Human Papillomavirus, Essay Example

Human Papillomavirus – Policies and Strategies to Address HPV Infection Introduction

Human papillomavirus strains are double-stranded small DNA viruses affecting the epithelium through viral infection. As of today, there are over 100 identified types of HPV. According to the CDC, the human papillomavirus (HPV) is currently one of the most common worldwide sexually transmitted infections.1

HPV, Human Papilloma Virus is an extremely common and potentially serious illness that infects both men and women around the world. Currently there are 100 types of HPV, which can be classified into two categories, low-risk and high-risk type. (2) 13 types of HPV are classified as high-risk, and are known to be linked to cancer causing cells. While HPV is mainly transferred through sexual contact, there are other ways to get infected. The problem arises as HPV’s types 16 and 18 have been linked to cause 70% of precancerous cervical lesions and cervical cancers, as well as additional linkage to cancers of the penis, vagina, vulva, and anus.(3) while policy has been implemented to provide the most effective interventions and treatment, many men and women in low-income countries are without access. The main purpose of this research is to provide an in-depth look at the background, and the factors that surround HPV, the policies in place in developed countries, the treatments available, and the recommendations for improving access to prevention and screening, as well as future studies to help reduce the amount of people affected.

According to a recent WHO publication4, one of the major risk factors of cervical cancer is human papillomavirus (HPV) infection. Therefore, the organization recommends health services worldwide to implement preventive strategies that slow down or eliminate the spreading of the virus, consequently reducing the number of cervical cancer cases. Bosch et al’s5 research also found that the sexually transmitted virus of HPV is currently creating major epidemic disease, and the most effective way of tackling the public health issue and reducing the number of infections leading to the development of cervical cancer is introducing preventive measures and educating at-risk population.

Background

Human papillomavirus impacts around 24 million people in the United States, and each year the number of new infections is around 6 million. This means that around one in five adults in the United States might be infected with HPV6. The CDC7 reports that every year 27.000 people get cancer that is caused by HPV. Several reports have also confirmed the link between human papillomavirus and cervical cancer8  Indeed, it has been revealed by researchers that the majority of cervical cancer cases are caused by long-term infection of HPV9. The virus is highly contagious genital condylomata. The main source of transmission is sexual intercourse, and other methods of infection are negotiable. According to a recent summary of the disease10, most infections are asymptomatic, and clear on their own in a year from the first infection. Only a small proportion of human papillomavirus infections manifest physical symptoms, and cell abnormalities that lead to the development of cancer. There are currently 40 known mucosal strains of the HPV virus, with strains 16 and 18 being the most common. Some virus types are more likely to cause genital warts, while others carry higher risk of developing into cancer over years11. In order to determine which strains of the virus are more likely to create serious long-term critical illnesses, however, further research is needed. Collaboration between researchers, health care providers, and policymakers is essential for creating a policy that is able to tackle future challenges related to sexually transmitted illnesses. One of the main problems identified below is that public budget is not available in every country, and this creates global inequalities in health outcomes related to HPV.

Risk Factors

There are several risk factors that increase some groups’ risk level of encountering HPV infection, and Bosch et al.12 found that one of the main determinants of risk is the number of sexual partners. The authors also found that women are at increased risk, if they or their partner engage in sexual relationship with more than one partners. Previous research also revealed that the presence of HPV DNA on the sexual partner is not only a risk factor for HPV infection, but also cervical cancer. The above finding indicates that educating adult population about the risks should be one of the main priorities of health professionals and organizations. Women who do not use condoms, but take prescription contraception pills might feel safe engaging in sexual activities with new partners, ignoring the risk of STD-s. On the other hand, women who are monogamous, but their partner is not, can be at a high risk, assuming that having only one sexual partner would keep them safe13.

Issues Identified

One of the main issues with HPV is that at least 50 percent of women who are carrying the virus have no symptoms14. This does not only mean that they are not getting treatment, but also that they would engage in unprotected sexual intercourse with new partners, contributing towards the spread of the virus15. Human papillomavirus does not only affect heterosexual individuals, and infection rates among homosexual men are higher than the rest of the population. In this case, the presence of HPV does not increase the risk of cervical cancer, but the chances of developing anal cancer16. The wide implementation of HPV immunization could, indeed reduce the number of new cervical cases by 70 percent, according to recent studies17 .

