Human papillomavirus vaccine uptake among 18‐ to 26‐year‐old women in the United States

BACKGROUND:

Human papillomavirus (HPV) vaccine uptake among young adult women has been reported to be very low. The authors conducted this study to provide an update on HPV vaccine uptake among 18‐ to 26‐year‐old women.

METHODS:

The authors used the National Health Interview Survey 2010 data to estimate HPV vaccine coverage and their correlates.

RESULTS:

Overall, 22.7% of women initiated (≥1 dose) and 12.7% completed the vaccine (≥3 doses). Thus, about 56% of women who initiated the vaccine completed it. Multivariate logistic regression analyses showed that younger age, unmarried status, Papanicolaou test, influenza vaccine, lifetime vaccines, and HPV vaccine awareness were positively associated with receiving ≥1 and ≥3 doses. In addition, uninsured women were less likely to receive ≥1 dose (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28‐0.84), and blacks (OR, 0.48; 95% CI, 0.23‐0.99) and women with a family income <100% of the federal poverty level (OR, 0.40; 95% CI, 0.21‐0.73) were less likely to receive ≥3 doses. Furthermore, based on vaccine initiators, blacks were less likely than whites to complete the vaccine (OR, 0.29; 95% CI, 0.16‐0.55). Two thirds of unvaccinated women were not interested in future vaccination. Among those who were interested, >76.4% preferred to receive it free or at a lower cost, whereas 20% would pay the full cost of the vaccine.

CONCLUSIONS:

One in 8 women completed the 3‐dose HPV vaccine. Educational and vaccine financing programs are needed to improve the uptake among low‐income minority women who are at increased risk for cervical cancer. Cancer 2013. © 2012 American Cancer Society.     

Human papillomavirus vaccine uptake among 9- to 17-year-old girls: National Health Interview Survey, 2008

BACKGROUND:

Since 2006, the human papillomavirus (HPV) vaccine has been routinely recommended for preadolescent and adolescent girls in the United States. Depending on uptake patterns, HPV vaccine could reduce existing disparities in cervical cancer.

METHODS:

HPV vaccination status and reasons for not vaccinating were assessed using data from the 2008 National Health Interview Survey. Households with a girl aged 9‐17 years were included (N = 2205). Sociodemographic factors and health behaviors associated with vaccine uptake were assessed using multivariate logistic regression.

RESULTS:

Overall, 2.8% of 9‐ to 10‐year‐olds, 14.7% of 11‐ to 12‐year‐olds, and 25.4% of 13‐ to 17‐year‐olds received at least 1 dose of HPV vaccine; 5.5% of 11‐ to 12‐year‐olds and 10.7% of 13‐ to 17‐year‐olds received all 3 doses. Factors associated with higher uptake in multivariate analysis included less than high school parental education, well‐child check and influenza shot in the past year, and parental familiarity with HPV vaccine. Parents' primary reasons for not vaccinating were beliefs that their daughters did not need vaccination, that their daughters were not sexually active, or had insufficient vaccine knowledge. More parents with private insurance (58.0%) than public (39.8%) or no insurance (39.5%) would pay $360‐$500 to vaccinate their daughters.

CONCLUSIONS:

Less than one quarter of girls aged 9‐17 years had initiated HPV vaccination by the end of 2008. Efforts to increase HPV uptake should focus on girls in the target age group, encourage providers to educate parents, and promote access to reduced‐cost vaccines. Cancer 2011;. © 2011 American Cancer Society.     

Prior human papillomavirus‐16/18 AS04‐adjuvanted vaccination prevents recurrent high grade cervical intraepithelial neoplasia after definitive surgical therapy: Post‐hoc analysis from a randomized controlled trial

