Human papillomavirus vaccine uptake among individuals with systemic inflammatory diseases

[Human papillomavirus and systemic lupus erythematosus: A systematic review]

BACKGROUND

Human papillomavirus (HPV) infections cause cancer of the cervix, vagina, vulva, anus, penis and upper respiratory tract. The prevention of HPV-induced cancers is a public health issue. Patients with systemic lupus are at increased risk of persistent HPV infection and cervical cancer due to treatment-induced immunosuppression. HPV vaccination and screening for precancerous lesions are two effective means of preventing cervical cancer. Despite the demonstrated safety and efficacy of the HPV vaccine, coverage of HPV vaccination in SLE adults remains low. Screening for cervical cancer is only carried out as recommended in one lupus patient in two. Catch-up HPV vaccination, therapeutic vaccination and vaginal self-sampling are innovative prevention strategies adapted to patients at risk of HPV-induced cancer.

CONCLUSIONS

Measures to prevent HPV-induced cancers are insufficiently implemented in patients managed for systemic lupus. Healthcare professionals and patients need to be made aware of the importance of HPV preventing vaccination.

HPV Infection and Prevention in Patients With Immune-Mediated Inflammatory Diseases: A Scoping Review

BACKGROUND/HISTORICAL PERSPECTIVE

Human papillomavirus (HPV) infections are a significant public health concern as they cause various cancers, including those of the cervix, vulva, vagina, anus, penis, and oropharynx, in both women and men.

SUMMARY INTEGRATING THE CURRENT PUBLISHED LITERATURE

Individuals with immune-mediated inflammatory diseases, particularly systemic lupus erythematosus, have an increased risk of developing persistent HPV infection and subsequent precancerous lesions due to their immunosuppression.

MAJOR CONCLUSIONS

Vaccination and screening for precancerous lesions are 2 central management strategies that must be implemented in patients with immune-mediated inflammatory diseases. Although HPV vaccination has been proven to be safe and effective in these patients, coverage remains low and should be encouraged. Screening for cervical cancer should be more widely implemented in this population, as recommended in guidelines for other immunosuppressed patients.

FUTURE RESEARCH DIRECTIONS

Catch-up vaccination, vaginal self-sampling screening for HPV detection, and therapeutic vaccination are new options that should be considered.

Reasons for refusal of the human papillomavirus vaccine among young cancer survivors

BACKGROUND

Cancer survivors are at risk for developing subsequent human papillomavirus (HPV)-related malignancies. HPV vaccination rates among survivors remain low, and the reasons for refusal of the vaccine are unclear in this population.

METHODS

The authors conducted a secondary analysis of data from an open-label clinical trial evaluating the immunogenicity and safety of the HPV vaccine among vaccine-naive cancer survivors who were 9-26 years old and 1-5 years from the completion of their cancer treatment. Survivors/parents who declined trial participation were asked their reasons for declining. Refusal reasons were categorized, and multivariable logistic regression models were developed to identify associations between survivor characteristics and primary refusal reasons.

RESULTS

Among the 301 survivors who refused participation in the clinical trial, 215 (71.4%) refused for reasons related to the HPV vaccine. Reasons for vaccine-related refusal included safety concerns, vaccine hesitancy/disinterest, external influences, vaccine-related information deficits, and health beliefs/family decisional processes. Compared with males, females were more likely to refuse for reasons related to health beliefs/family decisional processes (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.12-3.93; p = .022) and were less likely to do so because of external influences (OR, 0.43; 95% CI, 0.19-0.92; p = .035). Survivors approached about participation during the latter years of the trial were more likely to refuse because of safety concerns (OR, 3.33; 95% CI, 1.55-7.69; p = .003).

CONCLUSIONS

Cancer survivors refused participation in an open-label trial evaluating the immunogenicity and safety of the HPV vaccine primarily because of vaccine-related concerns that were unrelated to the research study. Many of these concerns are potentially addressable by health care providers using evidence-based messages tailored to the cancer survivor population.

