1. Martha A. Wojtowycz, PhD March 22, 2019
Journal Club Notes
Martha A. Wojtowycz, PhD
March 22, 2019

2. Learning Objectives
Describe the incidence of HPV-associated cancers by sex, cancer type, and race/ethnicity
Identify the most common HPV types attributable to the various HPV-associated cancers
Discuss HVP immunization coverage rates by sex, socioeconomic status and geographic location
Identify factors associated with HPV intent to vaccinate and with vaccination rates
Explain a nested case-control study design and when you would use it
Discuss the proportions of vulvar and vaginal lesions attributable to HPV that are not covered by the current 9vHPV vaccine

3. Number of New HPV-associated Cancers, 2010-2014
Source: CDC, 2018.

4. Incidence Rate of HPV-associated Cancers, by Sex and Race/Ethnic Groups (age-adjusted rate per 100,000)
Source: CDC, 2018.

5. Source: CDC, 2018.

6. HPV Vaccine
Currently in the United States only 9vHPV is available for both females and males
Protects against HPV types 6/11/16/18/31/33/45/52/58 which account for about 80% of HPV-associated cancers
Previously used 4vHPV for both females and males which protected against 6/11 which account for over 90% of genital warts and 16/18 which account for the majority of cancers
Previously also used 2vHPV on females to protect against 16/18
New dosing recommendations:
2 doses if start series prior to age 15; second dose 6-12 months after the first
Need three doses if immunocompromised or second dose received at less than 5 months after first dose
3 doses if start series between ages 15-26; with dosing at 0, 1-2 months, and 6 months

7. Estimated Vaccination Coverage Among Adolescents Aged 13-17 years, United States 2017
HPV Vaccine ≥ 1 Dose
HPV Vaccine – Up to Date
All adolescents
65.5%
48.6%
Female adolescents
68.6%
53.1%
Below poverty
73.3%
53.7%
At or above poverty
62.8%
46.7%
Rural
59.3%
42.4%
Urban
70.1%
52.4%
New York City
61.0%
Rest of NY State
48.8%
Source: Morbidity and Mortality Weekly Report, 67 (33), August 24, 2018.

9. Factors Associated with HPV Vaccination
Predictors of parental intent to vaccinate
Mother’s education – strongest predictor with lower education associated with higher intent
Race/ethnicity – strong predictor with Hispanic associated with higher intent
Predictors of actual receipt of vaccine
Provider recommendation – strongest predictor of higher receipt
Stronger association for males than for females

10. Garland SM et al., “Human Papillomavirus Genotypes From Vaginal and Vulvar Intraepithelial Neoplasia in Females Years of Age”, Obstetrics and Gynecology, vol. 132, no. 1, August 2018.

11. Nested Case Control Study Design
Nested case control studies are set within formed cohort studies and are typically conducted when you want to do testing on samples (e.g., specimens, blood, etc.) that were collected on the whole cohort but were not analyzed
Cases: The study subjects with the disease
Those who developed cervical or anogenital lesions during the four-year follow-up period
Controls: A sample of the study subjects without the disease
Those who did not develop cervical or anogenital lesions during the four-year follow-up period
5 controls per case randomly selected from group who did not develop lesions

13. Nested Case Control Study Design
Why use this study design?
Significant time savings – do not have to start a new study
Reduced efforts in data collection and analysis
Reduced in costs – do not have to study the entire cohort; some tests are very expensive
Statistical results minimally affected
Preserve some specimens, blood, etc. for future analyses

14. % that tested (+) for one or more of the 14 HPV types
These 5 HPV types are not covered by the 9vHPV vaccine. What proportion of lesions are attributable to these types?

15. Previous studies have found over 90% of vaginal lesions due to HPV
% not covered by 9vHPV

16. Is it time for 14vHPV?