American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors

Geographic variation of HPV-associated cancer incidence in Kentucky using spatial scan statistics

PURPOSE

Populations with high cancer risk that are targeted for screening, education, and vaccination have been shown to increase rates of screening, which ultimately may improve timing of diagnosis and overall outcome for certain cancers. Spatial scan analysis provides a visual representation of areas with higher rates of disease. Limited research has used this methodology to assess HPV-associated cancers. Using, spatial scan statistics, our goal was to identify regions within Kentucky having significantly higher rates of HPV-associated tumors. These regions can be targeted for public health efforts in the form of education, vaccination, screening, and physician recruitment.

METHODS

The Kentucky Cancer Registry data from 1995 to 2016 and spatial scan statistics were used to identify county-level clusters with high-incidence of HPV-associated cancers after adjustment for age and sex. Anatomic sites included in this analysis were oropharynx, cervix, anus, penis, and vulva.

RESULTS

There was one high-rate cluster of oropharyngeal cancer, which was observed in the Louisville metropolitan region (Relative Risk [RR] = 1.24, p < 0.001). One high-rate cluster of anal and penile cancer incidence in men was identified that partially overlapped with the oropharyngeal cluster. There were five clusters of higher cervical, vulvar, and anal cancer incidence in females, one of which overlapped with the oropharyngeal cluster.

CONCLUSION

Overlapping clusters of HPV-associated cancers were identified at the county-level and included both urban and rural counties of Kentucky. Findings can assist in the design of public health interventions to increase screenings, promote vaccination, and recruit physicians in these regions to improve prevention, diagnosis, and early treatment of HPV-associated cancers.

Mothers' intention to vaccinate their daughters against human papillomavirus in NorthWest Ethiopia, using the theory of planned behavior

Human papillomavirus (HPV) is the second most common cause of cancer worldwide among females. HPV vaccination is highly protective against HPV infection and can reduce 56% of HPV infections. Therefore, the study aims to assess mothers' intention to vaccinate their daughters aged 9-14 years old against human papillomavirus in Debre Tabor town, Northwest Ethiopia, using the theory of planned behavior. A community-based cross-sectional study design was employed using the theory of planned behavior from November 1 to 30, 2022, in Northwest Ethiopia. A total sample of 449 study participants was enrolled. The study participants were selected using a multi-stage random sampling technique. Data was collected using an interview-administered questionnaire. The data was entered into EPI data version 4.6 and then, exported to SPSS version 23 for analysis. Those variables with a p-value <.05 with 95% CI were considered significant predictors. Mothers' positive intention to vaccinate their daughters aged 9-14 years against HPV was 67.5%. Attitude, perceived behavioral control, and subjective norm were significant predictors with (AOR = 10.09, 95% CI = 6.23-16.32), (AOR = 4.12, 95% CI = 2.71-6.26), and (AOR = 16.397, 95% CI = 9.69-27.748), respectively. Only two-thirds of mothers have a positive intention to vaccinate their daughters against human papillomavirus. Attitude, perceived behavioral control, and subjective norm were predictors. Therefore, it is better to do community mobilization toward the advantage of HPV vaccination.

Essential cancer medicines and cancer outcomes: Cross-sectional study of 124 countries

BACKGROUND

Cancer is the second leading cause of death worldwide. Alongside other interventions, access to certain medicines may decrease cancer-associated mortality. Listing medicines on national essential medicines lists may improve health outcomes. We examine the association between cancer mortality amenable to care and the listing of cancer medicines on national essential medicines lists (NEMLs) of 124 countries.

METHODS

In this cross-sectional study, we determined the number of medicines used to treat eight cancers on NEMLs and used multiple linear regression to analyze the association between cancer health outcome scores and the number of medicines on NEMLs while controlling for GDP. A sensitivity analysis was also conducted using selected medicines.

FINDINGS

The number of cancer medicines on NEMLs was not associated with cancer health outcome scores when GDP was controlled for non-melanoma skin (p = 0.224), uterine (p = 0.221), breast (p = 0.145), Hodgkin's lymphoma (p = 0.697), colon (p = 0.299), leukemia (p = 0.103), cervical (p = 0.834), and testicular cancers (p = 0.178).

INTERPRETATION

There was a weak association between listing medicines for eight cancers in NEMLs and amenable mortality. Further studies are required to explore association between cancer health outcomes and other factors such as actual availability of medicines listed, access to surgeries, accurate diagnosis, radiotherapy, and early detection.

Prevalence and Predictive Factors of Cervical Cancer Screening in Saudi Arabia: A Nationwide Study

BACKGROUND

Cervical cancer, despite being preventable, is one of the most prevalent cancers among females globally and in Saudi Arabia. The literature demonstrated that, unlike global trends, cervical cancer incidence in Saudi Arabia is increasing. In addition to that, a high proportion of it is discovered in advanced stages. This state of late discovery was attributed to the absence of efficient preventive and screening programs. Observing the scale of the preventable morbidities and mortalities that can be caused by cervical cancer and the efforts and costs that are positioned to fight cervical cancer across the globe and the current ambiguity in the cervical cancer screening prevalence in Saudi Arabia brings the realization of the importance of conducting a study that properly explores the status of cervical cancer screening in Saudi Arabia.

AIM

This study aims to measure the prevalence and the predictive factors for cervical cancer screening among adult women who were previously sexually active in Saudi Arabia, as well as explore the participants' knowledge and attitude toward cervical cancer and human papillomavirus (HPV) vaccines.

METHODS

This study was a nationwide cross-sectional study conducted in Saudi Arabia between September 2023 and November 2023 on adult Saudi females between the ages of 21 and 65 years who were previously sexually active and did not undergo a hysterectomy. Data were collected through a convenience sampling technique where a self-administered survey was established and disseminated to the targeted population all over the country with the assistance of data collectors. Cervical cancer screening prevalence and screening predictive factors were measured. Factors associated with cervical cancer screening and knowledge of cervical cancer were tested using a chi-square test, an independent t-test, and an ANOVA test. Multivariate logistic regression was also used to determine predictors of cervical cancer screening.

RESULTS

The study included 2,337 participants. The prevalence of cervical cancer screening among Saudi females was observed to be 22.1%. The most commonly reported reason for not undergoing cervical cancer screening was that it was never recommended by a physician, as reported by 42.4%. Only 7.6% reported taking the HPV vaccine. The majority of the participants (84.1%) had a low knowledge level about cervical cancer. The multivariate logistic regression model revealed that the following factors were observed to be significantly predictive of undergoing cervical cancer screening: being 46-59 years of age (74% increase rate), having an income greater than 20,000 Saudi Riyals (SRs) (158% increase rate), having a history of gynecological problems (152% increase rate), knowing someone who underwent cervical cancer screening (393% increase rate), and receiving a recommendation from a healthcare practitioner to undergo cervical cancer screening (1300% increase rate).

CONCLUSION

There are clearly low rates of cervical cancer screening and even lower rates of uptake for the HPV vaccine, which are the prevention measures for cervical cancer. National initiatives and programs that promote HPV vaccine uptake and regular cervical cancer screening are highly recommended to minimize the morbidity and mortality of cervical cancer.

The Impact of Highly Effective Cystic Fibrosis Transmembrane Conductance Regulator Modulators on the Health of Female Subjects With CF

Cystic fibrosis (CF) is a genetic disorder that occurs in people of all genetic ancestries. CF is caused by variants in the CF transmembrane conductance regulator (CFTR) gene that result in decreased, absent, or nonfunctional CFTR protein at the cell surface of the mucous membranes. Clinical manifestations include chronic respiratory disease, malabsorption, and decreased fertility. Historically, therapies for CF were focused on the signs and symptoms of the disease. However, more recently, CFTR modulators, therapies directed at the basic defect, are improving the quality and duration of the lives of people with CF. The predicted survival of people with CF in the United States is now 53 years of age. With the hope of longer, healthier lives, female individuals with CF (fwCF) are expressing the desire to discuss fertility, pregnancy, and parenthood. Furthermore, pregnancy rates are increasing substantially. Understanding the impact of use or discontinuation of highly effective modulator therapy on the reproductive health of fwCF is critical. Finally, fwCF and their providers must consider preventative cancer screening. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier HS Journals, Inc.

