Women's knowledge about human papillomavirus and their acceptance of HPV vaccine

Objective: Recently, prophylactic human papillomavirus (HPV) vaccines were approved in the USA and Europe to protect against HPV-related disease. However, there is ongoing debate about the acceptance of the HPV vaccine as a part of routine vaccine scheme. The aim of this study is to determine the baseline knowledge Turkish women have about HPV and prophylactic HPV vaccines.
Method:  The study included 1434 women from four different cities of Turkey who completed a 22-item questionnaire that assessed their knowledge of HPV and cervical cancer, and their acceptance of HPV vaccine for themselves and their children.
Results:  The median age was 35.8 ± 10.8 years (range: 17–80 years). In all, 12% of the participants had a past history of an abnormal Pap test. Among the participants, 77% believed that sex education should be provided at school, 45% had heard of HPV and 55% had no knowledge about HPV. It was known by 43% of the women that HPV might cause genital lesions. Of the parents, 40% knew HPV is related to cervical cancer, while 34% had no opinion about the subject. Of the parents interviewed, 70% reported they would accept HPV vaccination for themselves, 64% for their daughters and 59% for their sons.
Conclusion:  Although less than half of the women had knowledge about HPV, the majority of the women sampled reported that they would accept vaccination for themselves and their children. Health-care providers must focus not only on the diagnosis and treatment of cervical cancer, but must also provide information and education about HPV to women.     

Human papillomavirus vaccines and adolescents

PURPOSE OF REVIEW: This review will describe human papillomavirus (HPV) vaccines in development, summarize data regarding safety and efficacy of these vaccines, and discuss key issues related to HPV vaccine implementation. RECENT FINDINGS: Evidence from epidemiologic and genetic studies has confirmed that HPV infection is a necessary cause of cervical cancer and contributes to the development of other cancers. HPV infection also may cause nonmalignant conditions such as external genital warts and recurrent respiratory papillomatosis. Over the past decade, several vaccines that target common HPV types have entered clinical trials. These vaccines are classified as prophylactic or therapeutic. The goal of prophylactic vaccines is to prevent primary or persistent HPV infections, and thus prevent cervical cancer and/or genital warts. Recent evidence indicates that prophylactic vaccines are well tolerated, highly immunogenic and effective in preventing persistent HPV infection and cervical intraepithelial neoplasia (CIN). Questions remain, however, concerning vaccine efficacy against HPV-related diseases other than cervical cancer, the duration of protection, vaccine acceptability and feasibility of vaccine delivery in the developing world. The goal of therapeutic vaccines is to prevent progression of HPV infection, induce regression of CIN or condylomata, or eradicate residual cervical cancer. Although therapeutic vaccines appear to induce both humoral and cell-mediated immunity, they have not consistently demonstrated clinical efficacy. SUMMARY: HPV vaccines in development have the potential to reduce the substantial morbidity and mortality associated with cervical cancer and other HPV-associated diseases. Large-scale efficacy studies that are planned or underway will provide additional information about vaccine tolerance and efficacy.     

Giving patients information on abnormal cytology and human papillomavirus: survey of health providers

OBJECTIVES: Knowledge of the link between HPV and cervical cancer is low among women. Health providers may be required to give information and counseling on HPV. This study surveyed health providers' comfort in counseling women about HPV. METHODS: Physicians, nurses and midwives attending a lecture on HPV completed a questionnaire (before the lecture) on their comfort level answering questions that a woman with an abnormal Pap may ask her health provider. Comfort level with knowledge was assessed on a 7-point Likert scale, with seven being very comfortable. RESULTS: Of the 96 attendees, 57.3% (55/96) were eligible and completed the questionnaire. Two-thirds of respondents were physicians (61.8%; 34/55), 38.2% were nurses or midwives (21/55). Telling a partner about HPV infection was the question about which the most respondents were very comfortable (69.1% answering 6 or 7) and chances of developing cervical cancer was the item about which the fewest respondents reported being very comfortable (36.4%). CONCLUSIONS: Less than one-half to two-thirds of health providers self-reported being very comfortable answering HPV-related questions that a woman may ask. More information is needed regarding health providers' actual knowledge of HPV and women's wishes for information.     