We evaluated the efficacy of the human papillomavirus (HPV)?16/18 AS04‐adjuvanted vaccine in preventing HPV‐related disease after surgery for cervical lesions in a post‐hoc analysis of the PApilloma TRIal against Cancer In young Adults (PATRICIA; NCT00122681). Healthy women aged 15–25 years were randomized (1:1) to receive vaccine or control at months 0, 1 and 6 and followed for 4 years. Women were enrolled regardless of their baseline HPV DNA status, HPV‐16/18 serostatus, or cytology, but excluded if they had previous or planned colposcopy. The primary and secondary endpoints of PATRICIA have been reported previously; the present post‐hoc analysis evaluated efficacy in a subset of women who underwent an excisional procedure for cervical lesions after vaccination. The main outcome was the incidence of subsequent HPV‐related cervical intraepithelial neoplasia grade 2 or greater (CIN2+) 60 days or more post‐surgery. Other outcomes included the incidence of HPV‐related CIN1+, and vulvar or vaginal intraepithelial neoplasia (VIN/VaIN) 60 days or more post‐surgery. Of the total vaccinated cohort of 18,644 women (vaccine = 9,319; control = 9,325), 454 (vaccine = 190, control = 264) underwent an excisional procedure during the trial. Efficacy 60 days or more post‐surgery for a first lesion, irrespective of HPV DNA results, was 88.2% (95% CI: 14.8, 99.7) against CIN2+ and 42.6% (?21.1, 74.1) against CIN1+. No VIN was reported and one woman in each group had VaIN2+ 60 days or more post‐surgery. Women who undergo surgical therapy for cervical lesions after vaccination with the HPV‐16/18 vaccine may continue to benefit from vaccination, with a reduced risk of developing subsequent CIN2+.     

Use of human papillomavirus vaccines among young adult women in the United States: an analysis of the 2008 National Health Interview Survey

BACKGROUND:

The Centers for Disease Control and Prevention recommends catch‐up administration of human papillomavirus (HPV) vaccines to girls and women ages 13 to 26 who have not been vaccinated previously. In response to debate regarding catch‐up vaccination of young adult women, this study examined whether 18‐ to 26‐year‐old women most likely to benefit from catch‐up vaccination were aware of the HPV vaccine, and initiated the vaccine series by the end of 2008.

METHODS:

We used data from the 2008 National Health Interview Survey to assess HPV vaccine awareness and use, and reasons for not vaccinating, among women aged 18‐26 years (n = 1583). Sociodemographic, health care access, and health history factors associated with vaccine initiation were assessed using multivariate logistic regression.

RESULTS:

Overall, 11.7% of women aged 18‐26 years reported receiving at least 1 dose of the HPV vaccine by the end of 2008. In multivariate analyses, younger age, history of previous HPV infection, unmarried status, health insurance, flu shot in the past year, and receipt of 1 or more recommended lifetime vaccines were significantly associated with HPV vaccine initiation. Two‐fifths (39.6%) of unvaccinated women were interested in receiving the HPV vaccine (n = 1327). Primary reasons for lack of interest in the vaccine were belief that it was not needed, not knowing enough about it, concerns about safety, and not being sexually active.

CONCLUSION:

HPV vaccine coverage among young adult women was low, and lower among the uninsured than the insured. Public financing and care provision programs have the potential to expand vaccine coverage among uninsured women, who are at increased risk of cervical cancer. Cancer 2011;. © 2011 American Cancer Society.     

Cervical Cancer‐Related Knowledge,Attitudes, and Practices of Health Professionals Working in Brazil's Network of Primary Care Units

Introduction.

Brazil’s national strategy for cervical cancer screening includes using the Papanicolaou (Pap) test every 3 years among women aged 25–64 years. Comprehensive primary care services are provided through a network of primary health units, but little is known about cervical cancer-related knowledge, attitudes, and practices among health professionals and coordinators working in these facilities.

Methods.

In 2011, we conducted a cross-sectional nationally representative phone survey of 1,600 primary health care units to interview one unit coordinator and one health care professional per unit (either nurse, physician, or community health worker). Responses were obtained from 1,251 coordinators, 182 physicians, 347 nurses, and 273 community health workers. Questionnaires were administered to assess health units’ characteristics and capacity for cervical cancer-related services as well as health professionals’ perceived effectiveness of the Pap test, preparedness to talk to women about cervical cancer, adherence with screening guidelines, and willingness to recommend human papillomavirus (HPV) vaccination to females.

Results.

