoimmune) thyroiditis; 2 and 2 cases of GBS; and 43 and 401 cases of IBD, respectively. In the case‐control study, there were 97 cases of AIT and 13 of GBS; matched with 802 and 130 controls, respectively. The primary analysis OR estimates were 1.46 (95% confidence interval [CI] 1.22‐1.76), 11.14 (2.00‐61.92), and 1.11 (0.75‐1.66) for (autoimmune) thyroiditis, GBS, and IBD, respectively.

Conclusions

This meta‐analysis did not show an increased risk of IBD following vaccination with AS04‐HPV‐16/18. The 1.5‐fold increased risk of (autoimmune) thyroiditis does not allow us to conclude about a causal association. For GBS, the very low number of cases and wide 95% CIs negate any firm conclusion.

Comparison of the implementation of human papillomavirus and hepatitis B vaccination programs in the United States: Implications for future vaccines

Vaccines for two viruses which cause cancer, human papillomavirus (HPV) and hepatitis B virus (HBV), are recommended for all children in the United States. Numerous parallels exist between the two vaccines in addition to their roles in cancer prevention, including transmission through sexual contact, multiple doses needed for series completion, and vaccine administration in adolescence for HPV and in the initial phase of the HBV vaccination program. All of these factors were viewed as potential barriers to achieving high rates of coverage, yet the ultimate success of the HBV vaccination program led to predictions that similarly high rates of coverage could be achieved for the HPV vaccine. However, currently, only the recommendation for HBV vaccination is supported by mandates for school entry in most states. Uptake of the HPV vaccine has lagged far behind U.S. goals for public health promotion. The aim of this paper is to examine factors which may account for the divergent pathways of the two vaccines. Four main factors are identified: logistical challenges of vaccine administration, attitudes of parents and healthcare providers, safety concerns, and cost. For each factor examined, recommendations are offered to confront similar barriers likely to arise for future vaccines. The authors conclude that gender-neutral state mandates coupled with school-located vaccination programs, stronger gender-neutral messaging from pharmaceutical companies and healthcare providers, and younger age of vaccine administration, if approved, present the most promising approaches to improving uptake of the HPV vaccine, and similar vaccines down the road.

Case of Paradoxical Cultural Sensitivity: Mixed Method Study of Web-Based Health Informational Materials About the Human Papillomavirus Vaccine in Israel

BACKGROUND

Designing web-based informational materials regarding the human papillomavirus (HPV) vaccine has become a challenge for designers and decision makers in the health authorities because of the scientific and public controversy regarding the vaccine's safety and effectiveness and the sexual and moral concerns related to its use.

OBJECTIVE

The study aimed to investigate how cultural sensitivity (CS) is articulated in the explanatory informational materials on the HPV vaccine that are posted on the websites of the Israeli health authorities. In addition, the study examined the effect of transparency on the expression of CS in the informational materials.

METHODS

The study employed a quantitative and qualitative content analysis of the texts of explanatory informational materials published on the Arabic and Hebrew websites of the Israel Ministry of Health and the Clalit health maintenance organization (HMO).

RESULTS

The findings revealed the differences in the dimensions of CS (based on the CS model by Resnicow) between the informational materials targeting the majority Jewish population and those targeting the minority Arab population. Indeed, the research findings point to a paradox. On the one hand, the materials appealing to the conservative Arab population exhibited CS, in that the sexual context of the vaccine was missing. On the other hand, analysis of Resnicow's deep dimensions showed that disregarding the sexual context does not allow the relevant target audience to reflect on the barriers and concerns. In addition, the way the information was provided exhibited a lack of transparency regarding the CS dimensions (surface and deep).

CONCLUSIONS

The public health authorities have 2 main objectives in the context of vaccinations. One is to raise the vaccination rates and the other is to provide full and culturally sensitive information to give the public the tools to make intelligent decisions. The findings of this study indicated that despite the high uptake rate for HPV vaccination in the Arab population, the health authorities did not exercise full transparency and CS in transmitting the association between engaging in sexual relations and the necessity of the vaccination. Thus, the major challenge for the health authorities is to find ways to implement the objective of communicating information about the vaccination in a way that is transparent and culturally sensitive, even if this raises questions and fears among the public deriving from their culture.

