High Human Papillomavirus Vaccination Coverage Research Articles

Impact of the human papillomavirus vaccine in low-resource settings

Impact of the human papillomavirus vaccine in low-resource settings

Estimating the effect of HIV on cervical cancer elimination in South Africa: Comparative modelling of the impact of vaccination and screening.

In 2020, the World Health Organization (WHO) launched its initiative to eliminate cervical cancer as a public health problem. To inform global efforts for countries with high HIV and cervical cancer burden, we assessed the impact of human papillomavirus (HPV) vaccination and cervical cancer screening and treatment in South Africa, on cervical cancer and the potential for achieving elimination before 2120, considering faster HPV disease progression and higher cervical cancer risk among women living with HIV(WLHIV) and HIV interventions. Three independent transmission-dynamic models simulating HIV and HPV infections and disease progression were used to predict the impact on cervical cancer incidence of three scenarios for all women: 1) girls' vaccination (9-14 years old), 2) girls' vaccination plus 1 lifetime cervical screen (at 35 years), and 3) girls' vaccination plus 2 lifetime cervical screens (at 35 and 45 years) and three enhanced scenarios for WLHIV: 4) vaccination of young WLHIV aged 15-24 years, 5) three-yearly cervical screening of WLHIV aged 15-49 years, or 6) both. Vaccination assumed 90% coverage and 100% lifetime protection with the nonavalent vaccine (against HPV-16/18/31/33/45/52/58). Cervical cancer screening assumed HPV testing with uptake increasing from 45% (2023), 70% (2030) to 90% (2045+). We also assumed that UNAIDS 90-90-90 HIV treatment and 70% male circumcision targets are reached by 2030. We examined three elimination thresholds: age-standardised cervical cancer incidence rates below 4 or 10 per 100,000 women-years, and >85% reduction in cervical cancer incidence rate. We conducted sensitivity analyses and presented the median age-standardised predictions of outcomes of the three models (minimum-maximum across models). Girls' vaccination could reduce age-standardised cervical cancer incidence from a median of 47.6 (40.9-79.2) in 2020 to 4.5 (3.2-6.3) per 100,000 women-years by 2120, averting on average ∼4% and ∼46% of age-standardised cumulative cervical cancer cases over 25 and 100 years, respectively, compared to the basecase. Adding 2 lifetime screens helped achieve elimination over the century among all women (2120 cervical cancer incidence: 3.6 (1.9-3.6) per 100,000 women-years), but not among WLHIV (10.8 (5.3-11.6)), and averted more cumulative cancer cases overall (∼45% over 25 years and ∼61% over 100 years compared to basecase) than girls' vaccination alone. Adding three-yearly cervical screening among WLHIV (to girls' vaccination and 2 lifetime cervical screens) further reduced age-standardised cervical cancer incidence to 3.3 (1.8-3.6) per 100,000 women-years overall and to 5.2 (3.9-8.5) among WLHIV by 2120 and averted on average 12-13% additional cumulative cancer cases among all women and 21-24% among WLHIV than girls' vaccination and 2 lifetime cervical screens over 25 years or longer. Long-term vaccine protection and using the nonavalent vaccine was required for elimination. High HPV vaccination coverage of girls and 2 lifetime cervical screens could eliminate cervical cancer among women overall in South Africa by the end of the century and substantially decrease cases among all women and WLHIV over the short and medium term. Cervical cancer elimination in WLHIV would likely require enhanced prevention strategies for WLHIV. Screening of WLHIV remains an important strategy to reduce incidence and alleviate disparities in cervical cancer burden between women with and without HIV, despite HIV interventions scale-up. World Health Organization. National Cancer Institute, National Institutes of Health. MRC Centre for Global Infectious Disease Analysis, UK Medical Research Council. National Institute of Child Health and Human Development research. Cancer Association of South Africa. Canadian Institutes of Health Research and the Fonds de recherche du Québec - Santé research.

If prophylactic HPV vaccination is considered in a woman with CIN2+, what is the value and should it be given before or after the surgical treatment?

Since the introduction of human papilloma virus (HPV) vaccination, the number of precancerous lesions has decreased in countries with a high HPV vaccination coverage. Currently women who present with a precancerous cervical lesions (CIN2 + ), are often not vaccinated or not vaccinated with the latest vaccine. Although resection of the precancerous lesion is the standard approach, the guidelines regarding vaccination are not clear. Vaccination will be valuable in reducing the risk of recurrence. Therefore, it is beneficial to understand the importance of vaccination or revaccination with the nonavalent vaccine in these cases. Furthermore, the timing of vaccination, either before or after surgery, should be determined. To answer these questions, twelve studies regarding vaccination and conization were reviewed. The inconsistency of study designs and inclusion criteria between the different studies introduced a considerable risk of bias. Nevertheless, the analysis showed that 43 women needed to be vaccinated and treated for CIN2 + lesions to prevent a recurrence. The ideal timing could not be established, but theoretically vaccination before the start of treatment was most logic. Although the data is not level 1 evidence, these recommendations should be used during counseling in the clinical setting until results of ongoing randomized controlled trials become available.