Most units conducted screening (91.9%), used home visits to conduct recruitment and outreach (83.4%), and provided follow-up to women who did not return to discuss Pap test results (88.1%). Approximately 93% of health professionals stated that Pap testing was effective in decreasing death rates from cervical cancer and 65% stated that national guidelines for cervical cancer screening are very influential; 93% of nurses and physicians reported screening women annually and 75% reported beginning to screen women younger than 25 years old. Regarding HPV vaccination, almost 90% of nurses and physicians would recommend the HPV vaccine to their females patients if it were available. A larger proportion of physicians and nurses recommended the HPV vaccine to older girls (13–18 years) and women (19–26 years and even older than 26 years) than to younger girls (12 years or younger).

Conclusion.

Although Brazil’s network of primary care units has significantly increased access to cervical cancer screening, effective strategies are needed to ensure that women get screened at the appropriate ages and intervals. Additionally, this study’s baseline data on HPV vaccination may be useful as Brazil embarks on a national HPV vaccination program in 2014.     

Potential lives saved in 73 countries by adopting multi‐cohort vaccination of 9–14‐year‐old girls against human papillomavirus

Up to 2016, low‐ and middle‐income countries mostly introduced routine human papillomavirus (HPV) vaccination for just a single age‐cohort of girls each year. However, high‐income countries have reported large reductions in HPV prevalence following “catch‐up” vaccination of multiple age‐cohorts in the year of HPV vaccine introduction. We used the mathematical model PRIME to project the incremental impact of vaccinating 10‐ to 14‐year‐old girls compared to routine HPV vaccination only in the same year that routine vaccination is expected to be introduced for 9‐year‐old girls across 73 low‐ and lower‐middle‐income countries. Adding multiple age‐cohort vaccination could increase the number of cervical cancer deaths averted by vaccine introductions in 2015–2030 by 30–40% or an additional 1.23–1.79 million over the lifetime of the vaccinated cohorts. The number of girls needed to vaccinate to prevent one death is 101 in the most pessimistic scenario, which is only slightly greater than that for routine vaccination of 9‐year‐old girls (87). These results hold even when assuming that girls who have sexually debuted do not benefit from vaccination. Results suggest that multiple age‐cohort vaccination of 9‐ to 14‐year‐old girls could accelerate HPV vaccine impact and be cost‐effective.     

Human papillomavirus vaccination of the daughters of obstetricians and gynecologists in Japan

Background

Most adolescents in Japan have recently been refraining from receiving the human papillomavirus (HPV) vaccine, following media reports of adverse medical events surrounding the vaccination and suspension of the Japanese governmental recommendation. We have previously reported that HPV vaccination of young girls is heavily influenced by guidance from their physicians concerning the vaccine and by the knowledge and attitude of the girls’ mothers towards cervical cancer. However, it has been unclear as to how the obstetricians and gynecologists were themselves affected by the negative media reports.

Methods

A questionnaire, including questions about their working status, attitudes toward HPV vaccination and about cervical cancer, and the HPV vaccination status of their daughters, was posted to obstetricians and gynecologists.

Results

None of the daughters of the responding obstetrician and gynecologists received the HPV vaccination after the announced suspension of the governmental recommendation for the vaccine. The number who received the HPV vaccine in the 6th to 9th grade in 2014 was significantly lower than those in 2012 (p = 0.012). However, 64.7 % of the responders whose daughters were eligible and in the 6th to 12th grade still intended to vaccinate their daughters in the future. Of the responders, 65 % also intended to recommend vaccination to their teenage patients.

Conclusions

Our study revealed that obstetricians and gynecologists, like the general population, were negatively influenced by media reports of the adverse effect of the HPV vaccine and the suspension of the governmental recommendation. However, their intention to vaccinate their daughters was much higher than that of the general population. Restart of the governmental recommendation for HPV vaccines and better education about the HPV vaccine, including its adverse effects, and about cervical cancer and cervical cancer screening, are strongly recommended, for both the general public and for doctors, for improved prevention of cervical cancer.

     

Evaluation of quantity and staining pattern of human papillomavirus (HPV)‐infected epithelial cells in thin‐layer cervical specimens using optimized HPV‐CARD assay

BACKGROUND.

