Human Papillomavirus Vaccination and Anogenital Warts: A Systematic Review of Impact and Effectiveness in the United States

Evaluation of the decision-making process underlying the initial off-label use of vaccines: A scoping review

BACKGROUND

This scoping review aimed to assess the non-standardized decision-making process of National or International Immunization Technical Advisory Groups (NITAG) in developing novel off-label recommendations by examining the supportive evidence.

METHODS

We used the Joanna Briggs Institute framework. A search strategy was developed with a librarian to identify recommendations and evidence from peer-reviewed and gray literature until January 2022, using PubMed, Medline, EMBASE, clinicaltrials.gov, the International Clinical trials registry, governmental agency and pharmaceutical websites, the Global NITAG Network center website, and Google Scholar. Recommendations involving one of 26 pre-identified vaccine-preventable diseases, human use, and the introduction of a novel change across time and countries, were included. Evidence regarding efficacy/effectiveness, safety, or immunogenicity were included. Recommendations for fast-track approval, unlabeled or individual level off-label use, passive immunization, booster doses or provincial strategies were excluded. Only English and French documents were included. Two reviewers reviewed title/abstracts and full-text documents, and three performed data extraction. The primary outcome was the presence and elements of the evidence.

FINDINGS

Out of 4023 documents, 12 were included, and 116 were found through manual search. Over the 40-year span captured (1982-2018), most recommendations were from the last two decades and included evidence, except three from the 1990s. Most included safety (69.2%) and immunogenicity (65.4%) studies and randomized controlled trials (57.7%). Indication-based recommendations included RCTs more often (84.6%) than posology-based recommendations (30.8%). There was evidence involving populations or vaccines different from those in the recommendation.

INTERPRETATION

Critical outcomes evidence is not systematically included in off-label recommendations, nor must it involve the exact population or vaccine(s) of concern. However, in recent years, more off-label recommendations include critical outcome evidence, mainly RCTs.

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

The Burden of Genital Warts in Finland: Cross-Sectional Analysis of the Prevalence and Direct Medical Costs in 2018

Genital warts (GWs) caused by the human papilloma virus (HPV) are a significant health problem due to high prevalence and rate of recurrence. Bivalent vaccine has been used since the start of the national vaccination program in 2013, making it feasible to study the GW burden in Finland. There is no national and up-to-date information available on the prevalence and the burden of GWs in the various healthcare sectors in Finland. The present study investigated the prevalence, healthcare resource use, and direct medical costs of the treatment of GWs in Finland in 2018 using data in national healthcare registers. GW cases were identified based on diagnoses in public healthcare and GW-related prescription medications. Cost analysis included public healthcare contacts, procedures in private care, and medications. The study showed that approximately 12,000 GWs cases were treated in Finland in 2018. Since less than half of GW diagnoses were recorded in public healthcare registers, determining the exact costs was challenging. The estimated direct treatment costs in 2018 were 2.6 M€, which is higher than the previous estimation in Finland, yet still likely an underestimation of the true burden. These results provide information for the management of the GW burden in Finland.

Human Papillomavirus Vaccine Impact and Effectiveness in Six High-Risk Populations: A Systematic Literature Review

Specific adult populations known to be at high risk for human papillomavirus (HPV)-related disease, such as men who have sex with men, are inconsistently included in national immunization programs. No compilation of the evidence on the real-world impact and effectiveness of HPV vaccines across these populations exists. This systematic literature review identifies and synthesizes the evidence of the real-world impact and effectiveness of the quadrivalent and nonavalent HPV vaccines in high-risk populations: women with prior/current HPV-related anogenital disease, men who have sex with men, immunocompromised/immunosuppressed individuals, female sex workers, transgender and non-binary individuals, and patients with recurrent respiratory papillomatosis (RRP). The outcomes included anogenital precancers/cancers, head and neck cancers, genital warts, and RRP recurrence. From the 2216 records identified, 30 studies (25 effectiveness and 5 impact studies) were included in this systematic literature review. The results, quantity, and quality of these studies were highly variable. The evidence for effectiveness was of high quality only in women with prior/current cervical disease and in individuals with RRP, the most frequently studied populations. No studies of transgender/non-binary individuals or female sex workers were identified. The real-world evidence supports HPV vaccination among women with prior cervical disease and individuals with RRP. Significant real-world data gaps remain in these high-risk populations.