Recurrent, non-traumatic, non-exertional rhabdomyolysis after immunologic stimuli in a healthy adolescent female: a case report

Background

Dysferlinopathy refers to a heterogenous group of autosomal recessive disorders that affect a skeletal muscle protein called dysferlin. These mutations are associated with limb-girdle muscular dystrophy type 2B, Miyoshi myopathy, asymptomatic hyperCKemia, and distal myopathy with anterior tibial onset.

Case presentation

A 16 year old female presented with myalgia, weakness and dark urine one week after her second BNT162b2 mRNA (Pfizer) vaccine. Initial serum creatine kinase (CK) was measured at 153,000 IU/L, eventually up-trending to over 200,000 IU/L. However, stable renal function precluded hemodialysis allowing discharge after 10 days of intravenous (IV) hydration and alkaline diuresis.

Just two years prior to the current presentation, the patient was hospitalized following Group A Streptococcal pharyngitis infection complicated by rhabdomyolysis. She presented with fatigue, lower extremity weakness, and dark oliguria with CK measuring 984,800 IU/L. IV hydration was attempted however hemodialysis was ultimately required throughout her 24-day hospital stay. Her episode was presumed to be idiopathic and no further work-up was performed at that time.

During the patient’s current hospitalization, she reported similar symptomology (myalgias and weakness) following her first quadrivalent Gardasil vaccine at age 11. No hospitalization was required at that time. A comprehensive workup was now initiated while the patient was being treated for her suspected second or third non-exertional, non-traumatic rhabdomyolysis. Rheumatologic, metabolic, infectious, and endocrinologic workup were all unremarkable. Patient eventually had whole exome sequencing performed which revealed a heterozygous pathogenic variant in the DYSF gene (DYSF c.2643 + 1G > A) encoding dysferlin. No clinically significant sequelae occurred thus far.

Conclusions

While there have been reports of symptomatic heterozygote carriers of dysferlinopathies, to our knowledge none have been associated with recurrent rhabdomyolysis after immunogenic stimuli. This unique case presentation highlights the importance of a multi-disciplinary care team, the utility of modern whole-exome gene sequencing, and the future challenges of balancing vaccine risk vs benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03561-2.

The Leaf Extract of Mitrephora chulabhorniana Suppresses Migration and Invasion and Induces Human Cervical Cancer Cell Apoptosis through Caspase-Dependent Pathway

Cervical cancer is rated to be the leading cause of cancer-related death in women worldwide. Since screening test and conventional treatments are less accessible for people in developing countries, an alternative use of medicinal plants exhibiting strong anticancer activities may be an affordable means to treat cervical cancer. Mitrephora chulabhorniana (MC) is the newly identified species; however, its biological functions including anticancer activities have been largely unexplored. Hence, in this study, we were interested in investigating anticancer effects of this plant on the human cervical cell line (HeLa). MC extract was profiled for phytochemicals by TLC. This plant was tested to contain alkaloids, flavonoids, and terpenes. HeLa cells were treated with MC extract to investigate the anticancer activities. Cytotoxicity and viability of cells treated with MC were determined by MTT assay and Trypan blue exclusion assay. Cell migration was tested by wound healing assay, and cell invasion was determined by Transwell assay. The level of caspase 7, caspase 9, and PARP was determined by western blot analysis. We found that the leaf extract of MC strongly reduced cancer cell survival rate. This finding was consistent with the discovery that the extract dramatically induced apoptosis of cervical cancer cells through the activation of caspase 7 and caspase 9 which consequently degraded PARP protein. Furthermore, MC extract at lower concentrations which were not cytotoxic to the cancer cells showed potent inhibitory activities against HeLa cervical cancer cell migration and invasion. Mitrephora chulabhorniana possesses its pharmacological properties in inhibiting cervical cancer cell migration/invasion and inducing apoptotic signaling. This accumulated information suggests that Mitrephora chulabhorniana may be a beneficial source of potential agents for cervical cancer treatment.

Fenofibrate Exerts Anticancer Effects on Human Cervical Cancer HeLa Cells via Caspase-Dependent Apoptosis and Cell Cycle Arrest

<b><i>Objective:</i></b> In the present study, we attempted to identify the effects of fenofibrate on human cervical cancer cells. <b><i>Methods:</i></b> The cytotoxicity of fenofibrate in cervical cancer cells was determined by Cell Counting Kit-8. Immunoblotting assay was used to determine the protein expression of caspase-3, poly ADP-ribose polymerase cleavage, B-cell lymphoma 2 family protein expression, microtubule-associated protein 1A/1B-light chain 3 (LC3), as well as cyclins and cyclin-dependent kinases. Immunofluorescence imaging was used to determine the expression of cleaved caspase-3 and LC3. Flow cytometry was used to determine cell cycle and apoptosis. <b><i>Results:</i></b> We first showed that fenofibrate treatment reduced cell viability in HeLa cervical cancer cells in a dose-dependent manner at 24 h and 48 h. Importantly, fenofibrate-induced cell death was mediated through cell cycle arrest in the G0–G1 phase and caspase-dependent apoptosis. Moreover, fenofibrate also induced autophagy activation in a dose-dependent manner and pharmacological inhibition of autophagy led to increase of sub-G1 phase and caspase-dependent cell death in HeLa cells. <b><i>Conclusion:</i></b> In conclusion, these data demonstrated that fenofibrate initially induced cell cycle arrest, followed by caspase-3-dependent cell death in cervical cancer HeLa cells. However, fenofibrate also induced autophagy activation, which is closely related to the survival of diverse cancer cells, thus reducing the anticancer effects of fenofibrate. Therefore, the combination of an autophagy inhibitor and fenofibrate might have the potential to become a new therapeutic strategy for cervical cancer.

Cervical Intraepithelial Neoplasia Grade 3 in a HPV-Vaccinated Patient: A Case Report

Persistent infection with human papillomavirus (HPV) causes almost all cervical precancerous lesions and cancers. Bivalent, quadrivalent, and nonavalent HPV vaccines effectively prevent high-grade cervical intraepithelial neoplasia (CIN3). The effectiveness of HPV vaccination against CIN3 is 97–100% in HPV-naïve populations and 44–61% in the overall population. Although HPV vaccination has substantially reduced the incidence of cervical cancers, several cases of precancerous cervical lesions in HPV-vaccinated patients have been reported. We report the clinical case of a 19-year-old woman whose first Pap smear was diagnosed as a high-grade squamous intraepithelial lesion (HSIL) after quadrivalent HPV vaccination. Colposcopy and cervical biopsy were performed, revealing HSIL/CIN3. Our multidisciplinary team decided to take a conservative approach with follow-up visits with cervical biopsies of this young patient. After six months, spontaneous regression of high-grade cervical dysplasia was observed. Although HPV immunization has shown to be extremely effective in preventing a high proportion of cervical precancerous lesions and cervical cancers, HPV vaccines do not protect against all oncogenic high-risk HPV genotypes. Consequently, healthcare providers must encourage HPV-vaccinated women to still regularly attend national cervical screening programs.

Inequalities in Mortality and Access to Hospital Care for Cervical Cancer-An Ecological Study

Cervical cancer is the second most common form of cancer in the world among women, and it is estimated to be the third most frequent cancer in Brazil, as well as the fourth leading cause of death from cancer. There is a difference in cervical cancer mortality rates among different administrative regions in Brazil along with an inadequate distribution of cancer centers in certain Brazilian regions. Herein, we analyze the trends in hospital admission and mortality rates for CC between 2000 and 2012. This population-based ecological study evaluated the temporal trend in cervical cancer between the years 2000 and 2012, stratifying by Brazilian administrative regions. The North and Northeast regions had no reduction in mortality in all age groups studied (25 to 64 years); when analyzing hospitalization rates, only the age group of 50 to 64 years from the North Region did not present a reduction. During the years studied, in the South Region, the age group ranging from 50 to 54 years had the greatest reduction in mortality rates (β = −0.59, p = 0.001, r² = 0.63), and the group ranging from 45 to 49 years had the greatest reduction in hospital admission rates (β = −8.87, p = 0.025, r² = 0.37). Between the years 2000 and 2012, the greatest reduction in the incidence of UCC was in the South Region (β = −1.43, p = 0.236, r² = 0.12) followed by the Central-West (β = −1, p < 0.001, r² = 0.84), the Southeast (β = −0.95, p < 0.001, r² = 0.88), the Northeast (β = −0.67, p = 0.080, r² = 0.25), and, finally, by the North (β = −0.42, p = 0.157, r² = 0.17). There was a greater reduction in mortality rates and global hospitalization rates for CC in Brazil than in the United States during the same period with exceptions only in Brazil’s North and Northeast regions.