Testing for human papillomavirus (HPV) is used in the triage of women with a cervical cytology of atypical squamous cells of undetermined significance (ASCUS). A fluorescent in situ hybridization assay was developed for the detection of HPV using the catalyzed receptor deposition technique (HPV‐CARD). In this study, the utility of this assay was tested for the detection of HPV in liquid‐based cervical cytology specimens.

METHODS.

A total of 195 liquid‐based cytology specimens were analyzed using the HPV‐CARD assay. The results from the assay were compared with HPV polymerase chain reaction (PCR) and typing results. The number of HPV‐infected cells and the staining pattern was correlated with the cytology classification.

RESULTS.

A 91% concordance between HPV‐CARD and PCR was observed for the detection of high‐risk HPV viruses. A 78% concordance was observed for specimens that were negative for HPV. In ASCUS, low‐grade squamous intraepithelial lesion (LSIL), and high‐grade squamous intraepithelial lesion (HSIL) categories, the average number of HPV‐positive cells per slide was 19 cells, 127 cells, and 450 cells, respectively. The number of cells with a punctate staining, suggestive of HPV integration, was 21% in ASCUS, 34% in LSIL, and 46% in HSIL specimens.

CONCLUSIONS.

The results of the current study indicate positive correlations between the severity of the disease and the increased overall quantity of HPV‐positive epithelial cells in cervical cytology specimens and accumulation of cells with punctate staining suggestive of integrated HPV. In summary, the developed HPV‐CARD assay was found to provide novel information regarding the proportion and staining pattern of HPV‐infected epithelial cells in different cytologic categories of cervical specimens. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

Quadrivalent HPV vaccine effectiveness against high‐grade cervical lesions by age at vaccination: A population‐based study

Human papillomavirus (HPV) types 16/18, included in HPV vaccines, contribute to the majority of cervical cancer, and a substantial proportion of cervical intraepithelial neoplasia (CIN) grades 2/3 or worse (CIN2+/CIN3+) including adenocarcinoma in situ or worse. The aim of this study was to quantify the effect of quadrivalent HPV (qHPV) vaccination on incidence of CIN2+ and CIN3+. A nationwide cohort of girls and young women resident in Sweden 2006–2013 and aged 13–29 (n = 1,333,691) was followed for vaccination and histologically confirmed high‐grade cervical lesions. Data were collected using the Swedish nationwide healthcare registers. Poisson regression was used to calculate incidence rate ratios (IRRs) and vaccine effectiveness [(1‐IRR)x100%] comparing fully vaccinated with unvaccinated individuals. IRRs were adjusted for attained age and parental education, and stratified on vaccination initiation age. Effectiveness against CIN2+ was 75% (IRR = 0.25, 95%CI = 0.18–0.35) for those initiating vaccination before age 17, and 46% (IRR = 0.54, 95%CI = 0.46–0.64) and 22% (IRR = 0.78, 95%CI = 0.65–0.93) for those initiating vaccination at ages 17–19, and at ages 20–29, respectively. Vaccine effectiveness against CIN3+ was similar to vaccine effectiveness against CIN2+. Results were robust for both women participating to the organized screening program and for women at prescreening ages. We show high effectiveness of qHPV vaccination on CIN2+ and CIN3+ lesions, with greater effectiveness observed in girls younger at vaccination initiation. Continued monitoring of impact of HPV vaccination in the population is needed in order to evaluate both long‐term vaccine effectiveness and to evaluate whether the vaccination program achieves anticipated effects in prevention of invasive cervical cancer.     