Assessment of knowledge and attitudes of young uninsured women toward human papillomavirus vaccination and clinical trials

STUDY OBJECTIVE: To assess knowledge and attitudes of young uninsured women toward human papillomavirus (HPV) vaccination and clinical trials. DESIGN: Cross-sectional study. SETTING: Clinic-based sample in Brazil. PARTICIPANTS: A consecutive sample of 204 women aged 16 to 23 years, attending a public outpatient gynecological clinic. INTERVENTIONS: A questionnaire administered by in-person interview. MAIN OUTCOME MEASURES: Data on knowledge and attitudes towards HPV vaccination. RESULTS: Overall, 72% of the respondents would enroll in a HPV vaccine trial, despite the fact that 69% of women were ignorant of what HPV may cause, and only 10% acknowledged that HPV might lead to cervical cancer. The need of a placebo arm (31%) and three vaccinations injections (26%) were the trial design characteristics most cited for deterring participation. Factors promoting participation were "careful/detailed consultations by the same physician" (92%), "access to more information on women's health" (84%), and "office visits on time" (79%); whereas "clinic too far from home" (36%), "fear of adverse events" (29%), and "gynecologic examination discomfort" (25%) were the most commonly reported reasons for not enrolling in a trial. Being sexually active, more than three lifetime sexual partners and perception of high risk for cervical cancer were predictors of participation in a HPV vaccine trial. CONCLUSIONS: Knowledge of HPV infection and cervical cancer is low in this urban, young population. Thus, when planning HPV vaccine trials, it is important to consider implementing educational programs to provide knowledge of the benefits of a preventive vaccine and information on the etiology of and risk factors for cervical cancer.     

Education about human papillomavirus and human papillomavirus vaccines in adolescents

PURPOSE OF REVIEW: The purpose of this article is to review recent literature that may help guide the development of effective, evidence-based strategies to educate adolescents about human papillomavirus (HPV) and HPV vaccines. Educational strategies are essential, given several new and highly effective technologies to prevent HPV and related diseases such as cervical cancer. RECENT FINDINGS: Although little has been published regarding adolescent knowledge about HPV and HPV vaccines, studies conducted primarily in adult women demonstrate that knowledge generally is poor. Studies of adolescent attitudes about HPV vaccines have identified several modifiable factors associated with intention and confidence in one's ability to receive the vaccine, including higher perceived severity of cervical cancer and fewer barriers to vaccination. Studies of clinician attitudes about HPV vaccines have demonstrated that although clinicians generally support vaccination, some report concerns; for example, adolescents may practice riskier sexual behaviors after vaccination. Studies also show that clinicians believe that educational materials developed specifically for adolescents are essential. SUMMARY: The recent literature on adolescent knowledge about HPV and attitudes about HPV vaccines supports the importance of designing developmentally appropriate educational materials for adolescents about HPV and HPV vaccines, and provides guidance for the development of key educational messages.     

Understanding and overcoming barriers to human papillomavirus vaccine acceptance

New vaccines designed to prevent human papillomavirus (HPV) infection have the potential to reduce the incidence of serious illness and death worldwide among women, substantially reduce the emotional suffering associated with abnormal Papanicolaou (Pap) test results and the diagnosis of cervical cancer, and save significant health care dollars. However, these benefits may not be fully realized until the vaccine is accepted by patients, parents, and health care practitioners. Furthermore, there may be unique issues related to the acceptance of a vaccine designed to prevent a sexually transmitted infection that is poorly understood by many women. Among the acceptance issues are: individual comfort with a sexually transmitted infection (STI) vaccine; parental comfort with vaccination of their preadolescent/early adolescent daughters; physician comfort with recommending a human papillomavirus vaccine to women and parents of preadolescents; and physician communication skills related to talking with women and parents about the vaccine. Potentially difficult as it might be to implement a vaccination program, vaccination and prevention of HPV-associated disease are still infinitely preferable to observation and treatment. This article will review some of the potential barriers to HPV Vaccine acceptance, with a particular focus on factors relevant to female patients, parents, and health care providers.     