Post Marketing Surveillance Study of 2nd Dose Quadrivalent Human Papilloma Virus Vaccine in Elementary School Children in Jakarta, Indonesia: Safety Result and Implementation of School-Based HPV Immunization Program

Objective: Quadrivalent human papillomavirus (QHPV) vaccine has been advised for routine vaccination of pre-adolescent girls globally, and a two-dose QHPV vaccination schedule has been introduced in Indonesia to vaccinate 5th and 6th grade elementary school female students. This post-marketing surveillance study evaluated the possible adverse events following immunization with the two-dose QHPV vaccine in Indonesia. Methods: Girls studying in grade 6 of five designated elementary schools in Jakarta, receiving their 2nd dose of QHPV vaccine and provided informed consent (represented by their parents), were included in the study. Students who had received other immunizations either simultaneously or <1 month ago were excluded. Local and systemic reactions noted at 30 min, and 72 h to 28th day, after the immunization were recorded using a Children Symptom Dairy Card/Kartu Harian Anak Sekolah (KHAS/ Student Daily Card). Results: A total of 500 students from 20 schools were included. No serious adverse events were reported during the study period. Fever (systemic reaction) of mild intensity was noted in 1.6 % (n=8) of participants, which subsided after day 6. Local reactions such as pain, redness and swelling were noted in 59.6% (n=295), 23.6% (n=118), and 17.2% (n=86) of participants, respectively. These resolved without any intervention in majority of the cases after day 5. Conclusion: These results along with the safety data from the pre-licensure clinical trials confirm the favorable safety profile of QHPV vaccine in pre-adolescent girls. The school-based two-dose QHPV immunization program in Indonesia is a safe and effective strategy for optimizing HPV vaccine coverage among pre-adolescent girls.

A cross-sectional study of the relationship between reported human papillomavirus vaccine exposure and the incidence of reported asthma in the United States

Objectives:

Asthma is a chronic disorder that affects persons of all ages impacting the quality of their lives. This cross-sectional hypothesis-testing study evaluated the relationship between human papillomavirus vaccine and the risk of an incident asthma diagnosis in a defined temporal period post-vaccination.

Methods:

The 2015–2016 National Health and Nutrition Examination Survey data were examined for a group of 60,934,237 weighted persons between 9 and 26 years old in Statistical Analysis Software.

Results:

Reported incident asthma significantly clustered in the year of reported human papillomavirus vaccination. When the data were separated by gender, the effects observed remained significant for males but not females.

Conclusion:

The results suggest that human papillomavirus vaccination resulted in an excess of 261,475 asthma cases with an estimated direct excess lifetime cost of such persons being US$42 billion. However, it is unclear what part of the vaccine and/or vaccine medium may have increased an individual’s susceptibility to an asthma episode, whether the asthma diagnosis represented one asthma episode or if it is chronic, and how much therapeutic support was needed (if any) and for how long, which would impact cost. Despite the negative findings in this study, routine vaccination is an important public health tool, and the results observed need to be viewed in this context.

HPV vaccine and autoimmune diseases: systematic review and meta-analysis of the literature

BACKGROUND

In the literature conflicting opinions are detectable on the onset of adverse events as autoimmune disease post HPV vaccine and often case reports describes the onset of one of these events, but don't emerge a clear relationship and we don't have data to support it.

METHODS

We carried out a systematic review to identify all scientific publications dealing with the correlation between vaccine anti-papillomavirus and new onset of autoimmune diseases. We searched the main scientific databases (PubMed, Sciverse Scopus, Web of knowledge and Cochrane Central Register of Controlled Clinical Trials) for the following search terms: "vaccine"; "anti-papillomavirus"; "autoimmune"; "disease"; "disorder". To evaluate the safety of HPV vaccines, the dichotomous data on the number of subjects experiencing an autoimmune disorder in the study vaccine group and the placebo group were extracted from each study with subsequent determination of the risk ratios and their 95% confidence intervals. We combined data statistically using a random effects model.

RESULTS

We conduct a meta-analysis on six studies on bivalent and quadrivalent HPV vaccine. The total number of subjects included in the meta-analysis comprised 243,289 in the vaccine group and 248,820 in control groups. Four of the six trials had a Jadad score of 3 or 4 indicating an adequate trial quality. The most frequent autoimmune disease observed across the six studies were musculoskeletal,CNS conditions and endocrinological conditions . The results of the meta-analysis demonstrated no correlation between autoimmune disorders and HPV vaccines (pooled OR 1.038, 95% CI 0.689-1.562).

CONCLUSIONS

No correlation was identified for bivalent and quadrivalent HPV vaccines. It's therefore essential to correctly inform the general population in order to try to increase both Italian and international vaccination coverage.

Quadrivalent human papillomavirus vaccination in girls and the risk of autoimmune disorders: the Ontario Grade 8 HPV Vaccine Cohort Study

BACKGROUND

Despite demonstrated effectiveness in real-world settings, concerns persist regarding the safety of the quadrivalent human papillomavirus (HPV4) vaccine. We sought to assess the risk of autoimmune disorders following HPV4 vaccination among grade 8 girls eligible for Ontario's school-based HPV vaccination program.

