HPV Vaccination: Does It Have a Role in Preventing Penile Cancer and Other Preneoplastic Lesions?

ObjectivesHuman papillomavirus (HPV) is the most common sexually transmitted infection globally, which causes nearly all cervix carcinomas and contributes to oropharyngeal, penile, vulva, vagina, and anal cancers. Despite the role of HPV in several preneoplastic and cancerous lesions in men, male vaccine coverage is low. This article aims to provide insights into the pathophysiology of HPV-related penile cancer and penile intraepithelial neoplasia (PeIN). Moreover, this review endeavors to outline the advantages of implementing HPV vaccination in male vaccination programs and the role of health care providers in this mission.Data SourcesThis is a narrative review of relevant literature. A search on PubMed and Cochrane database was conducted. The following search terms were used: HPV vaccination, gender-neutral vaccination, male, genital warts, penile cancer, vaccine recommendations.ConclusionHPV is responsible for 50.8% of penile cancers globally, 79.8% of PeIN, and 90% of genital warts. In 2009 the Food and Drug Administration licensed the quadrivalent HPV vaccine for use in males, with a potential efficacy of 90% and 77.5% to reduce genital warts and anal intraepithelial neoplasia, respectively. However, the uptake of HPV vaccination in men is low, and gender-neutral vaccination is estimated to be implemented only in 42 countries worldwide. Because data in penile cancer are lacking, further research is needed to study the efficacy of incorporation of HPV vaccines in male vaccination programs on preventing penile cancer and PeIN.Implications for Nursing PracticeNurses and other members of the multidisciplinary team should take every opportunity to recommend HPV vaccination in adolescent men. Moreover, they play an important role in raising community awareness about the incidence of HPV and the related range of diseases. A practical approach is needed to incorporate HPV vaccines in vaccination programs and to optimize vaccination coverage.     

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention’s (CDC) Healthy People 2020 target of 80% coverage. Parents’ willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a “bundle” along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action.

• Key messages

• ??Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.

• ??According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.

• ??First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.

• ??It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.

• ??Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.

• ??The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

     

Human papillomavirus vaccination for prevention of cervical cancer

Persistent infection of human papillomavirus (HPV) is the necessary cause for developing cervical cancer. Now cervical cancer is getting attention as not only early-detectable but also preventable cancer by developing vaccine for HPV. In Japan, the first HPV vaccine, "Cervarix, GlaxoSmithKline (GSK)" was licensed on October 2009 and vaccination was started on December 2009. This is the bivalent vaccine specifically targeting HPV-16 and -18 types. Domestic clinical trial is also about to demonstrate the efficacy, safety, and possibility to keep enough antibody levels. The widespread use of this vaccine will help cervical cancer eliminated.     

女大学生HPV疫苗的接种意愿及影响因素分析——基于健康信念模式

目的了解浙江省女大学生自费接种人乳头状瘤病毒疫苗的意愿,以健康信念模式为框架分析女大学生自费接种人乳头状瘤病毒疫苗的影响因素,为今后开展健康教育活动及制订干预措施提供参考依据。方法采用自行设计的关于女大学生人乳头状瘤病毒的认知及人乳头状瘤病毒疫苗自费接种意愿调查问卷对302名女大学生进行调查,并采用单因素及多重线性回归分析。结果302名女大学生接种人乳头状瘤病毒疫苗行为意图得分(3.39±0.79)分,人乳头状瘤病毒疫苗的评价、知觉易感性、知觉到障碍、自我效能及行动线索是影响人乳头状瘤病毒疫苗接种行为意图的因素。结论浙江省女大学生自费接种人乳头状瘤病毒疫苗的意愿一般,受多种因素影响。     

基于计划行为理论的家长对女中学生接种人乳头瘤病毒疫苗意愿及影响因素研究

目的以计划行为理论为框架,了解浙江省家长对女中学生接种人乳头瘤病毒疫苗接种意愿及影响因素。方法采取自行设计的《浙江省家长对女中学生接种人乳头瘤病毒疫苗接受度调查表》对283名女中学生(12~<18岁)家长进行调查,采用单因素分析、Pearson相关分析及多元Logistic回归分析了解影响接种疫苗意愿的因素。结果 283名家长对女中学生接种人乳头瘤病毒疫苗行为意愿得分(4.47±1.23)分,接种人乳头瘤病毒疫苗态度、性行为影响态度、主观规范、知觉行为控制、家族中有人曾患妇科肿瘤或妇科感染是影响家长对女中学生接种人乳头瘤病毒疫苗意愿的因素。结论家长对女中学生接种人乳头瘤病毒疫苗意愿较一般,受多种因素的影响。     

Human papillomavirus vaccination for boys

Question

In Canada, generally provincial human papillomavirus (HPV) vaccination programs exist for only the female population. What should I recommend when parents and teenage boys ask about male HPV vaccination?

