INFECTIOUS DISEASES AND IMMUNOLOGY ASSIGNMENT 2023

STUDENT: JUDITH AMUTUHAIRE SSEMASAAZI

REG NO: 2020/HD07/19903U

Human papillomavirus vaccine global impact.

Abstract

The introduction of vaccines against Human Papillomaviruses (HPV) marked a major milestone

in the history of preventive oncology. With more than a decade of implementation, these

vaccines have proven efficacious and cost-effective in preventing HPV-related cancers and

anogenital warts. Mathematical models have predicted that the implementation of HPV

vaccination along with screening programs will avert more than 12 million cervical cancer cases

by 2069. This predicted impact remains challenged by poor access to these vaccines in low-

income countries which unfortunately bare the highest burden of HPV-related diseases. The

world health organization (WHO) global strategy to eliminate cervical cancer through

vaccination and screening programs has emphasized the need to improve access to HPV

vaccines. With such optimistic strategies, HPV vaccines will continue to bring down the

incidence of HPV-associated cancers and anogenital warts over the next decades on a global

scale.

Introduction

Globally, the human papillomavirus (HPV) continues to devastate the health of women

accounting for more than 300,000 cervical cancer-related deaths in 20201. HPV accounts for

4.5% of all infection-related cancers2-5 and plays a major role in the etiology of cervical cancer,
the fourth most common cancer among women globally4. HPV oncogenic viruses have also been

linked to oropharyngeal, vulvovaginal, penile, and anal cancers6. Thus, HPV-related morbidity

spreads across all populations, though the most devastating effects have been seen among

women suffering from cervical cancer. Vaccines against HPV have been in use for over a decade

and studies demonstrated their efficacy in preventing HPV-related malignancies, precancerous

lesions, and warts7. These vaccines are cost-effective and the world health organization (WHO)

approved their use in all target populations worldwide8.

Prevalence of HPV infection and related diseases

Globally, HPV infections stand at 11-12% with the highest-burden in sub-Saharan Africa at

24%9,10. At least 90% of sexually active men and women get infected with HPV once in their life

time5. HPV is an icosahedral, non-enveloped, double-stranded DNA virus that belongs to the

Papillomaviridae family with more than 125 subtypes forty of whom have been identified in

anogenital lesions11. The human papillomaviruses (HPVs) have been classified as low-risk HPVs

(LR-HPVs) that cause anogenital and cutaneous warts like HPV 6,11, and high-risk HPVs (HR-

HPVs) like HPV 16,18 which cause oropharyngeal, cervical, anal, vulvar, vaginal, and penile

cancers 11. Among people living with HIV, its natural history is accelerated making HPV-

associated malignancies and other anogenital lesions more prevalent in this special group11.

Human papillomavirus vaccines

Worldwide, there are three vaccines that have been licensed by the U.S. Food and Drug

Administration (FDA) for use in prevention of HPV-related cancers and anogenital warts. All are

given as intramuscular injections. The bivalent vaccine, Cervarix, from GlaxoSmithKline,

approved for the prevention of HPV 16,18 is given at 0,1 and 6 months among girls and women

9-25 years of age. The quadrivalent vaccine, Gardasil, from Merck approved for the prevention
of HPV 6,11,16, 18 is given at 0,2 and 6 months to girls and women of 9-26 years of age. The

nonavalent, Gardasil-9, in addition to HPV 6,11,16 and 18, has efficacy against other strains

including HPV 31,33,45,52,58. It is approved for use among females 16-25 years11.

Global impact of human papillomavirus vaccine

HPV vaccination started in the early 2000s in developed countries12 and studies demonstrated its

cost-effectiveness13. Though many women from high- and middle-income countries have been

vaccinated, women from low-income countries where the burden of HPV-related disease is

highest have limited access to these vaccines14. Data continues to emerge from countries that

have implemented HPV vaccination showing a reduction in anogenital infections and cervical

intraepithelial neoplasia15. In Australia, the impact of HPV vaccination was visible more than 10

years ago with a 60% reduction in the incidence of anogenital warts16. It is estimated that HPV

vaccination programs coupled with early screening could reduce mortality from cervical cancer

by two-thirds in developing countries17. In 2017, WHO recommended that all member states

implement HPV vaccination for girls 9-14 years of age but even then, the global HPV vaccine

coverage remains unsatisfactory14,18. In 2019, the global HPV vaccine coverage for final dose

was still low at only 15%19. By mid-year 2020, at least half of the WHO member states had

implemented HPV vaccination programs with most introductions in the Americas and Europe19.

In 2018, Uganda and Rwanda were the only developing countries with high completion rates of

84% and 74% respectively14. However, in 2019, there were more introductions than ever in low-

and middle-income countries where access had previously been a problem19. Mathematical

models have shown that wide HPV vaccination and cervical cancer screening coverage if

implemented from 2020 onwards have the potential to avert more than 12 million deaths by

206920. On the background of such models and other data, WHO adopted a strategy to eliminate
cervical cancer by 2030 with targets of 90% of girls fully vaccinated with the HPV vaccine by

age 15, 70% of women screened with high-performance tests by age 35, and repeated by 45

years of age and 90% of women with cervical disease identified and receive treatment8. But of

course, these targets could be challenged by limited access to vaccines in the low- and middle-

income countries and their impact may remain a privilege of wealthy countries14. However, the

new strategy of WHO emphasizes the need and efforts to improve access to HPV vaccines in

low-income countries8. With such optimistic targets and global efforts, the impact of HPV

vaccine will not only be a privilege of wealthy countries but will be demonstrated across all

socioeconomic strata globally over the next few decades.

Conclusion

HPV vaccines have been in use for over a decade and indeed they have been found efficacious

and cost effective in reducing HPV-related morbidity. The WHO and the scientific research

community has demonstrated faith in the gains these vaccines can bring to the health of

populations globally. With expanded access to HPV vaccines, a balanced impact in the reduction

of HPV-related cancers and anogenital warts will surely be very evident across the globe over

the next few decades.