Increasing HPV Vaccination Uptake among Adolescents: A Systematic Review.

Human Papillomavirus (HPV) vaccination is a well-known fundamental strategy in the prevention of cervical cancer, as it is always caused by HPV infection. In fact, primary prevention of the infection corresponds to primary prevention of HPV-related cancers and other diseases. Since an effective prevention at the population level is the final goal, it is mandatory for healthcare systems to achieve a high HPV vaccination coverage among the adolescents to reduce the circulation of the virus and the burden of HPV-related diseases. This research identified, through a systematic literature review, 38 papers on strategies adopted to increase HPV vaccination coverage among adolescents. The evaluated strategies targeted adolescents/parents and/or healthcare providers and could be grouped in three main types: (1) reminder-based, (2) education, information, and communication activities, and (3) multicomponent strategies. Several types of strategy, such as those relied only on reminders and integrating different interventions, showed a positive impact on vaccination coverage. Nonetheless, the heterogeneity of the interventions suggests the importance to adapt such strategies to the specific national/local contexts to maximize vaccination coverage.

Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries

SummaryBackgroundThe WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination.MethodsThe WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions.FindingsGirls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4–19·8) to 2·1 (2·0–2·6) cases per 100 000 women-years over the next century (89·4% [86·2–90·1] reduction), and to avert 61·0 million (60·5–63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6–1·6) cases per 100 000 women-years (96·7% [91·3–96·7] reduction) and averted an extra 12·1 million (9·5–13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58–65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89–100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37–99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71–100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11–31 years. Long-term vaccine protection was required for elimination.InterpretationPredictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden.FundingWHO, UNDP, UN Population Fund, UNICEF–WHO–World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec–Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.

Temporal Trends in the Incidence of Anogenital Warts: Impact of Human Papillomavirus Vaccination.

Studies in countries with high human papillomavirus (HPV) vaccination coverage have demonstrated marked reductions in anogenital wart (AGW) incidence. Our goal was to assess the impact of HPV vaccination in a population with suboptimal coverage by comparing AGW incidence trends in the years before and after vaccine introduction. We conducted a retrospective analysis of AGW incidence trends using an ecologic study design among 11- through 39-year-olds enrolled at Kaiser Permanente Northwest. We defined incidence as the proportion of persons who had a new AGW diagnosis for each calendar year in the prevaccine periods (2000 through 2006 for female individuals, 2000 through 2010 for male individuals) and the postvaccine periods (2007 through 2016 for female individuals, 2011 through 2016 for male individuals). We also described cumulative HPV vaccination coverage. The average annual AGW incidence rates in the prevaccine periods were 27.8 per 10,000 in female individuals and 26.9 per 10,000 in male individuals. In the postvaccine periods, AGW incidence rates decreased by 31% (P < 0.001) in female individuals and 10% (P = 0.006) in male individuals; the largest reductions were observed in 15- to 19-year-old female individuals (67%, P < 0.001) and male individuals (45%, P < 0.001). Three dose HPV coverage rates were less than 50% in all age groups and both sexes. In a population of young adults with moderate HPV vaccination coverage, we observed declines in AGW incidence among both female and male year after the introduction of HPV vaccination. The largest incidence reductions were observed in 15- to 19-year-olds who were most likely to have been vaccinated.

Going beyond the individual: how state-level characteristics relate to HPV vaccine rates in the United States

BackgroundThe human papillomavirus (HPV) vaccine is an underutilized cancer control practice in the United States. Although individual contextual factors are known to impact HPV vaccine coverage rates, the impact of macro-level elements are still unclear. The aim of this analysis was to use HPV vaccination rates to explore the underuse of an evidence-based cancer control intervention and explore broader-level correlates influencing completion rates.MethodsA comprehensive database was developed using individual-level date from the National Immunization Survey (NIS)-Teen (2016) and state-level data collected from publically available sources to analyze HPV vaccine completion. Multi-level logistic models were fit to identify significant correlates. Level-1 (individual) and level-2 (state) correlates were fitted to a random intercept model. Deviance and AIC assessed model fit and sampling weights were applied.ResultsThe analysis included 20,495 adolescents from 50 U.S. states and the District of Columbia. Teen age, gender, race/ethnicity, and maternal education were significant individual predictors of HPV completion rates. Significant state-level predictors included sex education policy, religiosity, and HPV vaccine mandate. States with the lowest HPV coverage rates were found to be conservative and highly religious. Little variation in vaccine exemptions and enacted sex and abstinence education polices were observed between states with high and low HPV vaccine coverage suggesting various contextual and situational factors impact HPV vaccine completion rates.ConclusionsGiven that gender, religiosity, political ideology, and education policies are predictors of HPV vaccine completion, the interaction and underlying mechanism of these factors can be used to address the underutilization of the HPV vaccine.