Human Papilloma Virus Vaccination in Patients with Rheumatic Diseases in France: A Study of Vaccination Coverage and Drivers of Vaccination

Objectives: To describe human papillomavirus (HPV) vaccination practices in adolescent girls with systemic lupus erythematosus (SLE) and juvenile idiopathic arthritis (JIA) and to identify barriers to and motivators for vaccination. Methods: Cross-sectional, multicenter study on girls aged 9 to 19 years and their accompanying adults. The measurement criteria were the proportion of girls who were vaccinated against HPV, compliance with the vaccination schedule, factors associated with vaccination, and reasons for vaccination and non-vaccination through a self-administered questionnaire. Results: Seventy-one patients (16 with SLE and 55 with JIA) were included with a mean age of 13 years old (rank 11−18). According to parental questioning, 39% of patients were vaccinated against HPV or in progress (44% and 38% of SLE and JIA, respectively). This rate was 82% for the 22 patients ≥ 15 years of age. The vaccine was administered as often by a general practitioner (39%) as by a hospital pediatrician (also 39%). Two factors were significantly associated with vaccination: Older age (OR 53.68, 95% CI 5.85−429.29, p < 0.001) and previous hepatitis B vaccination (OR 4.97, 95% CI 1.03−24.01, p = 0.040). Recommendation of the vaccine by a health professional and fear of HPV-related diseases were the main facilitators. Lack of knowledge about the vaccine, lack of recommendation by a health professional, and fear of vaccine side effects were the main barriers. Conclusions: HPV vaccination coverage remains insufficient among patients with autoimmune disease. Education and awareness of health professionals about HPV infections are crucial elements in vaccine acceptance.

Human papillomavirus vaccination rates in adolescents with cerebral palsy compared to the general population

PURPOSE

To determine whether adolescents with cerebral palsy (CP) initiate and are up-to-date with the human papillomavirus (HPV) immunization series compared to adolescents in the general population.

METHODS

Data on initiation and up-to-date status of the HPV series were collected on adolescents with CP aged 13-17 years old (n = 74) via retrospective medical record review and compared to 616 age-matched peers from the National Immunization Survey, Teen 2019. Analysis by gender, Gross Motor Functional Classification System (GMFCS) level, and ambulatory status was performed in the CP group.

RESULTS

Adolescents with CP were three times less likely to start (p < 0.001) and two times less likely to be up-to-date (p = 0.004) with the HPV immunization series compared to age-matched peers. When the HPV immunization series was initiated in adolescents with CP, these adolescents were as likely to complete the series (p = 0.400), with 83.3% being up-to-date. In those with CP, there was no statistical difference in status of the HPV immunization series when comparing gender, GMFCS level, or ambulatory status.

CONCLUSION

Adolescents with CP were less likely to start the HPV immunization series; however, they were as likely to be up-to-date with the series if it was initiated. This presents an opportunity for pediatric physiatrists to help reduce the disparity.

Avoidable Acute Care Use for Vaccine-Preventable Illnesses Among Medicaid Beneficiaries With Lupus

OBJECTIVE

Nearly 25% of patients with systemic lupus erythematosus (SLE) are hospitalized yearly, often for outcomes that may have been avoided if patients had received sustained outpatient care. We examined acute care use for vaccine-preventable illnesses to determine sociodemographic contributors and modifiable predictors.

METHODS

Using US Medicaid claims from 29 states (2000-2010), we identified adults (18-65 years) with prevalent SLE and 12 months of enrollment prior to the first SLE code (index date) to identify baseline data. We defined acute care use for vaccine-preventable illnesses as emergency department (ED) or hospital discharge diagnoses for influenza, pneumococcal disease, meningococcal disease, herpes zoster, high-grade cervical dysplasia/cervical cancer, and hepatitis B after the index date. We estimated the incidence rate of vaccine-preventable illnesses and used Cox regression to assess risk (with hazard ratios and 95% confidence intervals) by sociodemographic factors and health care utilization, adjusting for vaccinations, comorbidities, and medications.

RESULTS

Among 45,654 Medicaid beneficiaries with SLE, <10% had billing claims for vaccinations. There were 1,290 patients with ≥1 ED visit or hospitalization for a vaccine-preventable illness (6.6 per 1,000 person-years); 93% of events occurred in unvaccinated patients. Patients who were Black compared to White had 22% higher risk. Greater outpatient visits were associated with lower risk.

CONCLUSION

Medicaid beneficiaries with SLE who are not vaccinated are at risk for potentially avoidable acute care use for vaccine-preventable illnesses. Racial disparities were noted, with a higher risk among Black patients compared to White patients. Greater outpatient use was associated with reduced risk, suggesting that access to ambulatory care may reduce avoidable acute care use.

Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study

OBJECTIVE

Individuals with systemic lupus erythematosus (SLE) are at high risk for infections and SLE- and medication-related complications. The present study was undertaken to define a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received.