Attitudes to HPV vaccination among parents of children aged 12‐15 years—A population‐based survey in Sweden

In this population‐based survey undertaken in Sweden in 2007, we investigated correlates of attitudes to human papillomavirus (HPV) vaccination among parents of children aged 12–15 years. We invited 16,000 parents of girls and 4,000 parents of boys, randomly selected from the Swedish population. Response rates were 70 and 69%, respectively. Multinomial logistic regression models were applied to investigate correlates of acceptability to HPV vaccination. Among studied parents, 76% were willing to vaccinate their child if the vaccine is for free and 63% were willing to vaccinate even if the vaccine comes with a cost. Having heard of HPV was associated with both willingness to vaccinate if the vaccine is free (odds ratio [OR]: 1.42; 95% confidence interval [CI]: 1.21–1.66) and willingness to vaccinate even if the vaccine is not free (OR: 1.96; 95% CI: 1.75–2.20) compared with those who never heard of HPV. Beliefs about vaccine safety and efficacy were also strong correlates of willingness to vaccinate. Parents born outside Europe and those with higher education were less willing to vaccinate if the vaccine is not free. In conclusion, the willingness to vaccinate was reasonably high and cost did not appear to be a major barrier. Information about vaccine safety and efficacy is important and parents need information about HPV and the HPV vaccine.     

Human Papilloma Virus Vaccination in Nepal: An InitialExperience

Cervical cancer is the commonest cancer among women in Nepal. Human papilloma virus (HPV) infection,a recognized cause of cervical cancer, is very common in sexually active women and HPV vaccination has beenrecommended as a prophylactic therapy. If HPV infection is prevented by the HPV vaccination to the adolescentgirls, cervical cancer is also prevented. We received 3,300 vials of quadrivalent human papilloma virus (types 6,11, 16, 18) recombinant vaccine (Gardasil; Merk & Co.) as a gift from the Australian Cervical Cancer Foundation(ACCF) which has a mission to provide life-saving HPV cervical cancer vaccines for women in developingcountries, who cannot otherwise afford vaccination. HPV vaccine was offered to 1,096 of 10 to 26 year aged girlsattending 17 secondary schools. In total, 1,091 (99.5%) received the second dose and 1,089 (99.3%) received thethird dose of the vaccine. The remaining 5 girls at second dose and 2 girls at third dose remained unvaccinated.No serious vaccine related adverse events were reported except mild pain at the injection site in 7.8% of thevaccine recipients. High cost and low public awareness are the key barriers for successful implementation ofthe vaccination program in resource limited developing countries. In conclusion, HPV vaccine is safe with highacceptability in Nepalese school girls. However a large population study for longer follow up is warranted tovalidate the findings of this vaccination program.     

A survey of adolescent experiences of human papillomavirus vaccination in the Manchester study

Background:

There is little information on girls'' experiences of human papillomavirus (HPV) vaccination in the prevention of cervical cancer. We investigated the views of adolescent girls who had been offered the vaccine as part of a feasibility study conducted in Manchester.

Methods:

All 12 to 13-year-old girls in two primary care trusts were offered three doses of Cervarix (manufactured by GlaxoSmithKline). A letter was sent to 1084 parents who had consented to research follow-up. It requested parents to pass a questionnaire regarding HPV vaccination to their daughters to complete and post back in a prepaid envelope.

Results:

A total of 553 girls completed the questionnaire. Altogether, 77% (422) had shared with their parents in the vaccine decision. In all, 42% (n=13) of girls, whose parents refused vaccination, stated that they wanted the vaccine, whereas 10% (50) of those who were vaccinated did not want the vaccine. Although 54% (277) said the vaccine was very important to them, 39% (153) of vaccinated girls thought they might not recommend it to others. The vaccine was perceived to be painful and there were exaggerated rumours of serious adverse events and needle scares. A total of 79% (420) of girls agreed with a statement that vaccination reminded them of the risks of sexual contact, but 14% (73) agreed they might take more sexual risks because they had been vaccinated.

Conclusion:

Girls of this age form their own views on HPV vaccination but parental support for vaccination remains important, especially for completing the three doses. By discussing the vaccine, parents can encourage their daughters to determine the importance and implications of HPV vaccination.     