The impact of anti HPV vaccination on cervical cancer incidence and HPV induced cervical lesions: consequences for clinical management

Cervical cancer is the second most common cause of cancer-related deaths in women worldwide. Screening for cervical cancer is accomplished utilizing a Pap smear and pelvic exam. While this technology is widely available and has reduced cervical cancer incidence in industrialized nations, it is not readily available in third world countries in which cervical cancer incidence and mortality is high. Development of cervical cancer is associated with infection with high risk types of human papillomavirus (HPV) creating a unique opportunity to prevent or treat cervical cancer through anti-viral vaccination strategies. Several strategies have been examined in clinical trials for both the prevention of HPV infection and the treatment of pre-existing HPV-related disease. Clinical trials utilizing prophylactic vaccines containing virus-like particles (VLPs) indicate good vaccine efficacy and it is predicted that a prophylactic vaccine may be available within the next five years. But, preclinical research in this area continues in order to deal with issues such as cost of vaccination in underserved third world populations. A majority of clinical trials using therapeutic agents which aim to prevent the progression of pre-existing HPV associated lesions or cancers have shown limited efficacy in eradicating established tumors in humans possibly due to examining patients with more advanced-stage cancer who tend to have decreased immune function. Future trends in clinical trials with therapeutic agents will examine patients with early stage cancers or pre-invasive lesions in order to prevent invasive cervical cancer. Meanwhile, preclinical studies in this field continue and include the further exploration of peptide or protein vaccination, and the delivery of HPV antigens in DNA-based vaccines or in viral vectors. Given that cervical cancers are caused by the human papillomavirus, the prospect of therapeutic vaccination to treat existing lesions and prophylactic vaccination to prevent persistent infection with the virus are high and may be implemented in the near future. The consequences for clinical management may include a significant reduction in the frequency of Pap smear screening in the case of prophylactic vaccines, and the availability of less invasive and disfiguring treatment options for women with pre-existing HPV associated lesions in the case of therapeutic vaccines. Implementation of both prophylactic and therapeutic vaccine regimens could result in a significant reduction of health care costs and reduction of worldwide cervical cancer incidence.     

Strategies for the prevention of cervical cancer by human papillomavirus vaccination

As cervical cancer is causally associated with 14 high-risk types of human papillomavirus (HPV), a successful HPV vaccine will have a major impact on this disease. Although some persistent HPV infections progress to cervical cancer, host immunity is generally able to clear most HPV infections. Both cell-mediated and antibody responses have been implicated in influencing the susceptibility, persistence or clearance of genital HPV infection. There have been two clinical trials that show that vaccines based on virus-like particles (VLPs) made from the major capsid protein, L1, are able to type specifically protect against cervical intra-epithelial neoplasia and infection. However, there is no evidence that even a mixed VLP vaccine will protect against types not included in the vaccine, and a major challenge that remains is how to engineer protection across a broader spectrum of viruses. Strategies for production of HPV vaccines using different vaccine vectors and different production systems are also reviewed.     

Ethnically diverse female university students’ knowledge and attitudes toward human papillomavirus (HPV), HPV vaccination and cervical cancer

Objective

Cervical HPV is the most common sexually transmitted disease among college-age women. This study aimed to assess knowledge and attitudes towards HPV infection, HPV vaccination and cervical cancer among female university students, to provide insight into development of HPV educational information.

Study design

A cross-sectional survey using a convenience sample. A total of 1083 ethnically diverse female students attending a public university were approached and 650 were interviewed.

Results

Knowledge regarding HPV, HPV vaccination, cervical screening and cervical cancer risk factors was remarkably poor. Across the sample, the mean total knowledge score (14-item) was only 3.25 (S.D. ±2.41; 95% CI 3.07–3.44). Only 10.3% had heard of the newly released HPV vaccine. Approximately 48% of participants indicated an intention to receive an HPV vaccine. Intention to receive an HPV vaccine was significantly associated with knowledge of HPV and genital warts (OR 1.53; 95% CI 1.25–1.88), and knowledge of cervical screening and cervical cancer risk factors (OR 1.21; 95% CI 1.11–1.33). Of those who refused HPV vaccination, 50.9% doubted the safety and efficacy of the new vaccine, and 41.5% perceived themselves as not at risk of HPV infection.

Conclusion

The findings suggest that providing education about the etiology of cervical cancer and the HPV link is an essential component to enhance HPV vaccine uptake.     