Policies Related to Human Papillomavirus

Policy Recommendations

The CDC18 has recently created a recommendation info graphics for practising sexual health professionals, outlining a change in policies targeting teenagers aged 11-12. According to the recommendation, the vaccination of people is the most effective when children get their follow-up vaccination for Meningitis and whooping cough. In Australia, the Australian National Immunisation Program (NIP)’s school-based program includes the vaccination against HPV for boys and girls aged 12-13. Further, there is a follow-up (catch-up) vaccination available for 14-15 year old-s. According to a recent report19, the effectiveness of the vaccination can be increased by providing children protection before they would become sexually active. Therefore, it is recommended to vaccinate teenagers as soon as it is safe to do so. There are two different preventive vaccines available through the program in Australia, both providing 90-100 percent of protection20.

Overview of Policies

Australia was also the first country to introduce HPV vaccination programs funded by the government21 in 2007. The new initiative provided free vaccination for females aged between 12 and 26. At the moment, preventive vaccinations are being delivered to 12-13 year old males and females. Up to 2013 December, the government program delivered 5.6 vaccines. While several debates have been started regarding the safety of the immunization in different countries22, the Australian government monitors the program’s safety on an on-going basis23. According to government statistics24, a fall in new cases has been reported since the introduction of the program.

Wong et al.25 created a comprehensive study comparing HPV related policies in early adopter countries. All countries seem to have advanced performance monitoring plans integrated in their health program, and these are founded by the government. However, without support from researchers and health care professionals, effective delivery and monitoring cannot be achieved. In order to maintain the balance between evaluation and improving health outcomes, the WHO position paper26 recommends balancing timely delivery of vaccines with research.

In the United Kingdom, an extensive research of policies has been undertaken by the research team of the NHS27. The authors found that “The most feasible and cost-effective strategy in terms of delivery could involve a single policy across the screening age range with 5- or 6-yearly screening intervals and 12-month recall for HPV positive women with negative cytology”28. Further, given that many patients do not have symptoms, a follow-up regular screening program is needed in order to provide adequate protection for the population29.

Issues Identified Related to Policies

One of the major issues related to vaccine policies and prevention is providing equality in health care. The American Cancer Society30 created some guidelines for implementing policies and preventive programs. One of the main recommendations is that policies need to ensure that all racial and age groups are equally benefiting from the program, therefore, public education and preventive interventions need to be culturally relevant, and target all social and ethnic groups. Further, the report states that it is necessary to educate not only the public about the risks of the virus, but also to educate health care professionals. In the United States, the vaccination is not recommended for females aged over 26 or males, and this means that men are likely to continue becoming infected. In relation with the previously quoted statistical data, it is evident that the policy leaves homosexual males more exposed at risk of cancer than young females who automatically receive the first and follow-up vaccination.

In Australia, the school-based intervention program was found to be effective, based on a research assessing the outcomes of the 2006 introduction of the quadrivalent vaccine31. This indicates that early prevention programs that focus on school-aged children, and those who are not yet sexually active are likely to deliver the best results worldwide. Policymakers, however, should focus on the safety of vaccine delivery, the coverage achieved, as well as the cost-effectiveness of the publicly founded interventions.

According to the American Cancer Society Guidelines32, health disparities in HPV infection outcomes are clearly visible. Resource-poor countries and their populations reported significantly higher mortality and cancer rates related to HPV infection than those countries where effective, government-funded programs are in operation. Incidence rates of cervical cancer in Africa and South America, for example, reach 50 cases per 100.000 females each year33. Likewise, in developed countries, racial inequalities persist34. Mortality and cancer rates among Hispanic and Black women in America are above those recorded among Whites. While the average worldwide cervical cancer mortality rate is 7.5 percent35, worldwide statistics show great geographical differences between developing and developed areas of the world. This indicates that countries where government-funded intervention and prevention programs are available (higher resources) it is easier to reduce the number of new cases and detect HPV at an early stage, providing effective treatment before cancer could develop. The above highlighted issue calls for policy changes that focus on underserved and disadvantaged populations in the developed world, and increase the effectiveness of health care delivery. Brisson et al.36found that several factors influence the effectiveness of intervention policies, such as sociodemographic status, behavioural and attitude, and HPV-related conditions.