Tumour neoantigen mimicry by microbial species in cancer immunotherapy

Tumour neoantigens arising from cancer-specific mutations generate a molecular fingerprint that has a definite specificity for cancer. Although this fingerprint perfectly discriminates cancer from healthy somatic and germline cells, and is therefore therapeutically exploitable using immune checkpoint blockade, gut and extra-gut microbial species can independently produce epitopes that resemble tumour neoantigens as part of their natural gene expression programmes. Such tumour molecular mimicry is likely not only to influence the quality and strength of the body's anti-cancer immune response, but could also explain why certain patients show favourable long-term responses to immune checkpoint blockade while others do not benefit at all from this treatment. This article outlines the requirement for tumour neoantigens in successful cancer immunotherapy and draws attention to the emerging role of microbiome-mediated tumour neoantigen mimicry in determining checkpoint immunotherapy outcome, with far-reaching implications for the future of cancer immunotherapy.

Prevalence and Genotype Distribution of Human Papillomavirus Infection among 12,076 Iranian Women

INTRODUCTION

Human papillomavirus (HPV) infection is one of the major health concerns of women in developing countries. This study gives an insight into the prevalence and genotype distribution of HPV infection and compares it with Pap smear results among Iranian women.

METHODS

In this study, 12,076 Iranian women underwent routine examination from November 2016 to November 2018 using HPV Direct Flow CHIP System for HPV DNA typing. Cytology methods were also undertaken for 5,138 samples.

RESULTS

Overall HPV prevalence was calculated at 38.68%. The most frequent HPV types were HPV 6, 16, 11, 62/81, 52, and 54, respectively; and, the most high-risk HPV types were HPV 16, 52, 18, 39, 31, and 51. These two groups represent about half of all HPV types detected-47% and 55%, respectively. Among individuals who underwent cytological tests, 135 individuals (2.63%) were cytologically positive. In this group, 81 individuals (60%) were HPV positive as well, 62 (76%) of whom were HR-HPV positive and among them, the most frequent type was HPV 16 (34%).

CONCLUSION

This study highlights the urgent need for public education and also early diagnosis using HPV screening tests to prevent cervical cancer.

Are malaria transmission-blocking vaccines acceptable to high burden communities? Results from a mixed methods study in Bo, Sierra Leone

BACKGROUND

Malaria transmission-blocking vaccines (TBVs) could help break the cycle of malaria transmission by conferring community rather than individual protection. When introducing new intervention strategies, uptake is dependent on acceptability, not just efficacy. In this exploratory study on acceptability of TBVs in Sierra Leone, it was hypothesized that TBVs would be largely acceptable to adults and health workers in areas with relatively few ongoing malaria interventions, and that (i) knowledge of malaria and vaccines, (ii) health behaviours associated with malaria and vaccines, and (iii) attitudes towards different vaccines types could lead to greater TBV acceptability.

METHODS

This study used a mixed methods approach in Bo, Sierra Leone, to understand community knowledge, attitudes, and practices related to malaria and vaccination in general. This included: (i) a population-based cross-sectional survey (n=615 adults), (ii) 6 focus group discussions with parents, and (iii) 20 key informant interviews. The concept of a TBV was explained to participants before they were asked about their willingness to accept this vaccine modality as part of an integrated malaria elimination programme.

RESULTS

This study found that most adults would be willing to receive a TBV vaccine. Respondents noted mostly positive past experiences with adult and childhood vaccinations for other infectious diseases and high levels of engagement in other malaria prevention behaviors such as bed nets. Perceived barriers to TBV acceptance were largely focused on general community-level distribution of a vaccine, including personal fears of vaccination and possible costs. After an explanation of the TBV mechanism, nearly all focus group and interview participants believed that community members would accept the vaccine as part of an integrated malaria control approach. Both parents and health workers offered insight on how to successfully roll-out a future TBV vaccination programme.

CONCLUSIONS

The willingness of community members in Bo, Sierra Leone to accept a TBV as part of an integrated anti-malarial strategy suggests that the atypical mechanism of TBV action might not be an obstacle to future clinical trials. This study's findings suggests that perceived general barriers to vaccination implementation, such as perceived personal fears and vaccine cost, must be addressed in future clinical and implementation research studies.

Knowledge on cervical cancer screening and vaccination among females at Oyibi Community

Background

Awareness about cervical cancer screening and vaccination in the developed countries are high as compared to the developing countries. Sixty to eighty percent (60–80%) of the women who develop cervical cancer in sub-Saharan Africa live in the rural areas with inadequate awareness of cervical cancer screening. However, cervical cancer knowledge remained a significant direct predictor of screening behaviors. The study therefore aim to explore the Knowledge on Cervical Cancer Screening and Vaccination among females at Oyibi Community.

Methods

A qualitative exploratory design was employed to purposively recruit 35 participants who were made up of 7 members in a group forming 5 Focus Group discussions in all. Data was retrieved using a semi-structured interview guide.

Results

The study revealed two main themes with 7 subthemes. The two main themes were cervical cancer screening and vaccination knowledge and cervical cancer vaccination effectiveness and cost. The subthemes were; knowledge on cervical cancer screening types, knowledge about cervical cancer screening and vaccination centers, knowledge about how cancer screening is performed, knowledge about cervical cancer vaccination, cervical cancer screening and vaccination sources of information, knowledge about the effectiveness of cervical cancer vaccination and awareness about cervical cancer screening cost and vaccination cost.

Conclusion

Ghanaian women are increasingly becoming aware of cervical cancer, nevertheless low knowledge on screening and vaccination of cervical cancer, and effectiveness was detected with high awareness about the screening and vaccination centers. There is therefore the need for heightened sensitization regarding cervical cancer screening and vaccination in rural communities to help reduce misconceptions and increase patronage rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01296-3.

The Roles of Programmed Cell Death Ligand-1/ Programmed Cell Death-1 (PD-L1/PD-1) in HPV-induced Cervical Cancer and Potential for their Use in Blockade Therapy

BACKGROUND

Cervical cancer induced by infection with human papillomavirus (HPV) remains a leading cause of mortality for women worldwide although preventive vaccines and early diagnosis have reduced morbidity and mortality. Advanced cervical cancer can only be treated with either chemotherapy or radiotherapy but the outcomes are poor. The median survival for advanced cervical cancer patients is only 16.8 months.

METHODS

We undertook a structural search of peer-reviewed published studies based on 1). Characteristics of programmed cell death ligand-1/programmed cell death-1(PD-L1/PD-1) expression in cervical cancer and upstream regulatory signals of PD-L1/PD-1 expression, 2). The role of the PD-L1/PD-1 axis in cervical carcinogenesis induced by HPV infection and 3). Whether the PD-L1/PD-1 axis has emerged as a potential target for cervical cancer therapies.

RESULTS

One hundred and twenty-six published papers were included in the review, demonstrating that expression of PD-L1/PD-1 is associated with HPV-caused cancer, especially with HPV 16 and 18 which account for approximately 70% of cervical cancer cases. HPV E5/E6/E7 oncogenes activate multiple signalling pathways including PI3K/AKT, MAPK, hypoxia-inducible factor 1α, STAT3/NF-kB and microRNA, which regulate PD-L1/PD-1 axis to promote HPV-induced cervical carcinogenesis. The PD-L1/PD-1 axis plays a crucial role in the immune escape of cervical cancer through inhibition of host immune response. Creating an "immune-privileged" site for initial viral infection and subsequent adaptive immune resistance, which provides a rationale for the therapeutic blockade of this axis in HPV-positive cancers. Currently, Phase I/II clinical trials evaluating the effects of PDL1/ PD-1 targeted therapies are in progress for cervical carcinoma, which provide an important opportunity for the application of anti-PD-L1/anti-PD-1 antibodies in cervical cancer treatment.

CONCLUSION

Recent research developments have led to an entirely new class of drugs using antibodies against the PD-L1/PD-1 thus promoting the body's immune system to fight cancer. The expression and roles of the PD-L1/ PD-1 axis in the progression of cervical cancer provide great potential for using PD-L1/PD-1 antibodies as a targeted cancer therapy.

Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: A cost-effectiveness analysis

BACKGROUND

A nonavalent human papillomavirus (HPV) vaccine has been licensed for use in women and men up to age 45 years in the United States. The cost-effectiveness of HPV vaccination for women and men aged 30 to 45 years in the context of cervical cancer screening practice was evaluated to inform national guidelines.

METHODS AND FINDINGS

We utilized 2 independent HPV microsimulation models to evaluate the cost-effectiveness of extending the upper age limit of HPV vaccination in women (from age 26 years) and men (from age 21 years) up to age 30, 35, 40, or 45 years. The models were empirically calibrated to reflect the burden of HPV and related cancers in the US population and used standardized inputs regarding historical and future vaccination uptake, vaccine efficacy, cervical cancer screening, and costs. Disease outcomes included cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancers, as well as genital warts. Both models projected higher costs and greater health benefits as the upper age limit of HPV vaccination increased. Strategies of vaccinating females and males up to ages 30, 35, and 40 years were found to be less cost-effective than vaccinating up to age 45 years, which had an incremental cost-effectiveness ratio (ICER) greater than a commonly accepted upper threshold of $200,000 per quality-adjusted life year (QALY) gained. When including all HPV-related outcomes, the ICER for vaccinating up to age 45 years ranged from $315,700 to $440,600 per QALY gained. Assumptions regarding cervical screening compliance, vaccine costs, and the natural history of noncervical HPV-related cancers had major impacts on the cost-effectiveness of the vaccination strategies. Key limitations of the study were related to uncertainties in the data used to inform the models, including the timing of vaccine impact on noncervical cancers and vaccine efficacy at older ages.

CONCLUSIONS

Our results from 2 independent models suggest that HPV vaccination for adult women and men aged 30 to 45 years is unlikely to represent good value for money in the US.

Encapsulating Polyethyleneimine-DNA Nanoplexes into PEGylated Biodegradable Microparticles Increases Transgene Expression In Vitro and Reduces Inflammatory Responses In Vivo

Encapsulating genetic material into biocompatible polymeric microparticles is a means to improving gene transfection while simultaneously decreasing the tendency for inflammatory responses; and can be advantageous in terms of delivering material directly to the lungs via aerosolization for applications such as vaccinations. In this study, we investigated the advantages of using polymeric microparticles carrying the luciferase reporter gene in increasing transfection efficiency in the readily transfectable HEK293 cell line and the difficult to transfect RAW264.7 cell line. The results indicated that there was a limit to the ratio of nitrogen in polyethylenimine (PEI) to phosphate in DNA (N/P ratio) beyond which further increases in transgene expression no longer, or only marginally, occurred. Microparticles encapsulating PEI:DNA nanoplexes induced cellular toxicity in a dose-dependent manner. PEGylation increased transgene expression, likely related to enhanced degradation of particles. Furthermore, intra-tracheal instillation in rats allowed us to investigate the inflammatory response in the lung as a function of PEGylation, porosity, and size. Porosity did not influence cell counts in bronchoalveolar lavage fluid in the absence of PEG, but in particles containing PEG, non-porous particles recruited fewer inflammatory cells than their porous counterparts. Finally, both 1 μm and 10 μm porous PLA-PEG particles recruited more neutrophils than 4 μm particles. Thus, we have shown that PEGylation and lack of porosity are advantageous for faster release of genetic cargo from microparticles and a reduced inflammatory response, respectively.

The Use of Nanobiotechnology in Immunology and Vaccination

Nanotechnology uses the unique properties of nanostructures with a size of 1 to 200 nanometers. Different nanoparticles have shown great promise for the production of new vaccines and drugs. Nanostructures can be used to deliver immunological compounds more effectively than microstructures to target sites. Different nanostructures can be applied to form a new generation of vaccines, adjuvants, and immune system drugs. The goal of nanotechnology is to better respond to a wide range of infectious and non-infectious diseases.

Monogamy as a Barrier to Human Papillomavirus Catch-Up Vaccination

Background: Human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) in the United States. Although a vaccine to prevent HPV infection exists, only 53.7% of females 13-17 years of age were up-to-date on the HPV vaccination series in 2018. There is a catch-up period of vaccination for females 18-26 years of age that shows consistent underparticipation. A potential barrier to vaccination is relationship status, as long-term relationships may negatively impact HPV risk perception. This study examined monogamy as a risk factor for nonvaccination and explored how risk perception may influence this association. Materials and Methods: An electronic survey was distributed to females 18-26 years of age who attended a large public university in the mid-Atlantic region (n = 629). Multivariable and descriptive statistics were estimated using SAS 9.4 to explore the likelihood of vaccination during the catch-up period by relationship status. Results: Most participants had received the HPV vaccine, a small proportion of whom received it during the catch-up period. After adjusting for confounders, women who were in monogamous relationships were significantly less likely to have participated in HPV catch-up vaccination compared to women who were single and dating (adjusted odds ratio: 0.36, 95% confidence interval: 0.15, 0.87). Women in monogamous relationships had a lower average sexually transmitted disease (STD) risk perception compared to women who were single and dating (p < 0.0001). Conclusions: A decreased risk perception may present a barrier to participating in catch-up vaccination for monogamous women. Practitioners and the public health community should focus on communicating HPV risk to women in monogamous relationships, especially given the recently expanded age range for HPV vaccination.

A hidden Markov model for population-level cervical cancer screening data

The Cancer Registry of Norway has been administrating a national cervical cancer screening program since 1992 by coordinating triennial cytology exam screenings for the female population between 25 and 69 years of age. Up to 80% of cancers are prevented through mass screening, but this comes at the expense of considerable screening activity and leads to overtreatment of clinically asymptomatic precancers. In this article, we present a continuous-time, time-inhomogeneous hidden Markov model which was developed to understand the screening process and cervical cancer carcinogenesis in detail. By leveraging 1.7 million individual's multivariate time-series of medical exams performed over a 25-year period, we simultaneously estimate all model parameters. We show that an age-dependent model reflects the Norwegian screening program by comparing empirical survival curves from observed registry data and data simulated from the proposed model. The model can be generalized to include more detailed individual-level covariates as well as new types of screening exams. By utilizing individual screening histories and covariate data, the proposed model shows potential for improving strategies for cancer screening programs by personalizing recommended screening intervals.

Cervical Cancer Screening Guidelines in the Postvaccination Era: Review of the Literature

Cervical cancer is relatively rare in high-income countries, where organized screening programs are in place, as well as opportunistic ones. As the human papillomavirus (HPV) vaccination rates increase, the prevalence of cervical precancers and cancers is going to decrease rapidly very soon, even if, in the most optimistic scenario, it is unlikely that optimal vaccination coverage will be achieved. Then, the optimal screening paradigm for cervical cancer prevention in the postvaccination era is still debated. Screening guidelines are being developed with the aim of reducing the number of tests a woman needs during her lifetime, in order to receive the maximum benefit from screening, while decreasing potential harms that may result with the use of a screening strategy (overdiagnosis, overtreatment, anxiety, and costs). With this purpose in mind, new management guidelines for cervical cancer screening abnormalities are recommendations based on risks, not on results. This review aims to summarize the process that led to the introduction of the HPV DNA test in screening programs and the different screening strategies. Moreover, it aims to introduce the new risk-based guidelines for the future, where full HPV genotyping can resize the risk on the basis of specific high-risk genotypes. In the same way, the data regarding HPV vaccination could be introduced as soon as women vaccinated with the nonavalent vaccine reach the screening age, with the recommendation of a prolonged screening interval.

Comparison of Definitive Cervical Cancer Management With Chemotherapy and Radiation Between Two Centers With Variable Resources and Opportunities for Improved Treatment

PURPOSE

Cervical cancer remains a major health challenge in low- to middle-income countries. We present the experiences of two centers practicing in variable resource environments to determine predictors of improved radiochemotherapy treatment.

METHODS AND MATERIALS

This comparative review describes cervical cancer presentation and treatment with concurrent chemoradiotherapy with high-dose-rate brachytherapy between 2014 and 2017 at the National Radiotherapy Oncology and Nuclear Medicine Center (NRONMC) in Korle-Bu Teaching Hospital, Accra, Ghana, and Moffitt Cancer Center (MCC), Tampa, FL.

