Human Papillomavirus prevalence and probable first effects of vaccination in 20 to 25 year-old women in Germany: a population-based cross-sectional study via home-based self-sampling.

BACKGROUND: Estimates of Human Papillomavirus (HPV) prevalence in a population prior to and after HPV vaccine introduction are essential to evaluate the short-term impact of vaccination. METHODS: Between 2010 and 2012 we conducted a population-based cross-sectional study in Germany to determine HPV prevalence, genotype distribution and risk factors for HPV-infection in women aged 20-25 years. Women were recruited by a two-step cluster sampling approach. A home-based self-collection of cervicovaginal lavages was used. Specimens were analysed using a general primer GP5+/GP6+-based polymerase chain reaction and genotyped for 18 high-risk and 6 low-risk HPV- strains by Luminex-based multiplexed genotyping. RESULTS: Among 787 included women, 512 were not vaccinated against HPV. In the non-vaccinated population, HPV prevalence of any type was 38.1%, with HPV 16 (19.5%) being the most prevalent genotype. Prevalence of any high-risk type was 34.4%, and in 17.4% of all women, more than one genotype was identified. A higher number of lifetime sexual partners and low educational status were independently associated with HPV-infection. In 223 vaccinated women, prevalence of HPV 16/18 was significantly lower compared to non-vaccinated women (13.9% vs. 22.5%, p = 0.007). When stratifying by age groups, this difference was only significant in women aged 20-21 years, who at time of vaccination were on average younger and had less previous sexual contacts than women aged 22-25 years. CONCLUSION: We demonstrate a high prevalence of high-risk HPV genotypes in non-vaccinated women living in Germany that can be potentially prevented by vaccination. Probable first vaccination effects on the HPV prevalence were observed in women who were vaccinated at younger age. This finding reinforces the recommendation to vaccinate girls in early adolescence.

Cervicovaginal self-sampling is a reliable method for determination of prevalence of human papillomavirus genotypes in women aged 20 to 30 years.

Self-sampling by cervicovaginal lavage could be an attractive method to detect high-risk human papillomavirus (hr-HPV) infections to identify women with a risk of cervical precancer. The objective of our study was to use self-sampling for the first time in a cross-sectional approach to determine HPV prevalence and genotype distribution. We evaluated participants' acceptance and laboratory results from self-obtained samples versus endocervical brush samples obtained by gynecologists. To determine the sensitivity of both sampling methods in presumed high- and low-prevalence settings, two groups of women 20 to 30 years of age with (n = 55) and without (n = 101) a recent suspicious cytological smear were compared. Overall, 76% (95% confidence interval [95% CI], 65 to 88) of women with and 40% (95% CI, 30 to 49) of women without a recent suspicious cytological smear tested HPV positive. The prevalences of high-risk HPV strains were 71% (95% CI, 59 to 83) and 32% (95% CI, 22 to 41), respectively, for these two groups. The agreement for hr-HPV between the two sampling methods for women with and without suspicious cytology was 84% (κ = 0.65; 95% CI, 0.44 to 0.86) and 91% (κ = 0.78; 95% CI, 0.64 to 0.92), respectively. Participants rated the user-friendliness of the self-sampling method on a visual analog scale from 0 (easy) to 100 (difficult) with a median of 12. In conclusion, self-sampling by cervicovaginal lavage is a reliable method to determine hr-HPV prevalence and is well accepted by young adult females.

Review of vaccine hesitancy: Rationale, remit and methods.

Despite a wide array of safe and effective vaccines in use globally, with major impacts on health worldwide, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization has been repeatedly confronted with reports of hesitancy towards accepting specific vaccines or vaccination programmes. This paper summarizes the rationale for a SAGE review of the issue of vaccine hesitancy, its impact and ways to address it, and the convening of a Vaccine Hesitancy Working Group in March 2012 to prepare for the SAGE review. It describes the methods used and mode of operations, and advances in the relatively new field of research on vaccine hesitancy. It further elaborates and references the work conducted, including a series of products, conclusions and recommendations that emerged from the SAGE review in October 2014.

Why are young adults affected? Estimating measles vaccination coverage in 20-34 year old germans in order to verify progress towards measles elimination.

BACKGROUND: The introduction of measles vaccination into routine childhood vaccination programmes has led to a shift of disease burden and incidence among young adults. This was confirmed by the recent rise in measles cases and outbreaks throughout Europe. To prevent outbreaks and eliminate measles, one of the key objectives of the WHO Europe measles elimination framework is achieving overall vaccination coverage of ≥95% in the population on a district level. In the absence of national registers, data on vaccination coverage in Germany is recorded at the age of school entry, through insurance refund claim data and population studies. Vaccination status (VS) of young adults is largely unknown. METHODS: We assessed measles vaccination coverage in young adults aged 20-34 years on a district level of the German Federal State of Rhineland-Palatinate. The knowledge and attitude towards immunization of unvaccinated to vaccinated young adults were compared using Likert questions. We used proportional allocation for stratified random sampling across 36 counties. We mailed a self-administered questionnaire with pre-paid return envelopes along with an offer to complete online. Prior to calculating coverage we tested for non-responder bias using logistic regression. RESULTS: 465 (28%) of 1,637 persons contacted responded (mail: 23%, online: 5%). More women responded than men (odds ratio (OR)=2.1; 95% confidence intervall (CI)=1.7-2.6) but age did not vary between responders and non-responders. Vaccination coverage was 90% (95%CI=87%-93%) for one and 56% (95%CI=51%-61%) for two doses. We found a statistically significant association between receiving two doses and age group. The 20-24 years age group had a 2.3 higher incidence rate ratio (95%CI=1.7-3.2) than the reference group of 30-34 year old to have received two doses of measles vaccination. The group of 25-29 year old had a 1.5 higher incidence rate (95%CI=1.0-2.1) than the reference group to have received two doses of measles vaccination. CONCLUSIONS: Coverage has failed to reach the WHO Europe elimination goal of 95% measles vaccination in the general population. Targeted approaches including enlistment of occupational health services and checking vaccination status during general practitioner (GP) visits are needed to increase vaccination uptake in this age group in order to achieve measles elimination.