Harnessing the power of prevention: human papillomavirus vaccines

Human papillomavirus (HPV) infection and HPV-associated diseases pose a considerable health care burden in the United States. The morbidity and mortality associated with HPV infection and HPV-associated diseases, ranging from genital warts to cervical cancer, have prompted both the use of screening measures to monitor HPV infection and the development of numerous treatment modalities to address its clinical sequelae. Although screening programs have dramatically reduced the incidence of cervical cancer through early detection and treatment, this devastating illness, which frequently affects women of reproductive age, remains a major public health concern. Prophylactic vaccines that prevent HPV infection have proved to be safe, well tolerated, highly efficacious, and induce long-lasting immunity to HPV. Multivalent vaccines that protect against the most common disease-causing HPV types should significantly reduce the morbidity and mortality associated with HPV.     

Human papillomavirus prophylactic vaccines: stakes and perspectives

Human Papillomavirus (HPV) infection is established as the necessary cause of cervical precancers and cancers. To date, more than 120 genotypes are known, but only high risk oncogen genotypes could induce a cancer. HPV 16 and 18 are implied in nearly 70% of cervical cancer around the world. Although some persistent HPV infections progress to cervical cancer, host immunity is generally able to clear most HPV infections providing an opportunity for cervical cancer prevention through vaccination. Candidate prophylactic vaccines based on papillomavirus L1 virus-like particles (VLPs) are currently on human clinical trials: one targeting cervical cancer with a bivalent VLP L1 vaccine containing the two genotypes most frequently involved in cervical cancer (type 16 and 18) and the other, protecting against warts as well as cervical cancer, with a quadrivalent HPV VLP L1 vaccine containing genotypes 6, 11, 16 and 18. The first clinical trials revealed the satisfactory tolerance and excellent immunogenicity of these vaccines inducing high serum antibody titers with minimal side effects. After more than three years, both clinical trials on women 15 to 25 years old have shown that vaccines are able to type specifically protect against nearly 90% of infection and all cervical intra-epithelial neoplasia. The vaccinal strategy defined to date targets preadolescents and adolescent young females (11-13 years) before the first sexual course but some questions are still not resolved concerning the prescriber, the actors of the vaccination and the duration of the protection. Nevertheless cervical cancer screening should be carried on for many years, even if a large vaccinal strategy is decided. Such a vaccine would save lives and reduce the need for costly medical procedures and the psychological stress induced by this cancer.     

Attitudes about human papillomavirus vaccine among family physicians

STUDY OBJECTIVE: Human papillomavirus (HPV) vaccines will soon be available for clinical use, and the effectiveness of vaccine delivery programs will depend largely upon whether providers recommend the vaccine. The objectives of this study were to examine family physicians' attitudes about HPV immunization and to identify predictors of intention to recommend immunization. DESIGN: Cross-sectional survey instrument assessing provider and practice characteristics, knowledge about HPV, attitudes about HPV vaccination, and intention to administer two hypothetical HPV vaccines. PARTICIPANTS: Surveys were mailed to a national random sample of 1,000 American Academy of Family Physicians (AAFP) members. MAIN OUTCOME MEASURE: Intention to administer two hypothetical HPV vaccines (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to boys and girls of different ages. RESULTS: One hundred fifty-five surveys (15.5%) were returned and 145 were used in the final sample. Participants reported higher intention to recommend both hypothetical HPV vaccines to girls vs. boys (P < 0.0001) and to older vs. younger adolescents (P < 0.0001). They were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine to boys and girls (P < 0.001). Variables independently associated with intention (P < 0.05) included: female gender of provider, knowledge about HPV, belief that organizations such as the AAFP would endorse vaccination, and fewer perceived barriers to vaccination. CONCLUSIONS: Female gender, knowledge about HPV, and attitudes about vaccination were independently associated with family physicians' intention to recommend HPV vaccines. Vaccination initiatives directed toward family physicians should focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination.     

Human papillomavirus infection: an old disease, a new vaccine

Human papillomavirus (HPV) infection is common and causes a wide spectrum of disease. With recent advances in the development of prophylactic HPV vaccines, it is likely that these will be licensed for use in the near future. This review focuses on the science behind HPV vaccines, published clinical trial results for both prophylactic and therapeutic HPV vaccines, important issues relevant to implementation and cost-effectiveness models of HPV vaccination programs. It may be that an HPV vaccine that protects against the complications of HPV infection such as cervical cancer will be one of the most significant public health initiatives of this decade.     