METHODS

We undertook a population-based retrospective cohort study using Ontario's administrative health and vaccination databases from 2007 to 2013. The self-controlled case series method was used to compare the rate of a composite end point of autoimmune disorders diagnosed during days 7-60 post-vaccination ("exposed" follow-up) to that at any other time ("unexposed"). The analysis was repeated to assess the effect of a history of immune-mediated diseases and time since vaccination. We also conducted an exploratory analysis of individual autoimmune disorders. Rate ratios and 95% confidence intervals (CIs) were estimated using conditional Poisson regression, adjusted for age, seasonality, concomitant vaccinations and infections.

RESULTS

The study cohort consisted of 290 939 girls aged 12-17 years who were eligible for vaccination between 2007 and 2013. There was no significant risk for developing an autoimmune disorder following HPV4 vaccination (n = 681; rate ratio 1.12, 95% CI 0.85-1.47), and the association was unchanged by a history of immune-mediated disorders and time since vaccination. Exploratory analyses of individual autoimmune disorders found no significant risks, including for Bell palsy (n = 65; rate ratio 1.73, 95% CI 0.77-3.89), optic neuritis (n = 67; rate ratio 1.57, 95% CI 0.74-3.33) and Graves disease (n = 47; rate ratio 1.55, 95% CI 0.92-2.63).

INTERPRETATION

We did not observe an increased risk of autoimmune disorders following HPV4 vaccination among teenaged girls. These findings should reassure parents and health care providers.

Association between Human Papilloma Virus (HPV) vaccination and risk of Multiple Sclerosis: A systematic review

INTRODUCTION

The vaccination against Humanpapilloma Virus (HPV) is an effective strategy to prevent high-risk HPV infection and subsequent cervical carcinogenesis. Although the safety profile has been ascertained, the relation with the development of central nervous system (CNS) autoimmune disorders (AD) appears still controversial. Multiple Sclerosis (MS) is the most common cause of chronic neurological impairment in young people, typically striking females. The main purpose of this review was to assess the association between HPV vaccination and MS.

METHODS

The systematic review of the literature was carried out using 5 search engines: MEDLINE, SCOPUS, ISI WEB OF KNOWLEDGE, GOOGLE SCHOLAR and ClinicalTrial.gov. The web search was updated on January 2017. PRISMA checklist was adopted to address the content of the systematic review. The measures of outcome were reported as relative risk (RR) in cohort studies and odds ratio (OR) in case-control studies.

RESULTS

The systematic review identified 5 observational studies, 9 reviews, and 1 randomized clinical trials (RCT) pooled analysis. The RR of MS onset detected by cohort studies ranged from 1.54 (95%CI, 0.04-8.59) to 1.37 (95%CI, 0.74-3.20). Concerning case-control studies, the OR spanned from 0.3, (95%CI 0.1-0.9) to 1.60 (95%CI = 0.79-3.25) for the group exposed to HPV vaccination. No result was significant.

CONCLUSION

This review showed no significant association between HPV vaccination and MS. The low statistical power of the studies agreed with the low incidence of MS disease among general population. In order to overcome the shortcoming the research may be extended to the entire pattern of CNS ADs.

Overcoming barriers in HPV vaccination and screening programs

The Human Papillomavirus Prevention and Control Board brought together experts to discuss optimizing HPV vaccination and screening programs. Board members reviewed the safety profile of licensed HPV vaccines based on clinical and post-marketing data, reaching a consensus that current safety data is reassuring. Successful vaccination programs used well-coordinated communication campaigns, integrating (social) media to spread awareness. Communication of evidence supporting vaccine effectiveness had beneficial effects on the perception of the vaccine. However, anti-vaccination campaigns have threatened existing programs in many countries. Measurement and monitoring of HPV vaccine confidence over time could help understand the nature and scale of waning confidence, define issues and intervene appropriately using context-specific evidence-based strategies. Finally, a broad group of stakeholders, such as teachers, health care providers and the media should also be provided with accurate information and training to help support prevention efforts through enhanced understanding of the risks and benefits of vaccination. Similarly, while cervical cancer screening through population-based programs is highly effective, barriers to screening exist: awareness in countries with population-based screening programs, access for vulnerable populations, and access and affordability in low- and middle-income countries. Integration of primary and secondary prevention has the potential to accelerate the decrease in cervical cancer incidence.