Reduction in HPV16/18 prevalence among young women with high‐grade cervical lesions following the Japanese HPV vaccination program

The Japanese government began a human papillomavirus (HPV) vaccination program for girls aged 12‐16 years in 2010 but withdrew its recommendation in 2013 because of potential adverse effects, leading to drastically reduced vaccination uptake. To evaluate population‐level effects of HPV vaccination, women younger than 40 years of age newly diagnosed with cervical intraepithelial neoplasia grade 1‐3 (CIN1‐3), adenocarcinoma in situ (AIS), or invasive cervical cancer (ICC) have been registered at 21 participating institutes each year since 2012. A total of 7709 women were registered during 2012‐2017, of which 5045 were HPV genotyped. Declining trends in prevalence of vaccine types HPV16 and HPV18 during a 6‐year period were observed in CIN1 (50.0% to 0.0%, P_trend < .0001) and CIN2‐3/AIS (83.3% to 45.0%, P_trend = .07) only among women younger than 25 years of age. Overall, HPV vaccination reduced the proportion of HPV16/18‐attributable CIN2‐3/AIS from 47.7% to 33.0% (P = .003): from 43.5% to 12.5% as routine vaccination (P = .08) and from 47.8% to 36.7% as catch‐up vaccination (P = .04). The HPV16/18 prevalence in CIN2‐3/AIS cases was significantly reduced among female individuals who received their first vaccination at age 20 years or younger (P = .02). We could not evaluate vaccination effects on ICC owing to low incidence of ICC among women aged less than 25 years. We found HPV vaccination to be effective in protecting against HPV16/18‐positive CIN/AIS in Japan; however, our data did not support catch‐up vaccination for women older than 20 years. Older adolescents who skipped routine vaccination due to the government’s suspension of its vaccine recommendation could benefit from receiving catch‐up vaccination before age 20 years.     

p16INK4a is superior to high‐risk human papillomavirus testing in cervical cytology for the prediction of underlying high‐grade dysplasia

BACKGROUND

The primary goal of this study was to compare the clinical performance of an optimized and rigorously controlled immunocytochemical (ICC) assay for p16^INK4a to high‐risk (HR) human papillomavirus (HPV) detection by polymerase chain reaction (PCR) as diagnostic adjuncts for cytology specimens from colposcopy patients.

METHODS:

The study included 403 cervical cytology specimens collected within 3 months of colposcopy. The colposcopic impression and cervical biopsy diagnosis served as the standards for correlation with cytological, p16^INK4a, and HPV data. p16^INK4a was evaluated using an immunoperoxidase‐based assay that was linear over 4 logs for the detection of HeLa‐spiked positive control cytology specimens, using a threshold for positive test results that was based on receiver operating characteristic curve analysis. HR‐HPV was detected by multiplex PCR using genotype‐specific primers.

RESULTS:

In all combined diagnostic categories (negative for intraepithelial lesion and malignancy, atypical glandular cells, atypical squamous cells of undetermined significance, atypical squamous cells cannot exclude high‐grade squamous intraepithelial lesion, low‐grade squamous intraepithelial lesion, and high‐grade squamous intraepithelial lesion), the p16^INK4a ICC and HR‐HPV assays, respectively, had sensitivity of 81.7% and 83.3% (P = .81) and specificity of 78.1% and 50.9% (P < .001) for the detection of underlying ≥grade 2 cervical intraepithelial neoplasia (CIN) lesions on biopsy. Furthermore, the positive predictive value of p16^INK4a ICC was greater than that of HR‐HPV for patients with biopsies ≥CIN‐2 (41.2% and 24.2%, respectively, P = .001).

CONCLUSIONS:

This p16^INK4a immunocytochemical assay has superior specificity but similar sensitivity to HR‐HPV testing to predict underlying high‐grade dysplastic lesions in patients who are referred for colposcopy. The determination of the overall performance characteristics of p16^INK4a immunocytochemistry, as an independent test or in combination with HPV testing in low‐risk screening populations, however, will require subsequent large‐scale prospective clinical trials. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Image‐guided ThinPrep Papanicolaou tests and cotesting with high‐risk human papillomavirus in women aged 30 years and older in a low‐risk private practice population

BACKGROUND:

Screening for cervical cancer precursors has evolved considerably with the introduction of new technologies to improve the early detection of disease. The objective of this study was to analyze the accuracy and effectiveness of combined screening with cytology and high‐risk human papillomavirus (HR‐HPV) testing in a low‐risk population of women aged ≥30 years.