Interventions

There are currently two main types of intervention methods utilized in order to tackle the worldwide epidemic of human papillomavirus. One focuses on early prevention through vaccination of teenagers and government-funded programs, and the other is based on increasing early detection rates, in order to prevent the disease from spreading and causing cancerous cells to develop. The recently published WHO recommendation document37 states that cervical cancer, related to HPV infection is the second most common forms of cancer among women. The authors state that there is a need for an intervention program that focuses on the early detection of precancerous lesions. While the cytological screening (Pap smear) are available in developed, western countries where government funding for screening and research is available, low- and middle- income countries seem to be lagging behind delivering effective screening and intervention through public health care. Over the life course of a person, the WHO document38 differentiates between three stages of programmatic interventions: primary prevention, secondary prevention, and tertiary prevention. Primary prevention involves the introduction of HPV vaccination, health education delivery, and promotion of safe sex practices. The secondary prevention policies should focus on screening and treatment if the virus is found, while the third stage would involve the treatment of already developed cancer. The recent CDC report39 recommends that males might be vaccinated, however, there are no clear recommendations and programs related to male prevention. This is a shortfall of the policies, provided that homosexual males are at a generally higher risk of encountering the virus and not seeking early treatment40.Comparing two different intervention programs, the capstone project created by Turquoise et al.41 focused on the effectiveness of intervention programs utilizing the health belief model42. The most important determinant of public engagement and increased take on rates of the vaccination was found to be community engagement activities. Patients and parents of school-aged children who received written information on the program, the significance of the issue, the protection provided by the vaccination were more likely to take part in the vaccination program. Sending reminders about the follow-up vaccinations, for example increased patient engagement.

The lack of male vaccination also creates misconceptions about the virus, and sends out a message that it is only women’s responsibility to stay clean43. At the same time, circumcision is currently the only prevention offered for males, which is more intrusive and less effective than repeated vaccination of females. Interventions, currently focusing on young women as a target group automatically exclude older women, who might have had asymptomatic human papillomavirus for a long time, and would be at risk of developing cervical cancer. Vaccination alone cannot solve the epidemic: screening of both men and women at a sexually active age would increase the effectiveness of screening programs, reduce the cost of treatment at a later stage, and positively impact patient outcomes.

Low participation rate in the Western world makes programs’ effectiveness and cost-effectiveness limited. In the United States, the participation rate (receiving at least one dose of the vaccine) remains low, between 5 and 26 percent44.

Implications and Outlooks for the Future

Based on the review of two intervention programs currently in place in America, North Carolina45, it is evident that community-based prevention and education programs should be further developed and improved in order to increase the participation rate across the at-risk population. However, in order to successfully deliver health related education and messages, and reduce the gap in health outcomes between the mainstream and disadvantaged population, it is important to review the health related behaviour of certain groups. Minorities, for example, are disadvantaged, as they are less likely to be aware of the risks and the preventive methods available for them. A recent study focusing on UK, USA, and Australian population46 found that across the board minority groups were less aware of HPV testing than those who belonged to majority groups. Health inequalities might be caused by information and health education materials targeting mainstream population, instead of focusing on groups with low health access and health literacy. Therefore, future policies and community programs should be based on an understanding of different groups: their preferences, beliefs, and health behaviours. Further, patient-centered approaches should be introduced in order to create a culturally and linguistically relevant intervention and education program.

It is also found that parents’ health beliefs were likely to influence the family’s decision whether or not to participate in screening and vaccination programs. Screening for HPV is effective, cheap, and reliable, however, the participation rate is still low47.  Becker’s48  Health Belief Model seems to be one of the most applicable frameworks in order to assess public beliefs and attitudes and create policies and education programs that focus on changing the population’s health related behaviour.