Evaluation of optic neuritis following human papillomavirus vaccination

To assess the relationship between human papillomavirus (HPV) vaccination and occurrence of optic neuritis (ON) and to evaluate a claims-based algorithm for identification of ON. Females of 9-26 year olds in the HealthCore's Integrated Research Database (HIRDSM) with and without claims evidence of HPV vaccination between 2007 and 2012 were included in this study. Potential ON cases were identified using the claims-based algorithm, positive predictive value (PPV) was determined using medical chart review. For the claims analysis, two study designs, a self-controlled temporal scan statistic and a retrospective matched cohort analysis, were used. ON was defined based on an algorithm developed using diagnosis and procedure codes from the medical claims. The PPV for ON cases using charts that had enough information for reviewers to make a determination was 62.5% (95% CI: 49.5%-74.3%). With the self-controlled temporal scan statistic, the primary analysis restricting on recommended vaccination schedule timing showed an increased risk of potential ON after second dose (RR = 3.39; p = 0.03), this finding was not confirmed for any of the additional analyses performed for individual or combined doses. With the cohort design, there was no increased risk of potential ON following vaccination in either individual or combined dose analyses. The risk of potential ON was higher among participants with a history of prior autoimmune diseases. In conclusion, identifying confirmed ON cases through administrative claims data proved challenging. The claims-based analysis in this study did not provide evidence for an association of ON with HPV vaccination.

Vaccinations and risk of systemic lupus erythematosus and rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

In the past several years, more and more studies proposed some concerns on the possibly increased risk of autoimmune diseases in individuals receiving vaccinations, but published studies on the associations of vaccinations with risks of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) reported conflicting findings. A systematic review and meta-analysis was carried out to comprehensively evaluate the relationship between vaccinations and risk of SLE and RA.

METHODS

Pubmed, Web of Science and Embase were searched for observational studies assessing the associations of vaccinations with risks of RA and SLE. Two authors independently extracted data from those eligible studies. The quality of eligible studies was assessed by using the Newcastle-Ottawa Scale (NOS). The pooled relative risk (RR) with 95% confidence intervals (CIs) was used to measure the risk of RA and SLE associated with vaccinations, and was calculated through random-effect meta-analysis.

RESULTS

Sixteen observational studies were finally considered eligible, including 12 studies on the association between vaccinations and SLE risk and 13 studies on the association between vaccinations and RA risk. The pooled findings suggested that vaccinations significantly increased risk of SLE (RR=1.50; 95%CI 1.05-2.12, P=0.02). In addition, there was an obvious association between vaccinations and increased risk of RA (RR=1.32; 95%CI 1.09-1.60, P=0.004). Meta-analysis of studies reporting outcomes of short vaccinated time also suggested that vaccinations could significantly increase risk of SLE (RR=1.93; 95%CI 1.07-3.48, P=0.028) and RA (RR=1.48; 95%CI 1.08-2.03, P=0.015). Sensitivity analyses in studies with low risk of bias also found obvious associations of vaccinations with increased risk of RA and SLE.

CONCLUSION

This study suggests that vaccinations are related to increased risks of SLE and RA. More and larger observational studies are needed to further verify the findings above and to assess the associations of vaccinations with other rheumatic diseases.

Background rates of disease in Latin American children from a rotavirus vaccine study

BACKGROUND

Knowledge of background rates of adverse events is crucial to assess vaccine safety concerns. We used data from a rotavirus vaccine study (Ruiz-Palacios et al., NEJM, 2006) including 63,225 infants from 11 Latin American countries to investigate reporting rates of serious adverse events (SAEs) among these infants, and describe rates by country, gender, age, and season.

METHODS

For this randomized, double-blind, placebo-controlled, phase 3 trial, investigators from Argentina, Brazil, Chile, Colombia, Dominican Republic, Honduras, Mexico, Nicaragua, Panama, Peru, and Venezuela recruited 6-to-13-week-old healthy infants. The infants received 2 oral doses of vaccine or placebo. The study population was followed 100 d for the assessment of adverse events. SAEs were captured by an active surveillance system.

RESULTS

Strong differences in event rates could be observed between countries (min. 48.1/10,000 person-years in Dominican Republic/Peru; max. 296.2/10,000 person-years in Brazil) and between genders: gastroenteritis, pneumonia, bronchiolitis and bronchitis occurred significantly more frequently in males. In addition, infections and infestations, and most disorders, including immune system and cardiac disorders, were more frequent at earlier ages. Finally, looking at seasonality we noted higher rates of SAEs in the second half of the year in all countries except Mexico.

DISCUSSION

Significant differences in reporting rates of SAEs between countries, gender and calendar months illustrate the importance of knowing the local epidemiology when interpreting SAEs. Data from clinical trials can be used to better understand background rates of diseases that may be perceived as potential adverse events following immunization.