METHODS:

Consecutive unselected samples from a group of 1871 women aged ≥30 years were screened with image‐guided ThinPrep tests and HR‐HPV tests during a 6‐month period. Histologic follow‐up was reviewed among women with positive HR‐HPV tests.

RESULTS:

A total of 85 (4.5%) women had positive HR‐HPV tests. In 48 HR‐HPV–positive women with follow‐up biopsies, 41 (85%) were found to have histologic abnormalities. Thirty‐three (1.9%) women with cytologically normal Papanicolaou (Pap) tests harbored HR‐HPV, and a cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 1 (16%) of 6 women with histologic follow‐up. Conversely, 2 (28%) of 7 women with high‐grade intraepithelial lesion on cytology tested negative for HR‐HPV during the same period. A case of serous carcinoma with atypical glandular cells on cytology was also negative for HR‐HPV, as expected.

CONCLUSIONS:

In this low‐risk population of women aged ≥30 years, histology‐confirmed CIN2+ lesions were identified in women with negative cytology and positive HR‐HPV tests, as well as in those with positive cytology and negative HR‐HPV tests. Because both cytology and HPV testing alone missed significant lesions, cotesting with Pap and HR‐HPV in women aged ≥30 years appears to be a reasonable option in a low‐risk population. (Cancer Cytopathol) 2009. © 2009 American Cancer Society.     

The Cost-Effectiveness of a Quadrivalent Human Papillomavirus Vaccine in Taiwan

Background: A quadrivalent human papillomavirus (HPV 6/11/16/18) vaccine has recently received regulatoryapproval in Taiwan for the prevention of cervical carcinoma, high-grade cervical dysplasia (cervical intraepithelialneoplasia 2/3 [CIN 2/3]), low-grade cervical dysplasia (CIN 1), high-grade vulvar and vaginal dysplasia, andexternal genital warts. Objective: To examine the potential long-term epidemiologic and economic consequencesof a quadrivalent HPV (6/11/16/18) vaccination program in Taiwan. Methods: A transmission dynamic modelwas used to estimate the long-term epidemiologic and economic consequences of quadrivalent HPV vaccination.Two vaccination strategies were evaluated in conjunction with current cervical cancer screening: 1) vaccinationof 12-year-old girls and 2) vaccination of 12-year-old girls with a temporary 5-year catch-up vaccination offemales aged 12–24 years (catch-up). Results: From an epidemiologic perspective, both vaccination strategiesreduce the overall incidence of HPV 16/18–related cervical cancer relative to no vaccination by 91% duringyear 100 following vaccine introduction. Likewise, both vaccination strategies reduce the incidence of CIN 2/3,CIN 1, and genital warts by ~90%, 86%, and 94%, respectively, at this time point. However, the catch-upprogram consistently achieves greater benefit earlier than the 12-year-old program. The catch-up strategy isboth more effective and efficient than the strategy that vaccinates 12-year-old girls only, with an incrementalcost-effectiveness ratio of New Taiwan dollars (NT$) 410,477 per quality-adjusted life-year gained. Conclusions:The results from this model suggest that in Taiwan, prophylactic HPV 6/11/16/18 vaccination of females can 1)substantially reduce genital warts, CIN, and cervical cancer, 2) improve quality of life and survival, and 3) becost-effective when implemented as a vaccination strategy that includes a temporary catch-up program.     

Vietnamese Health Care Providers’ Preferences Regarding Recommendation of HPV Vaccines

Physician recommendation is an important predictor of HPV vaccine acceptance; however, physicianwillingness and preferences regarding HPV vaccination may be influenced by factors including patient age, vaccinetype, and cost. A cross-sectional survey was administered to a convenience sample of health care providers in DaNang, Vietnam, to evaluate awareness, perceptions about HPV and HPV vaccines, and willingness to vaccinate afemale patient. Willingness to vaccinate was evaluated using a full-factorial presentation of scenarios featuringthe following factors: vaccine cost (free vs 1,000,000 VND), patient age (12, 16, or 22 years), and HPV vaccinetype (bivalent vs quadrivalent). Responses from 244 providers were analyzed; providers had a mean age of 34± 11.9 years; a majority were female, married, and had children of their own. Thirty-six percent specialized inobstetrics/gynecology and 24% were providers in family medicine. Of the three factors considered in conjointanalysis, vaccine cost was the most important factor in willingness to vaccinate, followed by patient age, andvaccine type. The most favorable scenario for vaccinating a female patient was when the vaccine was free, thepatient was 22 years of age, and the HPV4 vaccine was described. In multivariable analysis, older age, beinga physician, being married, and having children were all associated with increased willingness to recommendHPV vaccination (p<0.05). Provider willingness is an important aspect of successful HPV vaccination programs;identifying preferences and biases in recommendation patterns will highlight potential areas for education andintervention.     