Answer

The quadrivalent HPV vaccine is effective and will reduce the incidence of disease in boys and girls. The quadrivalent HPV vaccination is approved and recommended for both boys and girls in Canada. Public funding for male vaccination is available in Prince Edward Island and Alberta. The remaining provinces and territories will need to consider cost-effectiveness analyses before expanding their female-only vaccination programs to include the male population.     

Awareness,knowledge and beliefs about HPV,cervical cancer and HPV vaccines among nurses in Cameroon: An exploratory study

Background

While it is known that sub-Saharan African countries face multiple obstacles such as cost in adopting vaccination against human papillomavirus (HPV), the crucial role nurses can play in implementing such programs has not been adequately examined.

Objectives

To investigate the knowledge and awareness of HPV, primary cause of cervical cancer and HPV vaccine among nurses working at four Cameroon Baptist Convention Health Services facilities, and to explore what factors influence nurses’ willingness to inform and recommend HPV vaccine to adolescents and parents attending clinics.

Design and setting

A structured questionnaire survey was administered to a convenience sample of nursing staff working at the four health facilities.

Results

Of 192 eligible nurses 76 (39.6%) participated in the study. There were moderately low levels of knowledge about HPV infection and prevention of cervical cancer, but a moderately high level of knowledge about HPV vaccine. Although 90.8% acknowledged that cervical cancer is directly linked to HPV infection, nearly 32% failed to identify it as a sexually transmitted infection (STI), while 43.4% believed it is an uncommon infection. Willingness to recommend the HPV vaccine was moderate, with 69.7% intentionally initiating discussions with patients about the subject. The most important factors considered when deciding to recommend the vaccine included effectiveness (56.6%) and side effects/safety (11.8%). Cost was less of a concern (6.6%), likely due to the availability of donated vaccine.

Conclusion

Despite high awareness about HPV, more education about the virus, cervical cancer and the vaccine are required to further increase nurses’ willingness to recommend the vaccine and strengthen strategies for reaching adolescents through nurses in Cameroon.     

Lessons from the failure of human papillomavirus vaccine state requirements

The licensure in 2006 of a vaccine against the subtypes of human papillomavirus (HPV) responsible for the majority of cervical cancers and genital warts was heralded as a watershed moment for vaccination, cancer prevention, and global health. A safe and effective vaccine against HPV has long been viewed as an enormous asset to cervical cancer prevention efforts worldwide. This is particularly true for places lacking robust Pap screening programs where cervical cancer has the greatest prevalence and mortality. Well before its licensure, however, some observers noted significant obstacles that would need to be addressed in order for an HPV vaccination program to succeed. These included the vaccine's relatively high cost, availability, and opposition from socially conservative groups. Such concerns associated with the implementation of HPV vaccination were soon overwhelmed by the furor that followed the unexpectedly early efforts by the US state governments to require the vaccine as a condition of attendance in public schools, proposals imprecisely referred to as "mandates." In this study, we review the controversy surrounding this debate and its effects on important ethical and public health issues that still need to be addressed.     

Understanding the Two-Dose HPV Vaccine Schedule

Recent advances in human papillomavirus (HPV) science have led to updates to national HPV vaccine recommendations. This column takes a second look at two recent studies that provide evidence to support the current two-dose HPV vaccination schedule for youth ages 9 to 14 years. This short review will help nurses and other clinicians understand the health and economic benefits of the current dosing recommendation. Nurses are leaders in national vaccination efforts; therefore, it is vital that they remain up to date on the latest evidence that supports vaccination practice as well as health counseling and HPV vaccine recommendations.     

Public Health and School Nurses’ Perceptions of Barriers to HPV Vaccination in Missouri

Human Papilloma Virus (HPV) is associated with various forms of cancer and is preventable with vaccination. Nurses are in a unique position to directly influence a person’s decision to receive the HPV vaccine. A statewide sample of both school and public health nurses was used to assess knowledge and attitudes related to the HPV vaccine as well as nurse’s behaviors and behavioral intentions toward educating parents and recommending the vaccine. Positive attitudes and adequate knowledge levels were found, however, the majority of school nurses did not provide information and resources to parents. Targeted health promotion programs for school nurses are recommended.     

