Prevalence of Human Papillomavirus Infection by Number of Vaccine Doses Among US Women | Adolescent Medicine | JAMA Network Open | JAMA Network
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Table 1.  Prevalence of Genital HPV Infection Among HPV-Vaccinated and Unvaccinated Women Aged 18 to 26 Years, National Health and Nutrition Examination Survey, 2009-2016
Prevalence of Genital HPV Infection Among HPV-Vaccinated and Unvaccinated Women Aged 18 to 26 Years, National Health and Nutrition Examination Survey, 2009-2016
Table 2.  Difference in Predicted Probabilities of Infection With HPV Type 6, 11, 16, or 18 (4-Valent Vaccine–Type) by Risk Factor Among Women, National Health and Nutrition Examination Survey, 2009-2016
Difference in Predicted Probabilities of Infection With HPV Type 6, 11, 16, or 18 (4-Valent Vaccine–Type) by Risk Factor Among Women, National Health and Nutrition Examination Survey, 2009-2016
1.
Walker  TY, Elam-Evans  LD, Yankey  D,  et al.  National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2018.  MMWR Morb Mortal Wkly Rep. 2019;68(33):718-723. doi:10.15585/mmwr.mm6833a2PubMedGoogle ScholarCrossref
2.
Holman  DM, Benard  V, Roland  KB, Watson  M, Liddon  N, Stokley  S.  Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.  JAMA Pediatr. 2014;168(1):76-82. doi:10.1001/jamapediatrics.2013.2752PubMedGoogle ScholarCrossref
3.
Suk  R, Montealegre  JR, Nemutlu  GS,  et al.  Public knowledge of human papillomavirus and receipt of vaccination recommendations.  JAMA Pediatr. 2019. doi:10.1001/jamapediatrics.2019.3105PubMedGoogle Scholar
4.
Kreimer  AR, Herrero  R, Sampson  JN,  et al; Costa Rica HPV Vaccine Trial (CVT) Group.  Evidence for single-dose protection by the bivalent HPV vaccine—review of the Costa Rica HPV vaccine trial and future research studies.  Vaccine. 2018;36(32, pt A):4774-4782. doi:10.1016/j.vaccine.2017.12.078PubMedGoogle ScholarCrossref
5.
National Health and Nutrition Examination Survey. NHANES questionnaires, datasets, and related documentation. https://wwwn.cdc.gov/nchs/nhanes/Default.aspx. Accessed November 1, 2019.
6.
Lewis  RM, Markowitz  LE.  Human papillomavirus vaccination coverage among females and males, National Health and Nutrition Examination Survey, United States, 2007-2016.  Vaccine. 2018;36(19):2567-2573. doi:10.1016/j.vaccine.2018.03.083PubMedGoogle ScholarCrossref
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    David Nardo, PharmD | University of Kentucky
    While I am by no means an expert in vaccine immunology, I find that this article, suggesting that a single vaccination toward HPV results in similar disease prevalence as the recommended three vaccination series, is lacking in crucial details. The authors did not report power calculations, which are generally important in epidemiological studies, especially in diseases with low incidence. They also do not report the amount of time between the patient's vaccinations and infection. Antibody titers tend to wane over time and the time from vaccination in these patients could have contributed to the results observed in the study. Such a decline in antibody titers was observed for HPV18 in at study from 2017 comparing 2 vs. 3 vaccinations at 4.5 years from immunizations (J Infect Dis. 2017 Feb 1;215(3):359-367.) Overall, I think the suggestion that a single vaccine could result in optimal outcomes is irresponsible without clear clinical studies to substantiate the claim and could result in inappropriate vaccination practices in the uneducated public.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Infectious Diseases
    December 27, 2019

    Prevalence of Human Papillomavirus Infection by Number of Vaccine Doses Among US Women