Benefits of catch‐up in vaccination against human papillomavirus in medium‐ and low‐income countries

Human papillomavirus (HPV) vaccination of a birth cohort of girls in the 9–13 age range is recommended as a priority, but decreases in HPV vaccine cost may make catch‐up of a few additional cohorts more attractive not only in high‐income countries. We assessed the reduction in HPV16 and 18 infections that could be achieved in a medium‐ (Poland) and a low‐income (Guinea) country by adding one‐time catch‐up of 12‐ to 19‐year‐old girls to the vaccination of 11‐year‐old girls. According to our ad hoc adapted dynamic model of HPV infection transmission, the addition of catch‐up was estimated to bring forward the 50% reduction of HPV16/18 prevalence due to vaccination in women ≤35 by as much as 5 years. Catch‐up of 12‐ to 15‐year olds reduced the cumulative probability of HPV16/18 infections by age 35 in the relevant cohorts by about 30% in both countries. Catch‐up of 16‐ to 19‐year‐old girls added little. Regardless of the chosen catch‐up strategy, 16 to 20% of HPV16/18 prevention from vaccination was attributable to herd immunity. Assuming a sufficiently low vaccine cost, the addition of a catch‐up round is, therefore, worth considering in medium/low‐income countries to extend vaccine benefits to less young adolescent girls whose future access to cervical screening is uncertain.     

Evaluation of HPV type‐replacement in unvaccinated and vaccinated adolescent females—Post‐hoc analysis of a community‐randomized clinical trial (II)

Efficacy of human papillomavirus (HPV) vaccines promises to control HPV infections. However, HPV vaccination programs may lay bare an ecological niche for non‐vaccine HPV types. We evaluated type‐replacement by HPV type and vaccination strategy in a community‐randomized trial executed in HPV vaccination naïve population. Thirty‐three communities were randomized to gender‐neutral vaccination with AS04‐adjuvanted HPV16/18 vaccine (Arm A), HPV vaccination of girls and hepatitis B‐virus (HBV) vaccination of boys (Arm B) and gender‐neutral HBV vaccination (Arm C). Resident 1992‐95 born boys (40,852) and girls (39,420) were invited. 11,662 boys and 20,513 girls were vaccinated with 20–30% and 45–48% coverage, respectively. HPV typing of 11,396 cervicovaginal samples was performed by high throughput PCR. Prevalence ratios (PR) between arms and ranked order of HPV types and odds ratio (OR) for having multiple HPV types in HPV16 or 18/45 positive individuals were calculated. The ranked order of HPV types did not significantly differ between arms or birth cohorts. For the non‐HPV vaccinated 1992–1993 birth cohorts increased PR, between the gender‐neutral intervention versus control arms for HPV39 (PR_A 1.84, 95% CI 1.12–3.02) and HPV51 (PR_A 1.56, 95% CI 1.11–2.19) were observed. In the gender‐neutral arm, increased clustering between HPV39 and the vaccine‐covered HPV types 16 or 18/45 (OR_A16 = 5.1, OR_A18/45 = 11.4) was observed in the non‐HPV vaccinated 1994–1995 birth cohorts. Comparable clustering was seen between HPV51 and HPV16 or HPV18/45 (OR_B16 = 4.7, OR_B18/45 = 4.3), in the girls‐only arm. In conclusion, definitively consistent postvaccination patterns of HPV type‐replacement were not observed. Future occurrence of HPV39 and HPV51 warrant investigation.