It is, therefore, recommended that health care providers, policymakers, and communities work together with NGO-s in order to increase the participation rate in every segment of the society. Given that human papillomavirus is a sexually transmitted virus, several cultures might have issues with getting a vaccination. The stigma of STD-s has already been widely studied by authors49, across different cultures. Therefore, support groups need to be created in order to help individuals deal with the health issue at the same time as dealing with the stigma associated with sexually transmitted diseases.

The National Foundation for Infectious Diseases50 defined HPV prevention and screening as a public health priority. According to the document, in the United States, without intervention, every person would be eventually infected by the virus. While the highest infection rate across the entire population is among those aged 15 to 24, it is also important to note that socio-demographic factors impact the risk of infection. The document51 states that “A female between the ages of 15 and 24 has a 25 percent chance of becoming infected each year and a staggering 33 percent of females 15 to 19 years of age are infected with HPV at any point in time”. One of the main issues found by the researchers that policymakers should focus on is to increase the utilization rate of vaccines, and include populations that are not school-aged girls, but at risk. While several researchers have recently recommended the introduction of preventive vaccination for males, the rate of uptake is still below 15 percent52.

The main issues that need to be tackled in the future in order to prevent a human papillomavirus and cancer (anal and cervical) epidemics are listed below.

1. Increasing public awareness of the risk of developing cancer
2. Addressing vaccine safety issues currently creating misconceptions in the developed world53
3. Collaboration between researchers, health care providers, and policymakers in order to deliver more effective services and increase participation rates54
4. Introducing evidence-based health approach in education, collaboration, community programs, as well as policies targeting at-risk, underserved diverse populations55
5. Understanding health related behaviour of patients and parents related to sexually transmitted illnesses, in order to increase public awareness and overcome common objections56

Considering the high prevalence rate of human papillomavirus among young, sexually active people, it is important that national and global policies and initiatives focus on creating an awareness, working together with researchers to implement evidence-based programs to modify health-related behaviours of at-risk populations, increasing participation rate among young people, and engaging in discourses about the safety of the immunization with various stakeholders that can influence patient behaviour. Further, NGO-s also have an important role in delivering messages to communities around the world, creating awareness, increasing the disadvantaged population’s health literacy.

1. Centers for Disease Control and Prevention. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2013. MMWR Wkly Rep. 2014;63(29):625-33

2 . Ibid

3. Schiffman, M., & Castle, P. E. (2003). Human papillomavirus: epidemiology and public health. Archives of Pathology & Laboratory Medicine, 127(8), 930–934

4. LaMontagne, D. Scott, Sandhya Barge, Nga Thi Le, Emmanuel Mugisha, Mary E. Penny, Sanjay Gandhi, Amynah Janmohamed et al. “Human papillomavirus vaccine delivery strategies that achieved high coverage in low-and middle-income countries.”Bulletin of the World Health Organization 89, no. 11 (2011): 821-830.

5. Bosch, F. Xavier, You-Lin Qiao, and Xavier Castellsagué. “The epidemiology of human papillomavirus infection and its association with cervical cancer.” International Journal of Gynecology & Obstetrics 94 (2006): S8.

6 . Watson, Richard A. “Human papillomavirus: confronting the epidemic—a urologist’s perspective.”Reviews in Urology 7, no. 3 (2005): 137.

7. CDC. HPV Cancer Prevention. 2014. Web.

8. MUNOZ, N., et al. The causal link between human papillomavirus and invasive cervical cancer: A population?based case?control study in colombia and spain.International Journal of Cancer, 1992, 52.5: 743-749.

9. Schiffman, M., & Castle, P. E. (2003). Human papillomavirus: epidemiology and public health. Archives of Pathology & Laboratory Medicine, 127(8), 930–934

10. NCIRS. Human Papillomavirus (HPV) vaccines for Australians: Information for immunisation providers. (2013)

11. Bosch FX, Munoz N. The viral etiology of cervical cancer. Virus Res 2002;89:183–90

12. Ibid.

13.  Ferlay, J.; Bray, F.; Pisani, P.; Parkin, D.M. GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide, IARC CancerBase No. 5, version 2.0. http://www-dep.iarc.fr/globocan/ database.htm (accessed May 8, 2015).