High Human Papillomavirus Vaccination Coverage Is Achievable in Patients Vaccinated at the School-Based Health Center

High Human Papillomavirus Vaccination Coverage Is Achievable in Patients Vaccinated at the School-Based Health Center

Trends in the incidence of cervical cancer and severe precancerous lesions in Denmark, 1997-2012.

The incidence of cervical cancer, including squamous cell carcinoma (SCC), has been decreasing in several developed countries since the onset of organized screening programs; in some countries, however, the incidence of adenocarcinoma has increased among young women. We investigated the Danish incidence trends during 1997-2011 when cervical screening coverage was high. Incidences of cervical intraepithelial neoplasia grade 3 (CIN3) and adenocarcinoma in situ (AIS) were also assessed, with the latest part of the study period coinciding with introduction of free-of-charge human papillomavirus (HPV) vaccination. Using nationwide registries, we estimated age-specific and age-standardized incidence rates and estimated annual percentage change (EAPC). The incidence of SCC decreased significantly, especially in women aged ≥45years [EAPC: -3.1% (95% CI -4.3 to -2.5)], whereas the incidence of adenocarcinoma increased significantly, from 2.4 to 3.1/100,000 primarily due to increases in women aged ≤44years [EAPC: 4.3% (95% CI 1.8-6.7)]. The incidences of CIN3 and AIS increased significantly from 94.7 to 156.5/100,000 and 3.3 to 11.3/100,000, respectively, but, importantly, they decreased significantly during 2009-2012 in women aged ≤20years. The Danish screening program has successfully reduced the incidence of cervical cancer, especially of SCC in older women; however, the program has not significantly reduced the incidence in young women or the incidence of adenocarcinoma, which is increasing. Decreases in the incidences of CIN3 and AIS in age groups with high HPV vaccine coverage may herald a future decrease in cervical cancer incidence in young Danish women.

Incidence of cervical lesions in Danish women before and after implementation of a national HPV vaccination program.

Approximately 70% of cervical cancers and about 50% of high-grade cervical precursor lesions are caused by human papillomavirus (HPV) types 16 and 18. Denmark introduced the quadrivalent HPV vaccine into the vaccination program for 12-year-old girls in 2009 supplemented by a first catch-up program for 13-15-year-old girls in 2008, and a second program for women up to the age of 27 years in 2012; all with high vaccination coverage. The aim of this study was to evaluate the effectiveness of the vaccine by comparing the incidence trends of cervical lesions before and after its introduction. Incident cases of cervical lesions were identified from the nationwide Pathology Data Bank. Age-specific incidence rates were estimated for six age groups, and Poisson regression was used to calculate estimated annual percentage change (EAPC). The incidence of atypia or worse (atypia+) and cervical intraepithelial neoplasia grade 2 or worse (CIN2+) increased in all age groups in 2000-2010. After introduction of the quadrivalent HPV vaccine into the vaccination program, the incidence of atypia+ decreased significantly in women younger than 18 years (EAPC -33.4%; 95% CI -49.6; -12.0) and in 18-20-year-old women (EAPC -12.6%; 95% CI -19.3; -5.3). The incidence of CIN2+ also decreased significantly in 18-20-year-old women (EAPC -14.8%; 95% CI -21.6; -7.5) in 2010-2013, but no significant decrease was seen in older age groups. The incidence of cervical lesions decreased significantly in age groups with high HPV vaccine coverage, indicating an early effect of HPV vaccination.

Human Papillomavirus Types Distribution in Organised Cervical Cancer Screening in France

BackgroundKnowledge of prevalence rates and distribution of human papillomavirus (HPV) genotypes prior high HPV vaccine coverage is necessary to assess its expected impact on HPV ecology and on cervical lesions and cancers.MethodsResidual specimens of cervical cytology (N = 6,538) were obtained from 16 sites participating in organised cervical cancer screening pilot programs throughout France, anonymised and tested for HPV DNA using the PapilloCheck® genotyping test. Samples were stratified according to age of women and cytological grades.ResultsThe age-standardised prevalence rates of HPV 16 and/or 18 (with or without other high-risk types) was 47.2% (95% Confidence Interval, CI: 42.4–52.1) in high-grade squamous intraepithelial lesions (HSILs), 20.2% in low-grade SIL (95% CI: 16.7–23.7) and 3.9% (95% CI: 2.8–5.1) in normal cytology. Overall HR HPV were detected in 13.7% (95%I CI: 11.7–15.6) of normal cytology. In women below 30 years of age, 64% of HSILs were associated with HPV16 and/or 18. In our study population, HPV16 was the most commonly detected type in all cervical grades with prevalence rates ranking from 3.0% in normal cytology to 50.9% in HSILs. HPV16 was also detected in 54% (27/50) of invasive cervical cancers including 5 adenocarcinomas.ConclusionHPV16 was strongly associated with cervical precancer and cancer. The high prevalence rates of HPV16/18 infection among women below 30 years of age with HSILs suggests that the impact of vaccination would be primarily observed among young women.