RESULTS

Median follow-up for this study was 16.9 months. NRONMC patients presented with predominantly stage III disease (42% v 16%; P = .002). MCC patients received para-aortic node irradiation (16%) and interstitial brachytherapy implants (19%). Median treatment duration was longer for NRONMC patients compared with MCC patients (59 v 52 days; P < .0001), and treatment duration ≥ 55 days predicted worse survival on multivariable analysis (MVA; P = .02). Stage ≥ III disease predicted poorer local control on MVA. There was a difference in local control among patients with stage III disease (58% v 91%; P = .03) but not in survival between MCC and NRONMC. No significant difference in local control was observed for stage IB, IIA, and IIB disease.

CONCLUSION

Although there were significant differences in disease presentation between the two centers, treatment outcomes were similar for patients with early-stage disease. Longer treatment duration and stage ≥ III disease predicted poor outcomes.

Patient-Level Factors Associated With Lack of Health Care Provider Recommendation for the Human Papillomavirus Vaccine Among Young Cancer Survivors

PURPOSE

Young cancer survivors are at increased risk for morbidities related to infection with the human papillomavirus (HPV), yet their HPV vaccine initiation rates remain low. Patient-/parent-reported lack of health care provider recommendation for HPV vaccination is strongly associated with vaccine noninitiation. We aimed to identify patient-level factors associated with survivor-/parent-reported lack of provider recommendation for HPV vaccination among young cancer survivors.

METHODS

Cancer survivors ages 9-26 years and 1-5 years off therapy completed a cross-sectional survey (parent-completed for survivors 9-17 years of age). Lack of health care provider HPV vaccine recommendation was the outcome of interest in a multivariable logistic regression model that included relevant patient-level sociodemographic, clinical, and vaccine-related variables.

RESULTS

Of 955 survivors, 54% were male, 66% were non-Hispanic White, and 36% had leukemia. At survey participation, survivors were an average age (± standard deviation) of 16.3 ± 4.7 years and 32.8 ± 14.7 months off therapy. Lack of provider HPV vaccine recommendation was reported by 73% (95% CI, 70% to 75%) of survivors. For the entire cohort, patient-level factors associated with lack of reported provider recommendation included perceived lack of insurance coverage for the HPV vaccine (odds ratio [OR], 4.0; 95% CI, 2.7 to 5.9; P < .001), male sex (OR, 2.8; 95% CI, 1.9 to 4.0; P < .001), and decreased parent-survivor communication regarding HPV vaccination (OR, 1.7 per unit decrease in score; 95% CI, 1.3 to 2.2; P < .001). In the sex- and age-stratified models, perceived lack of insurance coverage (all models) and male sex (age-stratified models) were also significantly associated with lack of reported provider recommendation.

CONCLUSION

We identified factors characterizing survivors at risk for not reporting receipt of a health care provider HPV vaccine recommendation. Future research is needed to develop interventions that facilitate effective provider recommendations for HPV vaccination among all young cancer survivors.

Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation

The American Cancer Society (ACS) presents an adaptation of the current Advisory Committee on Immunization Practices recommendations for human papillomavirus (HPV) vaccination. The ACS recommends routine HPV vaccination between ages 9 and 12 years to achieve higher on-time vaccination rates, which will lead to increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine series at age 9 or 10 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. Providers should inform individuals aged 22 to 26 years who have not been previously vaccinated or who have not completed the series that vaccination at older ages is less effective in lowering cancer risk. Catch-up HPV vaccination is not recommended for adults aged older than 26 years. The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit.

What's New in Vaccine Science

Today vaccines can provide immunity against and treatment of a growing number of diseases including noninfectious conditions. Vaccine science continues to evolve newer and safer ways to deliver prevention and treatment of infectious and noninfectious diseases. This includes new adjuvants to enhance immunogenicity; delivery systems to reduce pain and improve acceptability; a wider range of uses including preventing emerging infectious diseases, such as Zika virus and Ebola, treatment of chronic diseases, such as cancer, and autoimmune disorders; and repurposing of existing vaccines, such as bacillus Calmette-Guérin for novel therapies.

The understudied half of undergraduates: Risky sexual behaviors among community college students

Objective: This study examines the prevalence and risk factors associated with risky sexual behaviors in community college students. Participants: A diverse sample of 18-19-year-old community college students (N = 264). Methods: Baseline data from an online prevention program administered in 2015. Results: Community college students in this sample disproportionately experienced sexual assault and were unlikely to test for STIs. Higher intentions to engage in risky sexual behaviors were associated with gender and sexual experience, but also with having lower intentions to communicate with a sexual partner about pregnancy and STIs, and having higher gender norm endorsement. Conclusions: Older adolescents attending community colleges may be at high risk for poor sexual health outcomes, and appropriate theory-based education should be tailored to meet the needs of these underserved students.

Human Papillomavirus Vaccination Schedule: Adherence Among Commercially Insured Adolescents and Young Adults in the United States, 2011–2017

Objectives. To determine rates of human papillomavirus (HPV) vaccine adherence to the 2011 and 2016 Advisory Committee for Immunization Practices (ACIP) recommendations in the United States.

Methods. We conducted a retrospective cohort study by using the 2011 to 2017 Marketscan data for beneficiaries aged 9 to 26 years who had at least 1 claim for HPV vaccination between January 1, 2011, and January 1, 2017. According to the 2011 ACIP recommendation, adherence is defined as 30 to 90 days between the first and second vaccination and 168 to 212 days between the first and third vaccination. According to the 2016 recommendation, preadolescents are classified as adherent if they had 2 claims of vaccination within 168 to 212 days. We calculated proportions of completion and adherence by recommendation.

Results. Among patients classified under the 2011 ACIP recommendation (n = 2 164 096), 8.3% completed all 3 doses of the vaccine series. Of those who completed, 69.6% were considered adherent to the recommended schedule. Completion and adherence increased to 9.6% and 70.8%, respectively, among patients who were classified under the 2016 ACIP recommendation.

Conclusions. Simpler recommendations lead to better adherence to the HPV vaccination schedule.

HPV vaccination and sexual behaviour in healthcare seeking young women in Luxembourg

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide. Despite recommendations for HPV vaccination of young women from health authorities, parental concerns were raised whether vaccination could induce unsafe sexual behaviour in young women. Therefore, the primary aim of this study was to investigate if HPV vaccination in healthcare seeking adult women in Luxembourg was associated with unsafe sexual behaviour.

Methods

Seven hundred twenty-nine women (mean age = 22.5; range 18-43 years) were recruited either at Luxembourg family planning centres or at private gynaecology practices. All participants completed a questionnaire on vaccination status and sexual behaviour. Poisson and logistic regressions were used to study the association between sexual behaviour and vaccination status (N = 538). Both models were restricted to women younger than 26 years, since the first cohort being vaccinated would be 25 years old at the time of sampling. Assortativity of sexual mixing by age was also assessed for further transmission modelling for women <30 years reporting age of last/current sexual partner (N = 649). Women older than 29 years were excluded from the assortativity analysis due to restricted sample size.

Results

In total, 386/538 (71.8%) of participants reported receiving HPV vaccine. Vaccination uptake significantly varied by nationality and was higher in Portuguese 112/142 (78.9%) and in Luxembourgish 224/313(71.6%) residents, and lower in residents of other nationalities 50/83 (60.2%) (p = 0.011). HPV vaccination was not associated with unsafe sexual behaviour such as shorter relationship duration with current or last sexual partner (odds ratio (OR) = 1.05, 95% CI [0.94-1.16]), younger age of sexual debut (OR = 1.00, 95% CI [0.88-1.14]), increased number of lifetime sexual partners (OR = 0.95, 95% CI [0.87-1.03), higher age difference with sexual partner (OR = 1.01, 95% CI [0.95-1.08]), condom use (OR = 0.97, 95% CI [0.60-1.56]), nor with other factors like smoking (OR = 0.73, 95% CI [0.47-1.15]) and nationality. HPV vaccination was only associated with younger age (OR = 0.84, 95% CI [0.75-0.94]). Relationship duration, age of sexual debut, age difference with sexual partner, smoking, age and non-Portuguese foreign nationality were predictors of number of lifetime sexual partners. Assortativity analysis revealed that young women chose sexual partners who were 2.3 years older on average.

Conclusions

Our study found no association between unsafe sexual behaviour and HPV vaccination.