    Author Affiliations
    • 1Center for Healthcare Data, Department of Management, Policy, and Community Health, UTHealth School of Public Health, Houston, Texas
    • 2Center for Health Services Research, Department of Management, Policy, and Community Health, UTHealth School of Public Health, Houston, Texas
    • 3Center for AIDS Intervention Research, Clinical Cancer Center, Medical College of Wisconsin, Milwaukee
    • 4Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
    • 5Department and Biostatistics and Data Science, UTHealth School of Public Health, Houston, Texas
    JAMA Netw Open. 2019;2(12):e1918571. doi:10.1001/jamanetworkopen.2019.18571
    Introduction

    More than a decade after the introduction of the human papillomavirus (HPV) vaccine in the United States, only 51.1% of adolescents have completed the vaccine series, while a greater number (68.1%) received at least 1 dose.1 The suboptimal series completion rate in the United States is partly attributable to the barriers, including unawareness of or forgetting the need for additional doses, lack of insurance coverage or health care professional recommendations, and less frequent contact with the medical system.2,3 To simplify the recommendations, trials are evaluating the efficacy of a single-dose regimen.4 In this study, we investigated HPV infection prevalence among women by number of vaccine doses received.

    Methods

    This cross-sectional study analyzed National Health and Nutritional Examination Survey (NHANES) 2009 to 2016 data, which are a stratified multistage probability sample of the US population. Demographic characteristics and immunization history were self-reported and collected by trained interviewers during a home interview. Sexual behavior data were self-reported by participants in the Mobile Examination Center. Participants provided self-collected cervicovaginal swab specimens. The specimens were evaluated by polymerase chain reaction followed by type-specific hybridization. Details of the survey questionnaire, sample collection, and laboratory methods are available elsewhere.5

    We identified women aged 18 to 26 years at the time of survey participation with nonmissing HPV vaccination and HPV test data. Nationally representative estimates for prevalence and the representative population counts were computed using NHANES sampling weights. The survey weight–adjusted Wald F test was used to examine the difference in the prevalence of HPV infection (4-valent vaccine types [HPV types 6, 11, 16, and 18]; cross-protection types [HPV types 31, 33, and 45]; and other high-risk types [HPV types 35, 39, 51, 52, 56, 58, 59, and 68]) by the number of doses received. The differences in predicted probability for HPV types 6, 11, 16, and 18 by number of vaccine doses and by the levels of risk factors were estimated using a multivariable logistic regression model. The model was adjusted simultaneously for age as a linear term, race/ethnicity, age at sexual debut, and lifetime number of male sexual partners. Statistical significance was tested at 2-sided P < .05. All analyses were performed with SAS software version 9.4 (SAS Institute) using SAS PROC SURVEY procedures, which included weight, cluster, and strata statements, to incorporate sampling weights and to adjust for the complex survey design.

    This study was deemed exempt from review and requirements for patient informed consent by the institutional review board of the University of Texas Health Science Center owing to the use of publicly available and anonymized data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Results

    The study sample included a total of 1620 women (mean [SE] age, 22.2 [0.1] years; 56.5% white), of whom 1004 were unvaccinated and 616 received at least 1 dose of HPV vaccine: 106 received 1 dose, 126 received 2 doses, and 384 received 3 doses.

    Compared with unvaccinated women (prevalence of 12.5% [95% CI, 9.7%-15.3%]), infection with HPV type 6, 11, 16, or 18 was significantly less prevalent among women who received 1 dose (2.4% [95% CI, 0%-4.9%]), 2 doses (5.1% [95% CI, 0.8%-9.5%]), or 3 doses (3.1% [95% CI, 0.9%-5.3%]) of HPV vaccine (Table 1). There was no significant difference in prevalence for 1 dose vs 2 doses or 1 dose vs 3 doses. Differences were not statistically significant for cross protection (except for 2 doses vs unvaccinated and 1 dose vs 2 doses) and other high-risk HPV types.

    In adjusted analysis, the predicted probability of infection with HPV 6, 11, 16, or 18 was higher in unvaccinated women (7.4% [95% CI, 7.1%-7.7%]) compared with women who received 1 dose (2.3% [95% CI, 1.9%-2.8%), 2 doses (5.7 [95% CI, 5.1%-6.2%]), or 3 doses (3.1% [95% CI, 2.9%-3.4%]) (Table 2). Black women had a greater predicted probability (10.8%) of infection with HPV type 6, 11, 16, or 18 compared with white women (6.6%). The predicted probability was also higher for women with more than 5 lifetime male sexual partners (11.6%) than women with 0 to 5 lifetime male partners (3.3%).