Significant Decrease in the Incidence of Genital Warts in Young Danish Women After Implementation of a National Human Papillomavirus Vaccination Program

Approximately 90% of genital warts (GWs) are caused by human papillomavirus (HPV) types 6 and 11. Denmark has provided the quadrivalent HPV vaccine to all 12-year-old girls since 2009 and catch-up vaccination to girls up to 15 years since 2008, with up to 80% to 85% vaccine coverage. We determined the incidence of GWs in Denmark since 1996, focusing on the period after licensing of HPV vaccination (October 2006). From the Danish National Patient Register, we identified all hospitalizations and outpatient consultations for GWs between January 1995 and July 2011. Poisson regression was used to estimate average annual percentage changes. The overall incidence of GWs in women increased significantly until 2007, followed by an average yearly decline of 3.1% (95% confidence interval [CI], -5.5 to -0.7). In men, the incidence increased by 6.2% per year from 2004 (95% CI, 4.6-7.8). Stratifying on age, a significant decline was seen only for young women, particularly those aged 16 to 17 years, in whom GWs were virtually eliminated (average annual percentage change, -45.3%; 95% CI, -55.8 to -33.3). The incidences of genital Chlamydia, syphilis, and gonorrhea were stable or increased during the study period. The incidence of GWs decreased substantially among women with high HPV vaccine coverage, pointing to the effect of the national HPV vaccination program.

Acceptability and uptake of HPV vaccine in Argentina before its inclusion in the immunization program: A population-based survey

In Argentina, human papillomavirus (HPV) vaccination was approved in 2006, but not included in the National Immunization Program. In 2008 a mass media campaign was carried out by a cancer Non-Governmental Organization (NGO), but it was stopped due to criticisms about the publicity. In October 2011 the Ministry of Health (MoH) has introduced HPV vaccination in the National Immunization Program. In this context, to assure high HPV vaccine coverage, evidence is needed on factors both associated to vaccine acceptability and uptake. In 2009-2010 we carried out a population-based survey among a representative sample of 1200 women aged 18-49 years from the Metropolitan Area of Buenos Aires. The objective was twofold: first to analyze socio-demographic determinants of women's knowledge on HPV vaccine and secondly, determinants of actual HPV vaccine uptake and acceptability in Argentina after the above-mentioned vaccine advertising shown in mass media in the year 2008. We analyzed vaccine uptake/acceptability separately for women and for their daughters aged 9-15, and willingness to vaccinate one's daughter younger than 9 to receive future HPV vaccination. Results of the 1200 women interviewed, 438 women (36.5%) knew the HPV vaccine and 303 (25%) remembered the mass media advertisement about HPV vaccination. When asked whether she would get vaccinated after having seen/heard the advertisement, around 75% (n=226) of women answered surely/probably yes. No significant differences in socio-demographic characteristics were found among women who would or not get vaccinated. When surveyed, 6 women had been vaccinated. Main reasons for non-vaccination were: "Doctor did not mention/recommend it" (34.1%) and "Vaccine is too expensive" (15.7%). No woman had had their 9-15 year-old daughter vaccinated. Among women who only had at least one daughter under 9 (n=278), 74% answered that they would get their daughter vaccinated if they were pre-adolescents. The conclusion is that, in Argentina, the potential acceptability of the vaccine is high, given that there is acceptance among the professional community, physicians recommend it, and vaccine is affordable.

P2-111 Improving the health of Japanese women: acceptance of HPV vaccination in mothers of adolescent girls

IntroductionCervical Cancer (CC) caused by oncogenic Human Papillomavirus (HPV) is the most common cancer in young Japanese women. Vaccination against HPV offers a primary prevention strategy. This study investigates knowledge...

Strategies to vaccinate against cancer of the cervix: Feasibility of a school-based HPV vaccination program in Peru

Operational research using a mixed method, cross-sectional, case-study approach assessed the feasibility and health system impact of large-scale implementation of human papillomavirus (HPV) vaccination into routine vaccine delivery by the Ministry of Health in Peru. The strategy was school-based vaccination of fifth grade girls in 527 primary schools in Piura region. Our evaluation showed that school-based HPV vaccination is feasible without major changes in existing health systems. This was reflected in the opinions of health personnel, the lack of impact on other vaccine coverage, and the high HPV vaccine coverage documented in routine records and by an independent community-based survey.