Adverse events following school-based vaccination of girls with quadrivalent human papillomavirus vaccine in Slovenia, 2009 to 2013

Adverse events following immunisation (AEFIs) with qHPV reported to the Slovenian AEFI Registry for the first four school years of the vaccination programme were analysed. We calculated annual reporting rates for 11-14 year-old vaccinees with AEFIs, using the number of qHPV doses distributed within the school-based vaccination programme as the denominator. Between September 2009 and August 2013, 211 AEFIs that occurred in 89 vaccinees were reported, a rate of 149.5 vaccinees with AEFI per 100,000 qHPV doses distributed. For five vaccinees, serious AEFIs (8.4 per 100,000 doses distributed) were reported. The highest reporting rates were for fatigue, headache, and fever (≥ 38.0⁰) (53.8, 40.3, and 35.3 per 100,000 qHPV doses distributed, respectively). As no AEFI resulted in permanent sequelae and they all were categorised as serious only due to the criterion of a minimum of one day of hospitalisation, this provides reassurance for the safety of our school-based HPV vaccination programme. Further AEFI surveillance is warranted to provide data for HPV vaccination programme monitoring and evaluation of its safety.

Quadrivalent HPV vaccine safety review and safety monitoring plans for nine-valent HPV vaccine in the United States

Quadrivalent human papillomavirus (4vHPV) vaccine was licensed for use in the United States in 2006 and through 2015 was the predominate HPV vaccine used. With the exception of syncope, a known preventable adverse event after any injected vaccination, both pre-licensure and post-licensure 4vHPV safety data have been reassuring with no confirmed safety signals identified. Nine-valent HPV vaccine (9vHPV) was licensed in 2014. This review includes post-licensure 4vHPV safety findings published to date that have informed the US vaccination program; these data will inform US safety monitoring and evaluation for 9vHPV.

An Overview of Quadrivalent Human Papillomavirus Vaccine Safety: 2006 to 2015

BACKGROUND

A quadrivalent human papillomavirus (HPV4) type 6/11/16/18 vaccine (GARDASIL/SILGARD®) has been licensed in many countries around the world for the prevention of cervical, vulvar, vaginal, and anal cancers and precancers, as well as external genital warts causally related to HPV types 6/11/16/18. Across 7 phase 3 clinical trials involving more than 29,000 males and females ages 9-45 years, vaccination was generally well tolerated. Because of its expected public health benefit in reducing cervical cancer and other HPV-related diseases, the vaccine has been implemented in the national vaccination programs of several countries, with over 178 million doses distributed worldwide.

METHODS

Extensive efforts to assess the safety of the vaccine in routine practice have been conducted over the past 9 years since licensure, including more than 15 studies in more than 1 million preadolescents, adolescents and adults from various countries. Most have been performed in the general population although there have been some in special populations (pregnant women, HIV-infected individuals and those with systemic lupus erythematosus).

RESULTS

We present a summary of the published, postlicensure safety data from active and passive surveillance. Only syncope, and possibly skin infections were associated with vaccination in the postlicensure setting. Serious adverse events, such as adverse pregnancy outcomes, autoimmune diseases (including Guillain-Barre Syndrome and multiple sclerosis), anaphylaxis, venous thromboembolism and stroke, were extensively studied, and no increase in the incidence of these events was found compared with background rates.

CONCLUSIONS

These results, along with the safety data from the prelicensure clinical trials, confirm that the HPV4 vaccine has a favorable safety profile. Key policy, medical and regulatory organizations around the world have independently reviewed these data and continue to recommend routine HPV vaccination.

Quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine (gardasil(®)): a review of its use in the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts

Quadrivalent human papillomavirus (HPV) [types 6, 11, 16, 18] recombinant vaccine (Gardasil(®); Silgard(®)) is composed of virus-like particles formed by self-assembly of recombinant L1 capsid protein from each of HPV types 6, 11, 16 and 18. It is indicated for use from the age of 9 years as a two- or three-dose vaccination course over 6 months for the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts caused by the vaccine HPV types. In placebo-controlled trials, quadrivalent HPV vaccine provided high-level protection against infection or disease caused by the vaccine HPV types over 2-4 years in females aged 15-45 years who were negative for the vaccine HPV types, and provided a degree of cross-protection against certain non-vaccine HPV types. The vaccine also provided high-level protection against persistent infection, anogenital precancerous lesions and genital warts caused by the vaccine HPV types over 3 years in susceptible males aged 16-26 years. Protection has been demonstrated for up to 8 years. In subjects who were negative for the vaccine HPV types, high seroconversion rates and high levels of anti-HPV antibodies were observed in females of all age ranges from 9 to 45 years and in males aged 9-26 years. The vaccine was generally well tolerated and was usually predicted to be cost effective in girls and young women. Therefore, quadrivalent HPV vaccine offers an effective means to substantially reduce the burden of HPV-related anogenital disease in females and males, particularly cervical cancer and genital warts.