    Discussion

    Our study suggests that US women who received 1 dose of the HPV vaccine may have gained similar protection against vaccine-type infections compared with those who received additional doses. These findings support previous observational studies and post hoc analyses of vaccine trials that demonstrated comparable effectiveness of 1 dose to 2 or 3 doses.4 The limitations of our study include a cross-sectional design that precluded us from evaluating the timing of HPV vaccination compared with potential exposure. Furthermore, any conclusion regarding efficacy by individual number of doses cannot be drawn given the self-reported immunization history that may be prone to recall bias.6 If ongoing trials confirm sufficient efficacy and sustained duration of protection from a single-dose regimen, vaccine initiation (as opposed to the series completion) will become a more achievable metric of population coverage.

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    Article Information

    Accepted for Publication: November 8, 2019.

    Published: December 27, 2019. doi:10.1001/jamanetworkopen.2019.18571

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Sonawane K et al. JAMA Network Open.

    Corresponding Author: Ashish A. Deshmukh, PhD, MPH, Center for Health Services Research, Department of Management, Policy, and Community Health, UTHealth School of Public Health, 1200 Pressler St, RAS-E 329, Houston, TX 77030 (ashish.a.deshmukh@uth.tmc.edu).

    Author Contributions: Dr Deshmukh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Sonawane, Deshmukh.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Sonawane, Deshmukh.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Sonawane, Deshmukh.

    Obtained funding: Deshmukh.

    Administrative, technical, or material support: Sonawane, Deshmukh.

    Supervision: Swartz, Deshmukh.

    Conflict of Interest Disclosures: Dr Chhatwal reported receiving grants from Merck and Gilead outside the submitted work. Dr Deshmukh reported receiving personal fees from Merck outside the submitted work. No other disclosures were reported.

    Funding/Support: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award number R01CA232888. Dr Swartz was funded, in part, by The Cancer Prevention Research Institute of Texas (grant RP170668).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We acknowledge the National Center for Health Statistics of the Centers for Disease Control and Prevention for making the National Health and Nutritional Examination Survey publicly available and the women who participated in the survey.

    References
    1.
    Walker  TY, Elam-Evans  LD, Yankey  D,  et al.  National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2018.  MMWR Morb Mortal Wkly Rep. 2019;68(33):718-723. doi:10.15585/mmwr.mm6833a2PubMedGoogle ScholarCrossref
    2.
    Holman  DM, Benard  V, Roland  KB, Watson  M, Liddon  N, Stokley  S.  Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.  JAMA Pediatr. 2014;168(1):76-82. doi:10.1001/jamapediatrics.2013.2752PubMedGoogle ScholarCrossref
    3.
    Suk  R, Montealegre  JR, Nemutlu  GS,  et al.  Public knowledge of human papillomavirus and receipt of vaccination recommendations.  JAMA Pediatr. 2019. doi:10.1001/jamapediatrics.2019.3105PubMedGoogle Scholar
    4.
    Kreimer  AR, Herrero  R, Sampson  JN,  et al; Costa Rica HPV Vaccine Trial (CVT) Group.  Evidence for single-dose protection by the bivalent HPV vaccine—review of the Costa Rica HPV vaccine trial and future research studies.  Vaccine. 2018;36(32, pt A):4774-4782. doi:10.1016/j.vaccine.2017.12.078PubMedGoogle ScholarCrossref
    5.
    National Health and Nutrition Examination Survey. NHANES questionnaires, datasets, and related documentation. https://wwwn.cdc.gov/nchs/nhanes/Default.aspx. Accessed November 1, 2019.
    6.
    Lewis  RM, Markowitz  LE.  Human papillomavirus vaccination coverage among females and males, National Health and Nutrition Examination Survey, United States, 2007-2016.  Vaccine. 2018;36(19):2567-2573. doi:10.1016/j.vaccine.2018.03.083PubMedGoogle ScholarCrossref
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