METHODS

We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of 16 nationally recognized US-based experts from 8 subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held 2 survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions.

RESULTS

Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into 4 categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8 conditions), reproductive health-related complications (6 conditions), and SLE-related complications (5 conditions).

CONCLUSION

We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients receive high-quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.

[Human papillomavirus and systemic lupus erythematosus]

Infection with human papillomavirus (HPV) is one of the most widespread sexually transmitted diseases and the main risk factor for cervical cancer. Underlying conditions, like immunosuppression, favour the persistence and the progression of cervical lesions to an aggressive form. Patients with autoimmune diseases, and particularly systemic lupus erythematosus (SLE), may be prone to HPV infection and cervical dysplasia. However, the risk factors for developing persistent HPV-related infection, dysplasia and cancer are not identified for patients with SLE. The existence of an increased risk of cervical cancer compared to the general population remains debated. Thus, HPV vaccine is recommended for SLE patients as well as for the general population. Vaccine coverage of SLE patients is not known in France. Adolescents with chronic health condition seem to be insufficiently vaccinated regarding their vulnerability to infectious diseases. Strategies are required to decrease HPV vaccination barriers.

Risk of human papillomavirus infection in women with rheumatic disease: cervical cancer screening and prevention

Human Papillomavirus (HPV) is the most common sexually transmitted infection in the USA, with over 14 million people acquiring HPV each year. HPV is also the cause of most anogenital cancers. About 90% of HPV infections spontaneously resolve over 3 years. However, about 10% remain as persistent infection defined as repeatedly detected in cervical samples. As HPV is controlled by local and systemic immune responses, individuals with immunosuppression are at risk for cervical cancer. It is hypothesized that immunosuppressed individuals are more likely to have HPV persistence, which is necessary for malignant transformation. Accordingly, women with rheumatic diseases such as SLE and RA are likely vulnerable to HPV infection and the progression of cervical disease. The HPV vaccine, given as a series of vaccinations, is safe and effective that can prevent HPV infection and cervical cancer. There is no contraindication to HPV vaccination for women to age 26 with rheumatic disease, as it is not live. As in the general population, timing is key for the efficacy of the HPV vaccine as the goal is to vaccinate prior to sexual debut and exposure to HPV. There are no formal recommendations for cervical cancer screening in women with rheumatic disease but recommendations for the HIV-positive population can be adopted, meaning to screen with a Pap test annually for three consecutive years and if all normal, to extend the interval to every 3 years with the option of co-testing with HPV at 30 years and older.

Vaccination Coverage of Adolescents With Chronic Medical Conditions

INTRODUCTION

Adolescents with chronic medical conditions (CMCs) are at increased risk of vaccine-preventable infections. Little is known about their vaccine uptake.

METHODS

This retrospective cohort study included 3,989 adolescents aged 11-17 years receiving care at academically affiliated pediatric clinics between August 2011 and June 2013. Data were abstracted from the medical center's electronic health record and immunization registry in 2014. Vaccination coverage, timeliness, and missed opportunities were evaluated and analyzed in 2015-2016.

RESULTS

Adolescents with CMCs had lower human papillomavirus vaccination initiation than those without CMCs (81.3% vs 85.0%), although this difference was only observed in stratified analysis among males (adjusted relative risk=0.90, 95% CI=0.85, 0.96), aged 13-17 years (adjusted relative risk=0.94, 95% CI=0.91, 0.98), and those with more primary care visits (adjusted relative risk=0.94, 95% CI=0.91, 0.98). Adolescents with CMCs had greater influenza vaccination coverage and timeliness than those without CMCs (2011-2012 season: 66.9% vs 50.1%; adjusted hazards ratio=1.27, 95% CI=1.15, 1.40; 2012-2013 season: 73.8% vs 64.5%; adjusted hazards ratio=1.20, 95% CI=1.10, 1.31). Only 32.1% and 18.2% of eligible adolescents had received pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccines, respectively. Missed opportunities were higher among adolescents with versus without CMCs for human papillomavirus vaccination initiation (4.2 vs 2.7, p<0.001), meningococcal vaccination (4.0 vs 2.9, p<0.001), and influenza vaccination (2011-2012 season: 2.1 vs 1.7, p<0.001; 2012-2013 season: 2.0 vs 1.6, p<0.001). Missed opportunities for pneumococcal vaccination were common.