14. Unger E, Duarte-Franco E. Human papillomaviruses: into the new millennium. Obstet Gynecol Clin North Am. 2001;28:653–666

15. Watson, Richard A. “Human papillomavirus: confronting the epidemic—a urologist’s perspective.”Reviews in urology 7, no. 3 (2005): 139.

16. Ibid, 140.

17. Smith, J. S., Lindsay, L., Hoots, B., Keys, J., Franceschi, S., Winer, R., et al. (2007). Human papillomavirus type distribution in invasive cervical cancer and highgrade cervical lesions: a meta-analysis update. International Journal of Cancer, 121(3), 621–632.

18. CDC. HPV Cancer Prevention. 2014. Web.

19. NCIRS. Human Papillomavirus (HPV) vaccines for Australians: Information for immunisation providers. (2013) 1

20. Ibid, 1

21.Brotherton, Julia, Andrew Grulich, Julia Brotherton, and Andrew Grulich. “Experience with human papillomavirus vaccination (HPV) in Australia.” (2013).

22. WONG, Charlene A., et al. Approaches to monitoring biological outcomes for HPV vaccination: challenges of early adopter countries. Vaccine, 2011, 29.5: 878-885.

23. Macartney KK, Chiu C, Georgousakis M, Brotherton J. Safety of human papillomavirus vaccines: A review. Drug Safety 2013 DOI 10.1007/s40264-013-0039-5

24. Ali H, Donovan B, Wand H, Read TRH, Regan DG, Grulich AE, Fairley CK, Guy RJ. Genital warts in young Australians five years into national human papillomavirus vaccination programme: national surveillance data. BMJ 2013;346: f2032, doi:10.1136/bmj.f2032

25. Wong, Charlene A., Mona Saraiya, Susan Hariri, Linda Eckert, Roberta I. Howlett, Lauri E. Markowitz, Julia ML Brotherton et al. “Approaches to monitoring biological outcomes for HPV vaccination: challenges of early adopter countries.” Vaccine 29, no. 5 (2011): 878-885.

26. Human papillomavirus vaccines WHOposition paper. Weekly epidemiological record. 2009; 84:117–32.

27. Canfell, K., C. Gilham, A. Sargent, C. Roberts, M. Desai, and J. Peto. “The clinical effectiveness and cost-effectiveness of primary human papillomavirus cervical screening in England: extended follow-up of the ARTISTIC randomised trial cohort through three screening rounds.” Health technology assessment (Winchester, England) 18, no. 23 (2014): 1-196.

28. Ibid, 99.

29. Australian Government National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. 2005. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf (accessed 17 Jul 2013)

30. Saslow, Debbie, Philip E. Castle, J. Thomas Cox, Diane D. Davey, Mark H. Einstein, Daron G. Ferris, Sue J. Goldie et al. “American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors.”CA: A Cancer Journal for Clinicians 57, no. 1 (2007): 7-28.

31. Brotherton, J. M., Sharron L. Murray, Madeline A. Hall, Lynne K. Andrewartha, Carolyn A. Banks, Dennis Meijer, Helen C. Pitcher, Megan M. Scully, and Luda Molchanoff. “Human papillomavirus vaccine coverage among female Australian adolescents: success of the school-based approach.” Med J Aust 199, no. 9 (2013): 614-7.

32. Saslow, Debbie, Philip E. Castle, J. Thomas Cox, Diane D. Davey, Mark H. Einstein, Daron G. Ferris, Sue J. Goldie et al. “American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors.”CA: A Cancer Journal for Clinicians 57, no. 1 (2007): 7-28.

33. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55:74–108.

34. Wang SS, Sherman ME, Hildesheim A, et al. Cervical adenocarcinoma and squamous cell carcinoma Incidence trends among white women and black women in the United States for 1976–2000.Cancer 2004;100:1035–1044.

35. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis. 1999;26(5):250–261.

36. Brisson, Marc; Drolet, Mélanie; MALAGÓN, Talía. inequalities in Human Papillomavirus (HPV)–   associated Cancers: implications for the Success of HPV Vaccination. Journal of the National Cancer Institute, 2013, djs638.

37. World Health Organization. Reproductive Health, World Health Organization. Chronic Diseases, and Health Promotion. Comprehensive cervical cancer control: a guide to essential practice. World Health Organization, 2006.

38. bid, 3

39. PETROSKY, Emiko, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep, 2015, 64.11: 300-304.

40. Brisson, Marc; Drolet, Mélanie; Malagón, Talía. inequalities in Human Papillomavirus (HPV)–   associated Cancers: implications for the Success of HPV Vaccination. Journal of the National Cancer Institute, 2013, djs638.

41. Turquoise, G., Sparks, A., Turner, K. Evaluation of Two Adolescent Vaccination Interventions: School Health Center Study and the North Carolina Assessment, Feedback, Incentives, and eXchange Intervention Cervical Cancer Free NC Capstone Team. 2009

42. Glanz, K., Rimer, B.K., & Viswanath, K. (Eds.)  Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass. 2008.

43. Carpenter, L. M., & Casper, M. J. (2009). A tale of two technologies: HPV vaccination, male circumcision and sexual health. Gender and Society, 23(6), 790-816.

44. Rosenthal, S. L., Rupp, R., Zimet, G. D., Meza, H. M., Loza, M. L., Short, M. B., et al. (2008). Uptake of HPV vaccine: demographics, sexual history and values, parenting style, and vaccine attitudes. Journal of Adolescent Health, 43(3), 239–245

45. Turquoise, G., Sparks, A., Turner, K. Evaluation of Two Adolescent Vaccination Interventions: School Health Center Study and the North Carolina Assessment, Feedback, Incentives, and eXchange Intervention Cervical Cancer Free NC Capstone Team. 2009.

46. Dodd, Rachael H., Kirsten J. McCaffery, Laura AV Marlow, Remo Ostini, Gregory D. Zimet, and Jo Waller.  “Knowledge of  human papillomavirus (HPV) testing in the USA, the UK and Australia: an international survey.” Sexually transmitted infections90, no. 3 (2014): 201-207.

47. Canfell, K., et al. The clinical effectiveness and cost-effectiveness of primary human papillomavirus cervical screening in England: extended follow-up of the Artistic randomised trial cohort through three screening rounds.Health technology assessment (Winchester, England), 2014, 18.23: 1-196.

48. Becker, M. H. (1974). The Health Belief Model and personal health behavior. Health Education Monographs, 2, 324–473.

49. Nack, Adina. “Damaged goods: women managing the stigma of STDs.” Deviant Behavior 21, no. 2 (2000): 95-121

50. National Foundation for Infectious Diseases. Call to Action HPV Vaccination as a Public Health Priority. 2014.

51. Ibid, 2

52. Centers for Disease Control and Prevention. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2013. MMWR Wkly Rep. 2014;63(29):625-33.

53. Charo, R. A. (2007). Politics, parents, and prophylaxis–mandating HPV vaccination in the United States. The New England Journal Of Medicine, 356(19), 1905-1908.

54. TSUI, Jennifer, et al. Policy development for human papillomavirus vaccine introduction in low-resource settings. The Open Vaccine Journal, 2009, 2: 113-22.

55. Andrus, J.K.; Toscano, C.M.; Lewis, M.; Oliveira, L.; Ropero, A.M.; Davila, M.; Fitzsimmons, J.W. A model for   enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac initiative. Public Health Rep., 2007, 122(6), 811-816.

56. Zimet, G.D.; Liddon, N.; Rosenthal, S.L.; Lazcano-Ponce, E.; Allen, B. Chapter 24: psychosocial aspects of vaccine acceptability. Vaccine, 2006, 24(Suppl. 3), S201-S209.