Deconstructing the measure of vaccine efficacy against disease irrespective of HPV in HPV vaccine clinical trials

BackgroundHuman papillomavirus (HPV) vaccines were licensed by demonstrating prevention of anogenital disease caused by specific HPV types in clinical studies. Measuring the impact of HPV vaccination on the overall burden of anogenital disease (irrespective of HPV) is an important public health question which is ideally addressed in post-licensure epidemiological studies. Attempts were made to use clinical trial data for that purpose. However, the interpretation of vaccine efficacy on the endpoint of disease irrespective of HPV is not widely understood.MethodsWe used the 9-valent HPV vaccine clinical program as a case study to determine the value of measuring vaccine efficacy in such endpoint. This assessment was rigorously performed by heuristic reasoning and through probability calculations.ResultsThe measure of vaccine efficacy in the irrespective of HPV endpoint is driven simultaneously in opposite directions by the high estimate of prophylactic efficacy and a numerically negative estimate of risk reduction that is also a reflection of high prophylactic efficacy and no cross-protection.ConclusionsThe vaccine efficacy estimate in the irrespective of HPV endpoint is ambiguous and difficult to interpret. Comparing this estimate across different HPV vaccine studies requires an understanding of the contributions of vaccine HPV type efficacy and the incidence of disease not related to vaccine HPV types for each study. Without such understanding, comparing studies and drawing conclusions from such comparison are highly misleading. Approaches are proposed to divide this endpoint in components that are easier to interpret.     

Increasing Human Papillomavirus Vaccination Rates Among Adolescents: Overcoming Vaccine Hesitancy and Using Practice Improvements

The human papillomavirus (HPV) is responsible for thousands of cases of cancer annually, including cancers of the cervix, oropharynx, and anogenital areas. Since 2006, a vaccine for HPV has been available that offers the hope of dramatically reducing rates of HPV-related cancers. Rates of vaccination for HPV are much lower than rates of other recommended childhood vaccinations, because of difficulties reaching teenage patients and hesitancy toward the vaccine. This article provides recommendations to help pediatric and family practice providers increase rates of uptake of the HPV vaccine among adolescent patients, including communication strategies, and practice improvements that encourage vaccination.     

HPV in Men is a Women's Health Issue

Human papillomavirus (HPV) is associated with several types of cancer in both women and men, including cervical cancer, anal cancer and head and neck cancer. Public health efforts to educate consumers about HPV and vaccination have largely focused on women. This article summarizes three recent studies in which researchers examined issues regarding male attitudes and acceptance of the human papillomavirus (HPV) vaccine. All three papers suggest that vaccination of males would be beneficial to both men and women in reducing the overall HPV-related health burden. Here, the three studies are summarized and evaluated, and implications for nursing practice are discussed.     

Establishing physician advocates for human papillomavirus vaccination in British Columbia

Objective

To survey general practitioners in oncology (GPOs) in British Columbia (BC) to identify opportunities for them to serve as public supporters of human papillomavirus (HPV) vaccination.

Design

A mailed or online survey.

Setting

British Columbia.

Participants

Forty-two GPOs who worked in the community in BC.

Main outcome measures

Current practices, knowledge, and resource needs concerning HPV, the vaccine, and the HPV immunization program, and the willingness of respondents to be contacted to participate in stated public HPV vaccine supporter activities.

Results

The survey found that 42% of surveyed GPOs were willing to act as public supporters of the HPV vaccine. The survey also identified education needs among GPOs concerning HPV, the vaccine, and the HPV immunization program in BC.

Conclusion

This study found that GPOs in BC are willing to publicly support the HPV immunization program. This study shows that involving physicians in the promotion of public health programs is a viable option that should be further explored and evaluated.     

Design of a large outcome trial for a multivalent human papillomavirus L1 virus-like particle vaccine