The Synthesis of Main Capsid Protein of Anogenital Type HPV6 L1 in Plant Expression System on the Basis of Tomato Fruits

The anogenital type HPV6 L1 major capsid protein was synthesized in a plant expression system on the basis of tomato fruits. The content of HPV6 L1 reached 380 μg per 1 mg of total soluble protein of raw fruit mass, which was represented as a single band with a molecular mass of 56 kDa on the SDS electrophoregram. When orally administrated to mice, the vaccine material from the tomato fruit transgenic for HPV6 L1 induced highly effective antibody immune response with a high titer. The cross-reactivity during the interaction of the antibody to the HPV6 L1 protein from peripheral blood serum of mice vaccinated with HPV6 L1 with the antigenic proteins HPV16 L1, HPV18 L1, HPV31 L1, and HPV45 L1 was found. This is promising for creating a vaccine with a broad reactivity against dangerous anogenital papillomatoses and cervical cancer.

Temporal Trends in the Incidence of Anogenital Warts: Impact of Human Papillomavirus Vaccination

BACKGROUND

Studies in countries with high human papillomavirus (HPV) vaccination coverage have demonstrated marked reductions in anogenital wart (AGW) incidence. Our goal was to assess the impact of HPV vaccination in a population with suboptimal coverage by comparing AGW incidence trends in the years before and after vaccine introduction.

METHODS

We conducted a retrospective analysis of AGW incidence trends using an ecologic study design among 11- through 39-year-olds enrolled at Kaiser Permanente Northwest. We defined incidence as the proportion of persons who had a new AGW diagnosis for each calendar year in the prevaccine periods (2000 through 2006 for female individuals, 2000 through 2010 for male individuals) and the postvaccine periods (2007 through 2016 for female individuals, 2011 through 2016 for male individuals). We also described cumulative HPV vaccination coverage.

RESULTS

The average annual AGW incidence rates in the prevaccine periods were 27.8 per 10,000 in female individuals and 26.9 per 10,000 in male individuals. In the postvaccine periods, AGW incidence rates decreased by 31% (P < 0.001) in female individuals and 10% (P = 0.006) in male individuals; the largest reductions were observed in 15- to 19-year-old female individuals (67%, P < 0.001) and male individuals (45%, P < 0.001). Three dose HPV coverage rates were less than 50% in all age groups and both sexes.

CONCLUSIONS

In a population of young adults with moderate HPV vaccination coverage, we observed declines in AGW incidence among both female and male year after the introduction of HPV vaccination. The largest incidence reductions were observed in 15- to 19-year-olds who were most likely to have been vaccinated.

Evaluation of the decision-making process underlying the initial off-label use of vaccines: a scoping review protocol

INTRODUCTION

Vaccination has become a central part of public health prevention. Vaccines are introduced after licensure by national regulatory authorities, whereas recommendations for use of licensed vaccines are made by national or international advisory committees and may include off-label use. The methodological and decision-making processes that are used to assess novel initial off-label vaccine use are unclear. This review aims to examine the off-label assessment processes to map evidence and concepts used in the decision-making process and present a common approach between all recommendations and specifics of each decision.

METHODS AND ANALYSIS

The methodological framework described at the Joanna Briggs Institute will be applied to this scoping review. A search strategy was developed, in collaboration with an experienced senior health research librarian, by combining Mesgarpour's highly sensitive search strategies. Peer-reviewed and grey literature will be systematically identified using PubMed, Medline and EMBASE; governmental agency and pharmaceutical websites; and search engines, such as Google Scholar. Reports and studies on off-label vaccine use in public health will be included. Screening will be independently undertaken by two reviewers. Data will be extracted using a standard form. Results will be narratively summarised to highlight relevant findings and guide the development of an analytical framework for off-label vaccination recommendations.

ETHICS AND DISSEMINATION

This research does not require ethical approval. This scoping review will provide decision-making elements and a synthesis of knowledge on vaccines off-label use. Findings will be relevant to decision-makers/advisory committees and public health. These will be disseminated through peer-reviewed articles and conferences.

Sexually transmitted coinfections in patients with anogenital warts - a retrospective analysis of 196 patients

BACKGROUND AND OBJECTIVES

Anogenital warts (AGWs) are most commonly caused by low-risk human papillomavirus (HPV) types, and although they are the most frequent viral sexually transmitted infections (STIs), little is known about STI coinfections in affected patients. We therefore sought to assess STI coinfection rates in patients with AGW, specify STI coinfections and calculate the number needed to screen (NNS) for each STI.