Cervical cancer screening behaviors and proximity to federally qualified health centers in South Carolina

INTRODUCTION

Lack of participation in cervical cancer screening in underserved populations has been attributed to access to care, particularly among women in rural areas. Federally Qualified Health Centers (FQHCs) were created to address this need in medically underserved populations. This study observed proximity to three health centers in relation to cervical cancer screening rates in South Carolina.

METHODS

Data were obtained from FQHC patient visits (from 3 centers) between 2007-2010 and were limited to women eligible for cervical cancer screening (n = 24,393). ArcGIS was used to geocode patients addresses and FQHC locations, and distance was calculated. Modified Poisson regression was used to estimate relative risk of obtaining cervical cancer screening within one yearor ever, stratified by residential area.

RESULTS

Findings differed markedly by center and urban/rural status. At two health clinics, rural residents living the furthest away from the clinic (∼9 miles difference between quartile 4 and quartile 1) were more likely to be ever screened (RRs = 1.05 and 1.03, p-values < 0.05), while urban residents living the furthest away were less likely to be ever screened (RR = 0.85, p-value < 0.05). At the third center, only urban residents living the furthest away were more likely to be ever screened (RR = 1.02, p-value < 0.05).

CONCLUSIONS

Increased travel distance significantly increased the likelihood of cervical cancer screening at two FQHC sites while significantly decreasing the likelihood of screening at the 3rd site. These findings underscore the importance of contextual and environmental factors that impact use of cervical cancer screening services.

HPV infection screening using surface plasmon resonance in women from Kunming (Southwest China)

No study examined the frequency of human papillomavirus (HPV) genotypes by surface plasmon resonance (SPR) in Southwest China. This was a cross-sectional survey (The Second Affiliated Hospital of Kunming Medical University, 10/2010 to 12/2011) in 150 patients who were hospitalized or volunteered for cervical cancer (CC) screening. A HPV typing kit was used to detect 24 types of HPV by the SPR technique. The HPV-positive rate was 34.8% in women with normal cytology and 92.9% in women with CC. The frequency of HPV16 increased from 9.4% for women with normal cytology to 28.9% for cervical intraepithelial neoplasia (CIN)1, 41.4% for CIN2, 54.1% for CIN3, and 71.4% for CC (p < 0.001). The frequency of HPV18 increased from 0% for women with normal cytology to 2.6% for CIN1, 3.4% for CIN2, 5.4% for CIN3, and 21.4% for CC (p = 0.03). HPV40 was only found in one patient with CC (p = 0.04). There was no relation between HPV genotype and women’s age. In Kunming (Southwest China), the frequency of HPV infection was 74.0% among women who underwent CC screening. HPV16 and HPV18 were the two most frequent genotypes. SPR could be of value for the screening of HPV infection.

Prognostic value of HPV status among patients with hypopharyngeal carcinoma: a population-based study

OBJECTIVE

To clarify the prognostic role of human papilloma virus (HPV) status among patients with hypopharyngeal carcinoma.

METHODS

Surveillance, Epidemiology and End Results (SEER) HPV head and neck cancer database has been accessed and cases with hypopharyngeal squamous cell carcinoma with known HPV status were retrieved. Kaplan-Meier survival estimates were used to evaluate the impact of HPV status on overall survival outcomes of included patients and multivariable cox regression analysis was used to assess the impact of HPV status on overall and head and neck cancer-specific survival.

RESULTS

A total of 1157 patients' records with hypopharyngeal carcinoma were included in the current analysis. Using Kaplan-Meier survival estimates, patients with HPV positive status seem to have better overall survival compared to patients with HPV negative status (P < 0.01). When stratified by stage, patients with HPV positive regional and distant disease have better overall survival compared to patients with HPV negative regional and distant disease (P < 0.01 for both categories). The same observation cannot be confirmed for patients with localized disease (P = 0.15). Using multivariable Cox regression analysis, HPV positive status seems to be associated with better overall survival (HR for HPV negative versus HPV positive status: 1.76; 95% CI 1.39-2.24; P < 0.01) and cancer-specific survival (HR for HPV negative versus HPV positive status: 1.54; 95% CI 1.12-2.11; P < 0.01).

CONCLUSIONS

Patients with HPV positive hypopharyngeal carcinoma seem to have better overall and cancer-specific survival compared to patients with HPV negative hypopharyngeal carcinoma.

Regulation of Biobanks in Italy

In Italy, a biobank is "a non-profit organization that must be officially recognized by the appropriate healthcare authority in the member states and must guarantee the treatment, distribution and conservation of biological material according to standards of quality and professionalism," but must not conserve material already regulated by specific laws, as is the case for organs for transplants, blood for transfusions, as well as embryos and gametes for medically assisted reproduction. The concept of biobank includes not only biological samples, but also the related database of clinical and personal information, from which the subject's lifestyle can be deduced. Unfortunately, at the moment, Italian law does not offer specific itineraries for achieving this legal status.

Awareness of human papilloma virus and cervical cancer prevention among Cypriot female healthcare workers

BACKGROUND

Cervical cancer incidence varies around the world with the highest rates in Eastern Africa and the lowest rates in Western Asia. In Cyprus, a small Mediterranean island, cervical cancer incidence was 6.4 per 100,000 in 2013. HPV is an established risk factor for cervical cancer with HPV-16 and HPV-18 being the most common carcinogenic strains. Cervical cancer is preventable through primary (HPV vaccination) and secondary (Pap and HPV tests) prevention. These prevention methods should be promoted, however, in order to design a cancer prevention programme and the awareness and characteristics of populations should be investigated so that prevention programmes can be targeted specifically to them.

METHODS

In this work, we sought to investigate awareness of HPV and cervical cancer prevention among female healthcare workers in Cyprus. To achieve this, we conducted a 60-item survey among 200 healthcare professionals in randomly selected hospitals in two different cities within Cyprus.

RESULTS

Our results revealed that nearly 10% of our participants reported not ever having had a Pap test. 88.5% of the healthcare workers knew about HPV and 86.5% reported that HPV is transmitted through sexual intercourse. 83.5% of the participants were willing to vaccinate themselves for cervical cancer prevention.

CONCLUSION

Even though awareness and vaccination acceptance were relatively high, they are still not optimal for healthcare professionals who play an essential role in health promotion. We suggest the design of educational programmes to target this population and improve their knowledge so that they can promote cervical cancer prevention in their health practice.

Impact of the Affordable Care Act on human papillomavirus vaccination initiation among lesbian, bisexual, and heterosexual U.S. women

OBJECTIVE

To examine the effect of the 2010 Affordable Care Act (ACA) extended dependent coverage and no cost-sharing provisions on human papillomavirus (HPV) vaccination in relation to sexual orientation identity among U.S. women.

DATA SOURCES

2006-2010 and 2011-2015 National Survey of Family Growth.

STUDY DESIGN

We used an interrupted time series design and multivariable Poisson regression to assess differences in HPV vaccination initiation before (2007-2010) and after (2011-2015) the 2010 ACA provisions among heterosexual, bisexual, and lesbian U.S. women aged 15-25 years (N = 7033), adjusting for temporal trends and demographic factors.

DATA COLLECTION

Computer-assisted personal interview and audio computer-assisted self-interview questionnaires.

PRINCIPAL FINDINGS

The adjusted prevalence of HPV vaccination initiation was significantly higher among lesbian and bisexual women after compared to before the 2010 ACA-at 19.1 (95% confidence interval [CI]: 5.4, 32.9) and 15.7 (95% CI: 4.4, 27.1) percentage points in 2015 compared to 2007-2010, respectively. We observed no association between the 2010 ACA provisions and HPV vaccination initiation among heterosexual women after adjusting for temporal trends and demographic factors.

CONCLUSIONS

The 2010 ACA provisions may have improved HPV vaccination initiation among lesbian and bisexual women. Policies and programs that increase access to health insurance and provide HPV vaccines at no cost to patients may facilitate HPV vaccine uptake in these marginalized populations.