Post-licensure safety surveillance for human papillomavirus-16/18-AS04-adjuvanted vaccine: more than 4 years of experience

Purpose

To summarise post-licensure safety surveillance over more than 4 years of routine use of the human papillomavirus-16/18-AS04-adjuvanted vaccine (HPV-16/18 vaccine: Cervarix®, GlaxoSmithKline, Belgium).

Methods

We describe global post-licensure passive surveillance data based on routine pharmacovigilance from 18 May 2007 until 17 November 2011 and enhanced surveillance implemented during the 2-year national immunisation programme in the UK (school years 2008–2010).

Results

Spontaneous reports from countries worldwide showed a similar pattern for the most frequently reported adverse events after HPV-16/18 vaccination. No patterns or trends were observed for potential immune-mediated diseases after vaccination. Observed incidences of Bell's palsy and confirmed Guillain–Barré syndrome were within the expected range in the general population. Outcomes of pregnancy in women who were inadvertently exposed to HPV-16/18 vaccine during pregnancy, were in line with published reports for similar populations. Enhanced surveillance of adverse events in the UK triggered a review of cases of anaphylaxis, angioedema and syncope reports, leading to an update to the prescribing information.

Conclusion

Collaborative partnerships between industry and national regulatory agencies facilitated rapid notification and transfer of safety information, allowing for rapid responses in the event of a safety signal of adverse event of concern. More than 4 years of post-licensure experience may provide confidence to providers and the public about the safety profile of HPV-16/18 vaccine in routine use. The safety profile appears to be consistent with pre-licensure data reporting that HPV-16/18 vaccine has an acceptable benefit–risk profile in adolescent girls and women.

Adverse events following immunization in Ontario's female school-based HPV program

BACKGROUND

In September 2007, a school-based human papillomavirus (HPV) vaccination program targeting grade 8 girls (approximately 13 years old) and delivered by public health was implemented in Ontario, Canada. We assessed reports of adverse events following immunization (AEFI) from the school-based program as part of quadrivalent HPV (HPV4) vaccine safety surveillance and to contribute to a comprehensive HPV vaccine program evaluation.

METHODS

AEFIs following HPV4 vaccine (Gardasil(®)) administered between September 1, 2007 and December 31, 2011 were extracted from the province's reportable disease system. Confirmed AEFI reports among females 12-15 years old (i.e. assumed to have received vaccine through the program) were included. Events were grouped according to provincial AEFI case definitions. Rates were calculated using doses distributed as the denominator.

RESULTS

Between 2007 and 2011, 133 confirmed AEFIs were reported while 691,994 HPV4 vaccine doses were distributed in the school-based program. The overall reporting rate was 19.2 HPV4 AEFI per 100,000 doses distributed. Annual reporting rates decreased from 30.0 to 18.3 per 100,000 doses distributed. Frequently reported events included 'allergic reaction-dermatologic/mucosa' (25%), 'rash' (22%), and 'local/injection site reaction' (20%); 26% of reports had a non-specific event of 'other severe/unusual events' selected. Ten serious AEFIs were reported (7.5% of reports) including 2 anaphylaxis, 2 seizures, 1 thrombocytopenia and 1 death. Further review found that the reports of anaphylaxis did not meet the Brighton anaphylaxis definition and the death was attributed to a preexisting cardiac condition.

CONCLUSIONS

Overall these findings are consistent with the safety profile of HPV4 vaccine from pre-licensure clinical trials and post-marketing surveillance reports and importantly, no new safety signals were identified, especially no reports of VTE in this younger female population. Continued assessment of HPV4 AEFI surveillance data may be important to detect and investigate safety signals.

[Adolescents' knowledge and behavior on sexuality, infectious transmitted diseases, and human papillomavirus vaccination: results of a survey in a French high school]

Teenager sexuality is a public health issue. In teenagers attending a high school, we assessed their knowledge and behavior on sexuality, infectious transmitted diseases, human papilloma virus (HPV) vaccination, and cervical cancer. Then in girls, we estimated the anti-HPV vaccination coverage and focused on factors associated with poor knowledge of these topics.

METHODS

This was a knowledge, attitudes, and practices cross-sectional study conducted at the beginning of the 2010-2011 school year in the Saint-Cyr military high school, using an anonymous self-administered questionnaire.