METHODS

A retrospective cross-sectional study analyzing data sets from AGW patients treated in our clinic between 2008-2016.

RESULTS

142/196 (72 %) patients had been variably screened for infections with HIV, HBV and HCV, Treponema pallidum, Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and HSV. The STI coinfection rate in all tested patients was 24.6 %, yielding an NNS of 4.1 to detect any STI. Of note, the coinfection rate did not differ significantly between heterosexual men, homosexual men and women, respectively. The NNS for syphilis was 8.4, for HIV 14.0, for HCV 28.5 and for HBV 39.0. The NNS for asymptomatic patients tested for HSV, Chlamydia trachomatis and Mycoplasma genitalium were 1.4, 5.3 and 12.0, respectively.

CONCLUSION

Due to the high prevalence of STI coinfections, AGW patients should be screened for other STIs.

Incidence of anogenital warts: epidemiological risk factors and real-life impact of human papillomavirus vaccination

Anogenital warts (AGWs) rank among the most frequent sexually transmitted infections in young adults. They are benign lesions, but they pose a significant economic cost to health care systems and a substantial psychological burden on patients, who need evidence-based counselling. Human papillomavirus (HPV) vaccination has shown very high protection rates against AGWs in clinical trials and real-world settings but vaccination coverage remains low in many countries. The aim of this review is to summarize the current evidence on the risk factors for AGW development and to present the available real-life data on the impact of HPV vaccination on AGW incidence. An increased number of lifetime sexual partners, a new sexual partner in the last 12 months, smoking, and immunosuppression have been associated with increased risk for AGWs. HPV vaccination has led to a dramatic decline in AGW incidence in populations that have achieved high vaccination rates. These conclusions can contribute to primary prevention of AGWs and evidence-based counselling of AGW patients.

Disparities in the Epidemiology of Anal Cancer: A Cross-Sectional Time Series

Purpose: To assess the trends and sociodemographic disparities of anal cancer.

Methods: For this time series, billing claims were reviewed for all encounters between 2007 and 2011 in the Yale New Haven Health System.

Results: There were 80 new cases identified. Decreasing trends were seen in women and increasing trend in men (−30.1% and 27.3%). Diagnoses were more common in areas with the highest proportion of racial minorities (incidence rate ratio [IRR]=1.75; p≤0.01) and poverty (IRR=1.72; p=0.04).

Conclusions: Anal cancer continues to rise in men during the postvaccine era. Communities with the highest proportion of poverty and racial/ethnic minority groups bear the highest burden of disease.

The quadrivalent HPV vaccine is protective against genital warts: a meta-analysis

BACKGROUND

The quadrivalent human papillomavirus (HPV) vaccine has been assumed to give protection against genital warts (GW) as well as cervical cancer. Our main question was whether HPV vaccine has any effects on the prevention of GW reported in randomised controlled clinical trials (RCTs) and time-trend analyses.

METHODS

This meta-analysis was performed according to the PRISMA guidelines using the PICO format. We searched in three electronic databases (PubMed, Embase, Cochrane Trials), and assessed heterogeneity using the Q-test and I-squared statistics, meta-regression was also performed. Odds ratios (OR) and their confidence intervals (CI) were calculated. The sensitivity was tested by leave-one-out method. We evaluated the presence of publication bias using the funnel plot graph and the Copas selection model. The strength of evidence was assessed using the GRADE approach.

RESULTS

Eight RCTs (per-protocol populations) and eight time-trend ecological studies were included in this meta-analysis. A significant reduction (pooled OR = 0.03, 95% CI: 0.01-0.09; I-squared = 53.6%) of GW in young women was recorded in RCTs, and in time-trend analyses both in young women (pooled OR = 0.36, CI 95% = 0.26-0.51; I-squared = 98.2%), and in young men (pooled OR = 0.69, 95% CI = 0.61-0.78; I-squared = 92.7%). In subgroup analysis, a significant reduction of the number of GW events was observed especially in women under 21 years (pooled OR = 0.33, 95% CI = 0.17-0.63). Leave-one-out analysis showed that similar results could be obtained after excluding one study, meta-regression did not show significant difference.

CONCLUSIONS

Prophylactic, quadrivalent HPV vaccination can prevent GW in healthy women and men, therefore, it should be included in routine immunization programme.

Summary of the evidence on the safety, efficacy, and effectiveness of human papillomavirus vaccines: Umbrella review of systematic reviews

BACKGROUND

This objective of this umbrella review was to summarize the evidence on safety, efficacy, and effectiveness of human papillomavirus (HPV) vaccines in the general population.