Prophylactic HPV Vaccines and Prevention of Cervical Intraepithelial Neoplasia

Cervical cancer kills women of all ages. The irrefutable link to oncogenic human papillomavirus (HPV), a sexually transmitted infection, forever changed society??s attitude toward cervical cancer. The advent of HPV vaccines has brought the link of sexual practices and personal behavior to the forefront. The vaccines were aggressively marketed to parents, young girls, public health officials, physicians, and all payor sources before the scientific data defining their actual benefit could be delineated. At this early time, the HPV vaccines prevent persistent type-specific HPV infections, some abnormal Pap tests, some colposcopies, and some excisional procedures in women who are HPV-DNA negative before vaccination. Health-modeling exercises have demonstrated that duration of vaccine efficacy is the most important parameter for any long-term cancer prevention benefit. Implementation efforts have demonstrated that a three-dose series is difficult to achieve and results in a high vaccine wastage rate.     

Assessment of knowledge about cervical cancer and its prevention among female students aged 17–26 years

Objective

To assess knowledge about cervical cancer and its primary and secondary prevention, and identify the sources of information about the disease among female high school and university students in Krakow, Poland.

Study design

This study was based on a questionnaire consisting of 64 questions, divided into six parts: personal data, general knowledge about cervical cancer, estimation of risk factors, knowledge about primary prevention, knowledge about secondary prevention, and information sources. Data were collected from students aged 17–26 years over a 3-month period in 2011 and 2012.

Results

Four hundred women living in Krakow or its vicinity were included in the study. Nearly all respondents (98.5%) had heard of cervical cancer, 89.4% were aware of the risk of death associated with cervical cancer, and 44.8% believed that the disease could affect them in the future. The interviewees considered genetics and family history to be the most important risk factors, followed by infection with human papillomavirus (HPV) and having multiple sex partners. Most (91.5%) respondents had not been vaccinated against HPV, 47.9% did not know where to go to get vaccinated, and 30.1% were unaware of vaccination as a prevention method. Most (91.5%) respondents were aware of cytological screening, and 86.5% thought that they should have it done in the future. Women who had not heard of cytological screening were more likely to be unaware of cervical cancer than women who had heard about cytological screening (odds ratio 0.24, 95% confidence interval 0.11–0.49, p = 0.0001). The Internet, television and newspapers were reported to be the main sources of information about the disease.

Conclusions

General awareness of cervical cancer among young women in Poland is insufficient. HPV infection is not considered to be the major aetiological factor. A relatively high percentage of women in this study had never heard of the HPV vaccine as a way of preventing cervical cancer. Knowledge about cytological screening, however, appears to be much better.     

Knowledge and attitudes about human papillomavirus, Pap smears, and cervical cancer among young women in Brazil: implications for health education and prevention

The objective of the study was to assess knowledge and attitudes about human papillomavirus (HPV), cervical cancer, and Papanicolaou (Pap) smears among young women. A questionnaire was administered to 204 women aged 16-23 years, attending a public clinic. Data were gathered on sociodemographic characteristics, knowledge, and attitudes related to HPV. Overall, 92% of women reported current/previous sexual activity, 42% perceived themselves at high risk of acquiring a sexually transmitted disease, 67% did not know that HPV can cause cervical cancer/warts, and only 10% acknowledged that HPV might lead to cervical cancer. In general, women had a poor knowledge on HPV diagnosis/treatment, condyloma signs, and Pap smear test. The main reasons for not having a Pap smear test done before were embarrassment (63%) and fear of pain (61%). Knowledge of HPV infection and cervical cancer was low in this urban young population. Our findings recommend for greater HPV education of the public and health care practitioners.     

Role of human papilloma virus testing in cervical cancer prevention

A clear causal relationship has been established between human papilloma virus (HPV) infection and the development of cervical cancer. Genital HPV infection is currently the most common sexually transmitted disease worldwide. The recent 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines have included HPV testing for management of women with cervical cytological abnormalities. Clinicians now face the challenge of deciding when to use HPV testing in follow-up of abnormal Pap tests. This article includes updates on HPV, cervical cancer screening, and HPV testing technology. Recommendations for integration of HPV testing into clinical practice are provided.     