RESULTS

Among 669 adolescents (M/F sex-ratio, 2.3; mean age, 17 years [IC 95%, 15-20]), 40% had already had sex and 92% had used contraception. Boys and girls had a poor level of knowledge on infectious transmitted diseases. Regarding knowledge on HPV and cervical cancer, a better level was significantly associated with female gender (P=10(-4)). In multivariate analysis, male gender, age under 18 years, lack of dialogue with parents on these subjects, low socioeconomic status of parents, and absence of health education were significantly associated with poor knowledge on these topics.

CONCLUSION

These data should help healthcare providers better target access and content of sexual health education training.

Answering human papillomavirus vaccine concerns; a matter of science and time

Since the introduction of the HPV vaccine, questions have been asked about its efficacy in preventing cancer linked with HPV. Concerns about the HPV vaccine safety profile have also been raised. This paper highlights the rapidly growing body of evidence (including clinical trials and post-marketing surveillance) illustrating both the safety of the HPV vaccine, through a detailed investigation of reported adverse events, and its efficacy in reducing both HPV infections rates and the resulting drop in cervical lesions, which have been demonstrated to be good predictors of cervical cancer risk.

Safety of human papillomavirus vaccines: a review

Vaccination to prevent human papillomavirus (HPV)-related infection leading to cancer, particularly cervical cancer, is a major public health breakthrough. There are currently two licensed HPV vaccines, both of which contain recombinant virus-like particles of HPV types 16 and 18 (which account for approximately 70 % of cervical cancer). One vaccine also protects against HPV types 6 and 11, which cause genital warts. The safety profile of both vaccines was assessed extensively in randomised controlled clinical trials conducted prior to licensure and has been further elucidated following licensure from surveillance and specific studies in large populations. This review aims to examine current evidence regarding the safety of HPV vaccines. In summary, both vaccines are associated with relatively high rates of injection site reactions, particularly pain, but this is usually of short duration and resolves spontaneously. Systemic reactions have generally been mild and self-limited. Post vaccination syncope has occurred, but can be avoided with appropriate care. Serious vaccine-attributable adverse events, such as anaphylaxis, are rare, and although not recommended for use in pregnancy, abnormal pregnancy outcomes following inadvertent administration do not appear to be associated with vaccination. HPV vaccines are used in a three-dose schedule predominantly in adolescent females: as such case reports linking vaccination with a range of new onset chronic conditions, including autoimmune diseases, have been made. However, well-conducted population-based studies show no association between HPV vaccine and a range of such conditions. Whilst this reassuring safety profile affirms the positive risk benefit of vaccination, as HPV vaccine use expands into more diverse populations, including males, ongoing safety assessment using well-conducted studies is appropriate.

[Plea for advancement of the age of vaccination against human papillomavirus in France: Position of the Pediatric Infections Pathology Group (GPIP) and the French Association of Ambulatory Pediatrics (AFPA)]

Vaccination against human papillomavirus (HPV) is recommended in France at 14 years. The Groupe de Pathologie Infectieuse Pédiatrique de la Société Française de Pédiatrie takes a clear position for advancement of age of vaccination at 11-12 years based on the following arguments: (i) data on the long-term persistence of protective antibodies are reassuring; (ii) these vaccines can be co-administered with vaccines recommended in the current immunization schedule at this age; (iii) actually, nearly 20% of adolescents have had sexual intercourse when the vaccination schedule is finished; (iv) vaccination beyond 14 years increases the risk of occurrence of coincidental autoimmune diseases; (v) the immunogenicity of vaccines against HPV is better when they are administered before age 15; (vi) finally, especially by reducing the number of injections from 3 to 2, the immunization at 11-12 years could improve immunization coverage which is insufficient nowadays.

Pharmacoepidemiology

Current concerns over the safety of medicines once they have been marketed mean that pharmacoepidemiology is of increasing importance. There are three main areas in which further research is needed. 1 To improve the methods used to make causal inference of effects of medicines and to raise the quality of the reporting and critical appraisal tools, so that the strengths and weaknesses of the new methods can be judged. 2 To apply the methods in areas where randomized trials cannot easily be done, such as in pregnancy. 3 To use electronic health records as fully as possible, using linkage between different databases, ensuring the data are of as high quality as possible. Public health and public perceptions mean that much of pharmacoepidemiology must be done using non-industry funding sources.

Use of population based background rates of disease to assess vaccine safety in childhood and mass immunisation in Denmark: nationwide population based cohort study

OBJECTIVES

To predict the number of selected outcomes temporally associated but not caused by vaccination, to aid causality assessment of adverse events arising after mass immunisation in a paediatric population.

DESIGN

Nationwide population based cohort study.

SETTING

Denmark.