CONCLUSIONS

Pockets of undervaccination and missed opportunities exist among adolescents with CMCs. Greater, more timely influenza vaccination suggests that optimal vaccination of high-risk adolescents is possible.

Text message reminders for vaccination of adolescents with chronic medical conditions: A randomized clinical trial

BACKGROUND

Many adolescents with chronic medical conditions (CMCs) are at risk of vaccine-preventable infection, yet are frequently under-vaccinated. Text message reminders, particularly those with embedded educational information, have been shown to increase general pediatric vaccination. Their use has not been studied specifically among adolescents with CMCs.

METHODS

Eligible parents of adolescents with CMCs receiving care at one of 4 academically-affiliated pediatric clinics and requiring human papillomavirus (first dose), influenza, and/or pneumococcal polysaccharide vaccines were randomized in 4 consecutive cohorts to receive text message vaccine reminders with or without embedded educational information ("educational" vs. "plain" arm, respectively). Educational reminders, including one interactive message, addressed infection risk, vaccine safety/efficacy, and physician recommendations. Up to 5 weekly and 2 booster reminders were sent (October 2014-January 2015). Receipt of any needed vaccine and missed vaccination opportunities by 4, 12, and 24weeks after the initial reminder were compared between arms.

RESULTS

Of randomized parents (n=295), 175 (59.3%) were Spanish-speaking; most had adolescents with CMCs who were 13-17years (n=229; 77.6%) and publically insured (n=272; 92.5%). Baseline demographics and parental vaccine beliefs were similar between arms. More adolescents in the plain vs. educational reminder arm received any needed vaccine by 4weeks (31.9% vs. 22.7%, adjusted relative risk [aRR] 1.47, 95% CI 1.01-2.14), but not by 12 or 24weeks. Plain reminders were noted in post hoc analyses to have a greater effect than educational reminders in certain sub-populations, including 11-12year-olds and those sent the initial reminder in early fall. Fewer adolescents in the plain vs. educational reminder arm had a missed vaccination opportunity by 4weeks (10.9% vs. 41.3%; aRR 0.21, 95% CI 0.07-0.60), but not by 12 or 24weeks.

CONCLUSION

Plain text message vaccine reminders appear to have a positive effect compared to educational ones in the short-term and for certain families.

TRIAL REGISTRATION

NCT02231957 (www.clinicaltrials.gov).

Biologic Disease-Modifying Antirheumatic Drugs and Risk of High-Grade Cervical Dysplasia and Cervical Cancer in Rheumatoid Arthritis: A Cohort Study

OBJECTIVE

Recent research showed an increased risk of high-grade cervical dysplasia and cervical cancer associated with rheumatoid arthritis (RA). The purpose of this study was to examine whether this risk was associated with the use of biologic versus nonbiologic disease-modifying antirheumatic drugs (DMARDs).

METHODS

We identified RA patients in the US Medicaid and commercial insurance databases (for the years 2000-2012) who were starting treatment with either a biologic or a nonbiologic DMARD. High-grade cervical dysplasia or cervical cancer was identified with a validated claims-based algorithm, and we assessed utilization of gynecologic procedures. To control for potential confounders, those starting therapy with a biologic DMARD were matched 1:1 to those starting therapy with a nonbiologic DMARD according to the propensity score (PS). Hazard ratios (HRs) and rate ratios (RRs) in the PS-matched Medicaid and commercial insurance cohorts were pooled by an inverse variance-weighted fixed-effects model.

RESULTS

We included 14,729 pairs of patients initiating biologic and nonbiologic DMARDs from the Medicaid cohort and 7,538 pairs from the commercial insurance cohort. During 73,389 person-years of active treatment with either biologic or nonbiologic DMARDs, 95 cases of high-grade cervical dysplasia or cervical cancer occurred in the 2 cohorts. The HR for high-grade cervical dysplasia or cervical cancer associated with biologic DMARD use was 1.25 (95% confidence interval [95% CI] 0.78-2.01) in the Medicaid cohort and 1.63 (95% CI 0.62-4.27) in the commercial insurance cohort, with a pooled HR of 1.32 (95% CI 0.86-2.01). The rate of gynecologic procedures involving the uterine cervix was not different between the 2 groups (pooled RR 0.96 [95% CI 0.90-1.02]).

CONCLUSION

Among women with RA, initiation of therapy with a biologic DMARD was associated with a numerically significant, but not statistically significant, increase in the risk of high-grade cervical dysplasia or cervical cancer as compared to initiation of a nonbiologic DMARD.

Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists

STUDY OBJECTIVE

Many adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown.

DESIGN AND SETTING

National cross-sectional study.

PARTICIPANTS

Pediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418).

INTERVENTIONS

Subspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices.

MAIN OUTCOME MEASURES

HPV vaccination recommendation.

RESULTS

Over half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary-subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination.

CONCLUSION

This study revealed that many subspecialists fail to recommend HPV vaccination to adolescents with CMCs and highlights potential targets for future interventions.

Incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease after quadrivalent human papillomavirus vaccination: a cohort study

OBJECTIVE

To assess whether quadrivalent human papillomavirus (qHPV) vaccination is associated with increased incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease.

METHODS

This register-based open cohort study included all girls and women between 10 and 30 years of age in Sweden in 2006-2012 diagnosed with at least one of 49 prespecified autoimmune diseases (n = 70 265). Incidence rate ratios were estimated for new-onset autoimmune disease within 180 days of qHPV vaccination using Poisson regression adjusting for, country of birth, parental country of birth, parental income and parental education.

RESULTS

A total of 70 265 girls and women had at least one of the 49 predefined autoimmune diseases; 16% of these individuals received at least one dose of qHPV vaccine. In unvaccinated girls and women, 5428 new-onset autoimmune diseases were observed during 245 807 person-years at a rate of 22.1 (95% CI 21.5-22.7) new events per 1000 person-years. In vaccinated girls and women, there were 124 new events during 7848 person-years at a rate of 15.8 (95% CI 13.2-18.8) per 1000 person-years. There was no increase in the incidence of new-onset autoimmune disease associated with qHPV vaccination during the risk period; on the contrary, we found a slightly reduced risk (incidence rate ratio 0.77, 95% CI 0.65-0.93).

CONCLUSION

In this nationwide study, qHPV vaccination was not associated with increased incidence of new-onset autoimmune disease in girls and women with pre-existing autoimmune disease.

Immunization in patients with inflammatory rheumatic diseases

Immunization represents the most efficient and simplest intervention to prevent certain viral and bacterial infections in the general population as well as in the vulnerable population of patients with inflammatory rheumatic diseases treated with immunosuppressives. Here, we present an updated review of literature data regarding the safety and efficacy of immunizations against different pathogens in rheumatic patients treated with conventional immunosuppressives or the newer biologic agents while at the same time we provide practical guidance for the appropriate vaccine administration in this patient population.

Risk of high-grade cervical dysplasia and cervical cancer in women with systemic lupus erythematosus receiving immunosuppressive drugs

Objective Prior studies suggest an increased risk of cervical cancer among women with systemic lupus erythematosus. However, the relationship with immunosuppressive drugs is not well studied in US nationwide cohorts. We compared the risk of high-grade cervical dysplasia and cervical cancer among women with systemic lupus erythematosus who started immunosuppressive drugs versus hydroxychloroquine. Methods We identified systemic lupus erythematosus patients initiating immunosuppressive drugs or hydroxychloroquine using claims data from two US commercial health plans and Medicaid (2000-2012). We used a validated claims-based algorithm to identify high-grade cervical dysplasia or cervical cancer. To account for potential confounders, including demographic factors, comorbidities, medication use, HPV vaccination status, and health care utilization, immunosuppressive drugs and hydroxychloroquine initiators were 1:1 matched on the propensity score. We used inverse variance-weighted, fixed effect models to pool hazard ratios from the propensity score-matched Medicaid and commercial cohorts. Results We included 2451 matched pairs of immunosuppressive drugs and hydroxychloroquine new users in the commercial cohort and 7690 matched pairs in Medicaid. In the commercial cohort, there were 14 cases of cervical dysplasia or cervical cancer among immunosuppressive drugs users and five cases among hydroxychloroquine users (hazard ratio 2.47, 95% CI 0.89-6.85, hydroxychloroquine = ref). In Medicaid, there were 46 cases among immunosuppressive drugs users and 29 cases in hydroxychloroquine users (hazard ratio 1.24, 95% CI 0.78-1.98, hydroxychloroquine = ref). The pooled hazard ratio of immunosuppressive drugs was 1.40 (95% CI 0.92-2.12). Conclusion Among women with systemic lupus erythematosus, immunosuppressive drugs may be associated with a greater, albeit not statistically significant, risk of high-grade cervical dysplasia and cervical cancer compared to patients receiving hydroxychloroquine alone.