METHODS

The authors conducted a literature search and selected systematic reviews if they were published from January 2006 through November 2018, included randomized controlled trials or observational studies, related to the general population, and evaluated HPV vaccine-related clinical outcomes. The authors independently and in duplicate screened literature, extracted data, and appraised reviews using AMSTAR 2, a critical appraisal tool for systematic reviews.

RESULTS

The authors selected 30 systematic reviews that included male and female participants aged 9 through 76 years from multiple countries. Reviews evaluated postvaccine seroconversion, HPV infection rates, precancerous or benign lesions, and adverse events; none of the researchers reported on oral or oropharyngeal lesions. Results from the reviews showed that, compared with those who received a placebo or non-HPV-type vaccine, HPV-vaccinated participants had statistically significantly higher rates of seroconversion and local adverse events, statistically significantly lower rates of HPV infection and condylomata lesions, and decreased rates of HPV-related precancerous lesions, which did not always attain statistical significance.

CONCLUSIONS

Systematic reviews have found evidence that the available HPV vaccines are safe, effective, and efficacious against vaccine-type HPV infection and HPV-associated cellular changes, including precancerous and benign lesions.

PRACTICAL IMPLICATIONS

Dentists may use this resource to better understand the literature on the potential harms and benefits of HPV vaccination.

Adenocarcinoma of the Uterine Cervix Shows Impaired Recruitment of cDC1 and CD8+ T Cells and Elevated β-Catenin Activation Compared with Squamous Cell Carcinoma

PURPOSE

Adenocarcinoma of the uterine cervix is the second most common type of cervical cancer after squamous cell carcinoma (SCC). Although both subtypes are treated similarly, patients with adenocarcinoma have a worse prognosis. In this study, immunologic features of the tumor microenvironment in these two subsets were pursued with potential therapeutic implications.

EXPERIMENTAL DESIGN

The immune microenvironment of primary tumors and nonmetastatic tumor-draining lymph nodes (TDLN) was compared between patients with cervical adenocarcinoma (n = 16) and SCC (n = 20) by polychromatic flow cytometry and by transcriptional profiling of the primary tumors (n = 299) using publicly available data from The Cancer Genome Atlas (TCGA).

RESULTS

Flow cytometric analyses revealed intact T-cell differentiation in TDLNs, but hampered effector T-cell trafficking to the primary tumors in adenocarcinoma, as compared with SCC. TCGA analysis demonstrated higher expression of chemokines involved in effector T-cell homing (CXCL9/10/11) in SCC primary tumors as compared with adenocarcinoma primary tumors, which was highly correlated to a transcriptional signature for type I conventional dendritic cells (cDC1). This was consistent with elevated frequencies of CD141/BDCA3⁺cDC1 in primary tumor SCC samples relative to adenocarcinoma and correspondingly elevated levels of CXCL9 and CXCL10 in 24-hour ex vivo cultures. Hampered cDC1 recruitment in adenocarcinoma was in turn related to lower transcript levels of cDC1-recruiting chemokines and an elevated β-catenin activation score and was associated with poor overall survival.

CONCLUSIONS

Our data have identified an opportunity for the investigation of potentially novel therapeutic interventions in adenocarcinoma of the cervix, that is, β-catenin inhibition and cDC1 mobilization.

Trends in Anogenital Wart Diagnoses in Connecticut, 2013-2017

This cross-sectional study examines trends in the diagnosis of anogenital warts over the course of 5 years in Connecticut, a state that achieved moderate uptake of human papillomavirus vaccine.

Condyloma acuminata on the nipple and coronary sulcus of the penis: A case report

RATIONALE

Condyloma acuminatum (CA) is a benign tumor primarily caused by infection with human papillomavirus (HPV) type-6 or type-11, lesions of which are most frequently found on the genital and perianal squamous mucosa and skin. CA outside the genitals is not common.

PATIENT CONCERNS

A 29-year-old male presented with lesions on the left nipple and coronary sulcus after heterosexual contact.

DIAGNOSES

Histopathological examination and HPV detection made a definite diagnosis of CA.

INTERVENTION

The patient was treated with microwave and topical imiquimod cream.

OUTCOMES

After 6 months follow-up, there was no sign of recurrence.

LESSONS

This case shows that we should pay more attention to CA outside the genitals in the process of diagnosis and treatment.