PARTICIPANTS

All liveborn infants delivered after 1 January 1980. Study population was followed from date of birth until hospital admission for selected outcome diagnoses, death, first emigration, age 18 years, or 31 December 2009. The study population was subject to vaccines used in standard childhood immunisation in Denmark, with 82-93% vaccine coverage.

MAIN OUTCOME MEASURES

Incidence of acute infectious and post-infectious polyneuritis (Guillain-Barré syndrome), acute transverse myelitis, optic polyneuritis, facial nerve palsy, anaphylactic shock, seizure, multiple sclerosis, autoimmune thrombocytopenia, type 1 diabetes mellitus, juvenile and rheumatoid arthritis, narcolepsy, and death of unknown cause stratified by sex, age, and season. We predicted the number of events for a hypothetical vaccine cohort of 1,000,000 people for follow-up periods of up to 182 days.

RESULTS

The study included 2,300,227 liveborn infants, yielding 37,262,404 person years of follow-up; median follow-up was 16.8 person years. Incidence of outcome diagnoses spanned from 0.32 per 100,000 patient years for autoimmune thrombocytopenia to 189.82 per 100,000 patient years for seizure. Seasonal differences were most pronounced for anaphylactic shock, seizure, and multiple sclerosis. Even for rare outcomes, numerous events were predicted in the hypothetical vaccine cohort. We predicted that 20 cases of type 1 diabetes mellitus, 19 of juvenile or rheumatoid arthritis, eight of facial nerve palsy, and five of multiple sclerosis per 1,000,000 children would occur within 42 days after vaccination.

CONCLUSIONS

Incorporating exact background rates of disease based on age, sex, and seasonal distribution could strengthen vaccine safety assessment, and provides an evidence based focus for discussing the incremental risk of newly introduced vaccines.

Assessing the safety of adjuvanted vaccines

Despite the very low risk-to-benefit ratio of vaccines, fear of negative side effects has discouraged many people from getting vaccinated, resulting in reemergence of previously controlled diseases such as measles, pertussis, and diphtheria. Part of this fear stems from the lack of public awareness of the many preclinical and clinical safety evaluations that vaccines must undergo before they are available to the general public, as well as from misperceptions of what adjuvants are or why they are used in vaccines. The resultant "black box" leads to a preoccupation with rare side effects (such as autoimmune diseases) that are speculated, but not proven, to be linked to some vaccinations. The focus of this review article is to open this black box and provide a conceptual framework for how vaccine safety is traditionally assessed. We discuss the strengths and shortcomings of tools that can be and are used preclinically (in animal studies), translationally (in biomarker studies with human sera or cells), statistically (for disease epidemiology), and clinically (in the design of human trials) to help ascertain the risk of the infrequent and delayed adverse events that arise in relation to adjuvanted vaccine administration.

Health problems most commonly diagnosed among young female patients during visits to general practitioners and gynecologists in France before the initiation of the human papillomavirus vaccination program

PURPOSE

Background rates for common health problems have seldom been estimated to facilitate interpretation of signals that may occur after a new public health intervention. Background rates of diagnoses from general practitioners (GPs) and gynecologists (GYNs) were assessed before the implementation of human papillomavirus (HPV) immunization program.

METHODS

This cross-sectional study used data collected in 2006 in France. All visits of women (aged 11-23 years) to a GP or a GYN participating in the longitudinal patient data (LPD) network were considered. Diagnoses and symptoms were retrieved and classified according to the International Classification of Primary Care. Only diagnoses made in ≥ 1% of visits were reported in primary analyses. Independent analyses were performed for visits to GPs and GYNs and for adolescents and young adults. Finally, the rates of pre-specified health problems of interest (e.g., because of their potential identification as signals after HPV immunization) were computed from processed diagnostic data, using time windows consistent with HPV vaccination scheme.

RESULTS

About 380,813 GP and 36,329 GYN visits were analyzed. Acute upper respiratory infections were the most frequently recorded diagnoses by GPs, accounting for 11,783 per 100,000 visits per year. Visits related to the respiratory system accounted for 10 of the 23 most frequent diagnoses by GPs. Genital candidiasis was the most frequent GYN diagnosis, accounting for 4746 per 100,000 visits per year. Most GYN visits were for pregnancy-related issues or menstrual problems. The main diagnoses were similar in adolescents compared with young adults in both GP and GYN settings. Pre-specified health problems occurred at high rates, as exemplified by acne that was diagnosed in 0.8% of patients during time windows consistent with HPV immunization.

CONCLUSION

Diagnostic data processed from electronic health records identified the rates of common health events experienced by young female patients routinely visiting their GP or GYN before HPV immunization. Such rates may prove useful in interpreting adverse events reported after the launch of new medical interventions.