Cervical cancer prevention: the impact of HPV vaccination

Cervical cancer remains a critical public health problem that is second only to breast cancer in overall disease burden for women throughout the world. In spite of the success of cervical cancer screening, Pap cytology screening is yet to be effectively implemented or has failed to reduce cervical cancer rates to an appreciable extent. Screening appears to benefit only a small fraction of women although a much larger percentage endures the inconvenience of the Pap test in order to avoid cervical cancer. The establishment of Human Papillomavirus (HPV) infection as the necessary cause of cervical precancers and cancers provides a tremendous opportunity for cervical cancer prevention through vaccination. HPV 16 and 18 which cause 70% of cervical cancers worldwide. Thus a prophylactic vaccine to prevent HPV related precancerous lesions and cancers would save lives, reduce the need for costly medical procedures and provide both women and communities throughout the world with substantial benefits. Based on the induction of neutralizing antibodies by non infectious Virus Like Particles (VLP) of L1 capside protein, prophylactic HPV vaccines have consistently induced high titter of neutralizing antibodies with minimal side effects and induce more than 90% protection from persistent HPV 16-18 infection and HPV 16 and 18 associated high-grade Cervical Intraepithelial Neoplasia (CIN) in proof of concept efficacy trials. HPV 16-18 vaccination will prevent HPV16-18 incident infection, and subsequently decrease in 90% the frequency of abnormal Pap attributable to these types and in about 50% overall abnormal Pap. HPV vaccination will reduce the number of women who require colposcopy, biopsy and cervical treatment for precancerous cervical lesions. The level of protection from death due to cervical cancer could exceed 95%. Three large phases prophylactic HPV VLP trials are now in progress and will form the basis for licensing of candidate vaccines in 2006. HPV vaccination targeting young female adolescents, aged 11 to 16 years, with a catch-up of those aged 17-25 years, would be a strategy to be addressed. Cervical cancer screening strategies, that will be cost-effective for the proper surveillance of women protected by HPV vaccination, are under analysis.     

The role of human papillomavirus vaccines in cervical neoplasia

Cervical cancer is the second most common cause of cancer-related death in women, in some developing countries accounting for the highest cancer mortality. The evidence for the association of high-risk human papillomavirus types with the aetiology of cervical neoplasia is firmly established, human papillomavirus being detected in virtually all cervical cancers. The risk of progression of precursor cervical intra-epithelial neoplasia lesions is associated with persistence of human papillomavirus infection. One strategy for the management of cervical neoplasia worldwide could be the development of prophylactic and/or therapeutic human papillomavirus vaccines. This chapter will discuss the natural history of human papillomavirus infection, viral immunity and the clinical course of resultant disease as the background to the effective design and use of human papillomavirus vaccines for protection or therapy. The progress of ongoing phase I and II clinical trials for several different vaccine preparations and the challenges for establishing their future use will be discussed.     

The role of human papillomavirus in risk management

In the UK, systematic cervical screening with high population coverage has been successful in reducing both the incidence and mortality from cervical cancer but further improvements are limited by the inherent performance of the Papanicalaou smear test. Early cross-sectional data on association between HPV infection and cervical intraepithelial neoplasia (CIN) has generated world-wide interest in HPV testing to enhance both the sensitivity and specificity of cervical screening. Whilst infection with HPV is recognised as the single most important factor in the development of cervical disease, for most women these infections are transient and of no clinical significance. Very few infections ultimately result in invasive cancer, which is associated with oncogenic subtypes and HPV DNA persistence. Data from large prospective longitudinal clinical studies on the efficiency and cost-effectiveness of HPV testing are just beginning to be reported and HPV testing cannot be recommended in routine clinical care as yet. However, the available evidence on the natural history of HPV infection and the development of CIN does highlight clinical situations in which HPV may have an important role in assessing risk. These are women with low-grade smear results, women on surveillance after the treatment of CIN and older women who could be exited early from the national screening programme. The key function may be to identify those women at such low risk that they no longer warrant intensive surveillance or indeed to continue screening.