Patterns of incident genital human papillomavirus infection in women: A literature review and meta-analysis

Human papillomavirus (HPV) infection acquisition is a necessary step in the development of cervical cancer. No study has systematically quantified the rate of newly acquired HPV infections from the published literature and determined its relationship with age. We performed a systematic review and meta-analysis to describe incident HPV infections in women. Medline® and Thomson Reuters Web of Science via PubMed® databases were searched. A total of 46 of 5136 studies met inclusion criteria and contributed results. We conducted a meta-regression analysis of 13 studies, which reported incidence rate estimates on over 13 high-risk HPV types, to provide pooled stratum-specific incidence rates and rate ratios for key population and study characteristics among 8488 women. Studies with mean age < 30 years had relatively higher HPV incidence rates compared to studies with mean age ≥30 years: relative risk = 3.12; 95% CI: 1.41–6.93. HPV-16 was most frequently detected, followed by HPV-18: relative risk = 0.47; 95% CI: 0.33–0.67, and by HPV-58: relative risk = 0.45; 95% CI: 0.27–0.74. Younger age is a key predictor of genital HPV incidence in women. These data on the relative distribution of incident HPV infections will provide a baseline comparison for monitoring of changes in HPV incidence following the implementation of population-level HPV vaccination.

Advances in technologies for cervical cancer detection in low-resource settings

Introduction: Cervical cancer mortality rates remain high in low- and middle-income countries (LMICs) and other medically underserved areas due to challenges with implementation and sustainability of routine screening, accurate diagnosis, and early treatment of preinvasive lesions. Areas covered: In this review, we first discuss the standard of care for cervical cancer screening and diagnosis in high- and low-resource settings, biomarkers that correlate to cervical precancer and cancer, and needs for new tests. We review technologies for screening and diagnosis with a focus on tests that are already in use in LMICs or have the potential to be adapted for use in LMICs. Finally, we provide perspectives on the next five years of technology development for improved cervical cancer screening and diagnosis in LMICs. Expert opinion: Innovation toward improved molecular and imaging tests is needed to enable effective, affordable see-and-treat approaches to detect and treat cervical precancer in a single visit. Current molecular tests remain too complex and/or costly for widespread use. Especially with imaging tests, decision support may improve performance of new technologies.

Clinical Controversies in Cervical Cancer Screening

Through the implementation of systematic cervical cancer screening in the mid-20th century, the United States and other developed countries have seen death rates from cervical cancer decreased by ≥70%.The purpose of this article is to address several of the most controversial issues associated with cervical cancer screening recommendations in light of historical and evolving data. In this article, we will explore the controversies around the age at which to initiate and exit screening, human papilloma virus testing alone as a primary screening approach, and the impact of human papilloma virus vaccination on cervical cancer rates.

Trends in cervical cancer incidence rates by age, race/ethnicity, histological subtype, and stage at diagnosis in the United States

Recent trends of cervical cancer incidence by histology and age in the United States (U.S.) have not been reported. We examined contemporary trends in cervical squamous cell carcinoma (SCC) and adenocarcinoma (AC) incidence rates in the U.S. by age group, race/ethnicity, and stage at diagnosis after accounting for hysterectomy. Incidence data (1999-2015) were obtained from the U.S. Cancer Statistics Incidence Analytic Database. Hysterectomy prevalence was estimated using National Health Interview Survey data (2000-2015). Overall SCC incidence rates continued to decrease in all racial/ethnic groups except among non-Hispanic whites in whom rates stabilized in the 2010s, largely driven by stable trends in ages <50 years and a slower pace of decrease in ages 50-59 years. After a stable trend between 1999 and 2002, AC incidence rates among non-Hispanic whites rose during 2002-2015 (1.3% per year), mostly due to increases in ages 40-49 (4.4% annually since 2004) and 50-59 years (5.5% annually since 2011). Overall AC incidence rates during 1999-2015 decreased in blacks and Hispanics but were stable in Asian/Pacific Islanders; in all these race/ethnicities, rates were generally stable in ages <50 years but decreasing in older ages. Rates of distant stage cervical SCC and AC among non-Hispanic whites increased in several age groups but were generally stable in non-whites. Increasing or stabilized incidence trends for AC and attenuation of earlier declines for SCC in several subpopulations underscore the importance of intensifying efforts to reverse the increasing trends and further reduce the burden of cervical cancer in the U.S.

Immunization and Moral Hazard: The HPV Vaccine and Uptake of Cancer Screening

Immunization can lead to moral hazard by reducing the cost of risky behaviors and reducing preventive efforts. In this study, we examine the effect of HPV (human papillomavirus) vaccination on participation in the Pap test, which is a diagnostic screening test to detect HPV and non-HPV-related cancerous processes. The HPV vaccination is explicitly recommended for women up to age 26 years who were not previously vaccinated. Pap tests are strongly recommended for women between 21 and 65 years old even after having the HPV vaccine. To study the effect of HPV vaccination on Pap test uptake, we construct a fuzzy regression discontinuity design, centered on the vaccination threshold age. The results suggest that moral hazard was not the dominant effect. The estimates show that women who have been vaccinated, if anything, are actually more likely to have a Pap test, possibly due to increased awareness of its benefits at the time of vaccination.

Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening

Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the current American Cancer Society cancer screening guidelines are summarized, and the most current data from the National Health Interview Survey are provided on the utilization of cancer screening for men and women and on the adherence of men and women to multiple recommended screening tests.

Exploitation of Neisseria meningitidis Group B OMV Vaccines Against N. gonorrhoeae to Inform the Development and Deployment of Effective Gonorrhea Vaccines

Have potential clues to an effective gonorrhea vaccine been lurking in international disease surveillance data for decades? While no clinically effective vaccines against gonorrhea have been developed we present direct and indirect evidence that a vaccine is not only possible, but may already exist. Experience from Cuba, New Zealand, and Canada suggest that vaccines containing Group B Neisseria meningitides outer membrane vesicles (OMV) developed to control type-specific meningococcal disease may also prevent a significant proportion of gonorrhea. The mechanisms for this phenomenon have not yet been elucidated but we present some strategies for unraveling potential cross protective antigens and effector immune responses by exploiting stored sera from clinical trials and individuals primed with a meningococcal group B OMV vaccine (MeNZB). Elucidating these will contribute to the ongoing development of high efficacy vaccine options for gonorrhea. While the vaccine used in New Zealand, where the strongest empirical evidence has been gathered, is no longer available, the OMV has been included in the multi component recombinant meningococcal vaccine 4CMenB (Bexsero) which is now licensed and used in numerous countries. Several lines of evidence suggest it has the potential to affect gonorrhea prevalence. A vaccine to control gonorrhea does not need to be perfect and modeling supports that even a moderately efficacious vaccine could make a significant impact in disease prevalence. How might we use an off the shelf vaccine to reduce the burden of gonorrhea? What are some of the potential societal barriers in a world where vaccine hesitancy is growing? We summarize the evidence and consider some of the remaining questions.

Pharmacist insights into adolescent human papillomavirus vaccination provision in the United States

HPV vaccination coverage in the United States (US) falls short of the Healthy People 2020 goal of 80% coverage among 13-15 year-old adolescents. Pharmacies are a promising alternative vaccine delivery site that may increase access to HPV vaccination. Our objective was to assess pharmacists' insights into HPV vaccination provision to adolescents. We recruited 40 licensed pharmacists in eight states with different pharmacy vaccination laws: Alabama, California, Indiana, Kentucky, Maine, Tennessee, Texas, and Washington. Eligible pharmacists either previously provided or were currently providing HPV, tetanus-diphtheria-pertussis, or meningococcal vaccines to adolescents aged 9-17 years. Pharmacists were administered a semi-structured survey to explore insights into HPV vaccination provision. Forty-five percent of surveyed pharmacies offered HPV vaccination to adolescents. Pharmacists' reported challenges to providing HPV vaccination were parental consent (28%), tracking and patient recall (17%), perceived stigma of vaccination (17%), and education about or promotion of vaccination (17%). Pharmacists offering HPV vaccination sent patient reminders for vaccines with multiple doses (89%) and utilized telephone reminders (72%). Pharmacists informed patients' primary care providers of HPV vaccination doses most commonly through fax (72%) and updating electronic medical records (22%). One-third of pharmacists reported vaccination provision using the state immunization information system (IIS). Seventy-five percent reported vaccination rates could be increased at their respective pharmacy. Pharmacies are underutilized, although highly accessible, for HPV vaccination in the US. National efforts should expand educational programs to improve public awareness of in-pharmacy HPV vaccination, and improve the utilization of state IIS for reporting immunization coverage of adolescents by pharmacists.