BackgroundThe 9-valent human papillomavirus (HPV) (9vHPV) vaccine targets the four HPV types (6/11/16/18) covered by the licensed quadrivalent HPV (qHPV) vaccine and five additional types (31/33/45/52/58). A large outcome trial of 9vHPV vaccine was conducted.MethodsAn active control (qHPV vaccine) was used because a placebo is not ethically acceptable. Since qHPV vaccine is (and 9vHPV vaccine was anticipated to be) highly efficacious against HPV 6/11/16/18, low incidence of HPV 6/11/16/18-associated disease was expected. Consequently, an efficacy comparison of 9vHPV versus qHPV vaccine for HPV 6/11/16/18 would have been prohibitively large in size. Moreover, no minimum antibody level predicting protection against infection or disease is defined for HPV vaccination. As an alternative approach, the two vaccines were compared using immunogenicity bridging for HPV 6/11/16/18 and clinical efficacy for HPV 31/33/45/52/58.ResultsThe two co-primary objectives were to demonstrate: (1) non-inferior anti-HPV 6/11/16/18 antibody response; and (2) superior efficacy in HPV 31/33/45/52/58-related clinical outcome, for 9vHPV vaccine versus qHPV vaccine. For HPV 6/11/16/18, supportive analyses included a non-inferiority assessment of the percent risk reduction (compared to historical placebo) for 9vHPV versus qHPV vaccine.ConclusionsA Phase III study of 9vHPV vaccine was successfully implemented. Experience from this study design may be applicable when developing a multivalent vaccine covering the same serotypes as an existing vaccine plus additional serotypes and there is no immune correlate of protection. Also, this study established that efficacy of a new HPV vaccine may be demonstrated using immunogenicity endpoints, which may open new options in HPV vaccine development.     

CA7-03: Adolescent and Adult Immunizations: Health Impact and Cost-Effectiveness

Background/Aims The scope of vaccines recommended for adolescents and adults by ACIP has grown in number of vaccines and populations covered. We estimated the relative health impact and cost-effectiveness of these vaccines to help guide quality improvement initiative decisions. Methods Markov deterministic and micro-simulation models were used to estimate the health impact and CE ratios for birth cohorts of four million using a societal perspective. All models used methods consistent with the 'reference case' of the Panel of Cost-Effectiveness in Health and Medicine, producing results that are comparable and suitable for ranking. The influenza model recognized the 2010 ACIP recommendation for universal vaccination. The pneumococcal model recognized the recent decline in adult incidence after introduction of the PCV7 childhood vaccine. The meningococcal model included the 2010 ACIP recommendation for a booster five years after an initial vaccination at age 11 or 12. The HPV model estimated the influence of vaccine on rates of cervical cancer with and without cancer screening. Parameter estimates were from published literature. Single- and multiple-variable sensitivity analyses were performed. Results Health impacts, measured as QALYs saved during the lifetime of the cohort, were greatest for influenza vaccine (283,300), followed by HPV vaccine with screening (221,100), pneumococcal vaccine (17,100) and meningococcal vaccine (2,900). CE ratios ranged from $9,300 for adult pneumococcal vaccination to over $640,000 for adolescent meningococcal vaccination. CE of influenza vaccination for ages 18 and older was $6,100, but the vaccine was most cost-effective for ages 65 and older ($4,000) and least cost-effective for ages 18 to 49 ($260,500). HPV vaccine CE was $15,100 without screening and $17,900 with screening. Results from micro-simulation of the zoster vaccine will also be presented. Discussion Priority among preventive health care services is important because of the limited time and resources of the health care delivery system and the need to focus on the most effective services. Our consistent methods allow for comparison of estimates across a number of services. Our updated models showed the greatest health impact from HPV vaccine in the presence of screening and influenza vaccination of adults ages 65 and older.     

Evidence-Based Practice Model to Increase Human Papillomavirus Vaccine Uptake: A Stepwise Approach

ObjectiveTo increase uptake of human papillomavirus (HPV) vaccination by implementing a stepwise evidence-based practice model to offer HPV education along with a strong provider recommendation to parents of youth and adolescents.DesignEvidence-based practice change model.SettingA nurse practitioner–run, primary care walk-in clinic in a rural area of the southeastern United States.ParticipantsParents of youth and adolescents ages 11 to 17 years.Interventions/MeasurementsEducation targeting parental hesitancy and strong recommendations for immunization was administered by health care providers to parents of youth and adolescents eligible for vaccination. The Parent Attitudes About Childhood Vaccine instrument was used to identify the presence and degree of parental hesitancy. Vaccination uptake was measured and compared to the same time period from the previous year.ResultsData collected from the clinic vaccination log during the same 6-week time period in 2018 identified that four youth/adolescents were vaccinated with the HPV vaccine in 2018. During the same 6-week period in 2019 when the practice change was implemented, 38 parents were approached; 24 met eligibility criteria, and all 24 of their youth/adolescents received HPV vaccination.ConclusionImplementation of an evidence-based practice model that includes standing vaccine orders and reminders and recalls may provide an effective way to ensure completion of the HPV vaccine series. Every missed clinical opportunity to vaccinate youth and adolescents against HPV can contribute to lower vaccination rates and increased risk for genital warts and cancers associated with HPV infection.