Using the health belief model to assess beliefs and behaviors regarding cervical cancer screening among Saudi women: a cross-sectional observational study

Background

Cervical cancer in Saudi Arabia is ranked as the third most frequent gynecological cancer among women. The Pap smear test is a screening test that can be used as a primary prevention tool for cervical cancer, and prophylactic vaccination against HPV is also considered to be a factor in decreasing the prevalence of the disease. This study aimed to assess women’s beliefs about cervical cancer and the Pap smear test. In addition, the relationship between cervical cancer and the social and demographic characteristics was also evaluated.

Methods

A descriptive cross-sectional study was performed among Saudi women living in Riyadh in 2018. Women were randomly selected, and the total sample size was 450. A predesigned self-administered questionnaire that included the Health Belief Model scale was used to collect data. Data were analyzed using SPSS 21.0. P values < 0.05 were considered as statistically significant in this study.

Results

Among the 450 participants, the Pap smear test uptake was 26% and the HPV vaccine uptake was less than 1%. A low education level and family history for cervical cancer were significantly associated with the belief of high susceptibility for developing cervical cancer (p < 0.05). The seriousness of the disease was recognized by 38%, and the benefit of screening was recognized by 82% of the participants. In addition, 27% of the participants perceived barriers to obtaining a Pap smear test.

Conclusions

This study showed a high level of perception regarding benefits and motivation, and a low incidence of perceived barriers among women regarding cervical cancer screening. However, these attitudinal aspects did not translate into practice, as reflected by the low uptake of the screening test. Our findings imply that concerted efforts are needed to promote cervical cancer screening programs in Saudi Arabia. In view of the planned implementation of Saudi vision 2030, which emphasizes on prevention, we recommend launching a national cervical cancer screening program, to be available and accessible to all women in primary health care centers and hospitals.

Interaction Between Susceptibility Loci in MAVS and TRAF3 Genes, and High-risk HPV Infection on the Risk of Cervical Precancerous Lesions in Chinese Population

Persistent high-risk HPV infection is considered as a major cause of cervical cancer. Nevertheless, only some infected individuals actually develop cervical cancer. The RIG-I pathway in innate immunity plays an important role in antivirus response. Here, we hypothesized that altered function of mitochondrial antiviral signaling protein (MAVS) and mitochondrial TNF receptor-associated factor 3(TRAF3), key molecules downstream of the viral sensors RIG-I, may impair their ability of clearing HPV and thereby influence the risk for cervical precancerous lesions. To investigate the effects of MAVS and TRAF3 polymorphisms on susceptibility to cervical precancerous lesions, 8 SNPs were analyzed in 164 cervical precancerous lesion cases and 428 controls. Gene-environment interactions were also calculated. We found that CA genotype of rs6052130 in MAVS gene were at 1.48 times higher risk of developing cervical precancerous lesion than individuals with CC genotype (CA vs. CC: OR_adjusted = 1.48, 95% CI, 1.02-2.16). In addition, a significant synergetic interaction between high-risk HPV infection and rs6052130 was found on an additive scale. A significantly decreased risk of cervical precancerous lesions for the TC genotype of rs12435483 in the TRAF3 gene (OR_adjusted = 0.67, 95% CI, 0.45-0.98) was also found. Moreover, MDR analysis identified a significant three-locus interaction model, involving high-risk HPV infection, TRAF3 rs12435483 and number of full-term pregnancies. Our results indicate that the MAVS rs6052130 and TRAF3 rs12435483 confer genetic susceptibility to cervical precancerous lesions. Moreover, MAVS rs6052130-mutant individuals have an increased vulnerability to high-risk HPV-induced cervical precancerous lesions.

Factors associated with Human Papilloma Virus (HPV) vaccine recommendation by physicians in Lebanon, a cross-sectional study

Persistent Human Papilloma Virus (HPV) infection is associated with the development of cervical cancer, a leading cause of female death worldwide. In Lebanon, cervical cancer is the 6th most common cancer amongst girls and women aged 14-44 years. Cervical cancer is preventable through HPV vaccination; however, Lebanon does not include HPV vaccination in its national routine vaccination schedule. Hence, physician recommendation is key for patient vaccine uptake. We conducted a cross-sectional study in Beirut, Lebanon to assess factors affecting physician recommendation regarding HPV vaccination. Physicians practicing in Obstetrics and Gynecology (OBGYN), Pediatrics, Family Medicine and Infectious Diseases were included in the study. In total, 228 physicians completed the survey (28.79% response rate). The survey consisted of a set of demographic and HPV knowledge questions along with clinical vignettes. The vignettes presented theoretical patients who differed in gender, age, sexual activity, social background and whether the patient presented with his mother or not. The results show that physicians tend to recommend the vaccine more commonly for vignettes presenting female patients, with an Adjusted Odds Ratio (AOR) of 6.8. Also, physicians were more likely to recommend the vaccine for vignettes with patients coming from a non-conservative background (AOR = 2.1), vignettes where patients claim to be sexually active (AOR = 2.7) and vignettes where patients presented with their mother (AOR = 1.4). Physicians tend to recommend the vaccine less in vignettes with married patients (AOR = 0.5). Physicians with higher knowledge scores recommended the vaccine more often (AOR = 3.4). Overall, OBGYN physicians recommended the vaccine less than pediatricians (AOR = 0.5). These results show that Lebanese physicians' recommendations rely on factors external to international guidelines. The results also highlight the importance of knowledge in adequate patient consultation. Thus, improved physician awareness towards international guidelines and physician education regarding HPV vaccination is essential in order to improve patient care in Lebanon.

HPV Vaccination of Girl Child in India: Intervention for Primary Prevention of Cervical Cancer

Over the past 40 years mortality from carcinoma of the cervix has fallen due to improved treatment and the introduction of national screening programs. Awareness and health-seeking practices have been shown to be poor in many developing countries, necessitating the need for proper awareness and vaccination program The HPV vaccination is of public health importance. The Indian Academy of Pediatrics Committee on Immunization (IAPCOI) recommends offering HPV vaccine to all females who can afford the vaccine. Vaccination can be given to females as young as 9 years as well as in those aged 13–26 years who have not previously completed vaccination. The primary obstacle to HPV vaccination is financial. There are bivalent, Quadrivalent and Nonavalent HPV vaccines available based on protection against number of HPV subtypes. HPV vaccination and regular cervical screening is the most effective way to prevent cervical cancer. Parents/caregivers of child must be educated regarding HPV vaccination before offering this chemoprophylaxis against cervical cancer. Gaps and barriers to the access and delivery of HPV vaccination need to be identified, so that scientific and public health communities and civil society can be mobilised to adopt the vaccination policy.

Reaching 80% human papillomavirus vaccination prevalence by 2026: How many adolescents need to be vaccinated and what are their characteristics?

BACKGROUND

Human papillomavirus vaccination (HPVV) prevents several types of cancer. The American Cancer Society recently established a goal that by 2026, 80% of adolescents will be up to date (UTD) before their 13th birthday. However, the number in need of vaccination to reach this goal is unknown. This study estimated the number of additional adolescents (11-12 years old) who need HPVV for 80% prevalence to be reached by 2026.

METHODS

The study used de-identified and publicly available data and exempt from institutional review board approval and informed consent. The 2016 National Immunization Survey for Teens was used to estimate the baseline HPVV prevalence. Linear growth to 80% HPVV prevalence by 2026 was applied to set intermediate targets. US Census Bureau data were used for population projections. This study estimated the cumulative number of additional adolescents 11 to 12 years old who would need to become UTD (ie, receive 2 doses) by first subtracting the number who would need to be vaccinated to achieve an intermediate target prevalence from the estimated number currently compliant and then summing these numbers between 2018 and 2026.

RESULTS

Nationwide, an additional 7.62 million males (95% confidence interval [CI], 6.78 million to 8.40 million) and an additional 6.77 million females (95% CI, 5.95 million to 7.55 million), aged 11 to 12 years, would need to receive 2 doses of the vaccine between 2018 and 2026 for 80% prevalence to be achieved. Most adolescents not UTD (80%) also needed to initiate vaccination, and more than 90% recently visited a health care provider.

CONCLUSIONS

It is estimated that at least 14.39 million additional adolescents aged 11 to 12 years in the United States will need to receive 2 doses of HPVV for a UTD HPVV prevalence of 80% to be achieved by 2026. To reach this goal, improvements in facilitators of HPVV initiation, including physician recommendations and parental acceptability, are needed.