How to deal with vaccine hesitancy?

Based on the concerns about vaccine hesitancy and its impact on vaccine uptake rates and the performance of national immunization programmes, the Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy [1], carried out a review, and proposed a set of recommendations directed to the public health community, to WHO and its partners, and to the World Health Organization (WHO) member states. The final recommendations issued by SAGE in October 2014 fall into three categories: (1) those focused on the need to increase the understanding of vaccine hesitancy, its determinants and the rapidly changing challenges it entails; (2) those focused on dealing with the structures and organizational capacity to decrease hesitancy and increase acceptance of vaccines at the global, national and local levels; (3) and those focused on the sharing of lessons learnt and effective practices from various countries and settings as well as the development, validation and implementation of new tools to address hesitancy.

Measuring vaccine hesitancy: The development of a survey tool.

In March 2012, the SAGE Working Group on Vaccine Hesitancy was convened to define the term "vaccine hesitancy", as well as to map the determinants of vaccine hesitancy and develop tools to measure and address the nature and scale of hesitancy in settings where it is becoming more evident. The definition of vaccine hesitancy and a matrix of determinants guided the development of a survey tool to assess the nature and scale of hesitancy issues. Additionally, vaccine hesitancy questions were piloted in the annual WHO-UNICEF joint reporting form, completed by National Immunization Managers globally. The objective of characterizing the nature and scale of vaccine hesitancy issues is to better inform the development of appropriate strategies and policies to address the concerns expressed, and to sustain confidence in vaccination. The Working Group developed a matrix of the determinants of vaccine hesitancy informed by a systematic review of peer reviewed and grey literature, and by the expertise of the working group. The matrix mapped the key factors influencing the decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine-specific. These categories framed the menu of survey questions presented in this paper to help diagnose and address vaccine hesitancy.

Mapping vaccine hesitancy--country-specific characteristics of a global phenomenon.

The term vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccination services. Different factors influence vaccine hesitancy and these are context-specific, varying across time and place and with different vaccines. Factors such as complacency, convenience and confidence are involved. Acceptance of vaccines may be decreasing and several explanations for this trend have been proposed. The WHO Strategic Advisory Group of Experts (SAGE) on Immunization has recognized the global importance of vaccine hesitancy and recommended an interview study with immunization managers (IMs) to better understand the range of vaccine hesitancy determinants that are encountered in different settings. Interviews with IMs in 13 selected countries were conducted between September and December 2013 and various factors that discourage vaccine acceptance were identified. Vaccine hesitancy was not defined consistently by the IMs and most interpreted the term as meaning vaccine refusal. Although vaccine hesitancy existed in all 13 countries, some IMs considered its impact on immunization programmes to be a minor problem. The causes of vaccine hesitancy varied in the different countries and were context-specific, indicating a need to strengthen the capacity of national programmes to identify the locally relevant causal factors and to develop adapted strategies to address them.

Human papillomavirus vaccine uptake, knowledge and attitude among 10th grade students in Berlin, Germany, 2010.

PURPOSE: Since March 2007, the Standing Committee on Vaccination (STIKO) recommends HPV vaccination for all 12-17 y-old females in Germany. In the absence of an immunization register, we aimed at assessing HPV-vaccination coverage and knowledge among students in Berlin, the largest city in Germany, to identify factors influencing HPV-vaccine uptake. METHODS: Self-administered questionnaires were distributed to 10th grade school students in 14 participating schools in Berlin to assess socio-demographic characteristics, knowledge, and statements on vaccinations. Vaccination records were reviewed. Multivariable statistical methods were applied to identify independent predictors for HPV-vaccine uptake among female participants. RESULTS: Between September and December 2010, 442 students completed the questionnaire (mean age 15.1; range 14-19). In total 281/442 (63.6%) students specified HPV correctly as a sexually transmitted infection. Of 238 participating girls, 161 (67.6%) provided their vaccination records. Among these, 66 (41.0%) had received the recommended three HPV-vaccine doses. Reasons for being HPV-unvaccinated were reported by 65 girls: Dissuasion from parents (40.2%), dissuasion from their physician (18.5%), and concerns about side-effects (30.8%) (multiple choices possible). The odds of being vaccinated increased with age (Odds Ratio (OR) 2.19, 95% Confidence Interval (CI) 1.16, 4.15) and decreased with negative attitude toward vaccinations (OR = 0.33, 95%CI 0.13, 0.84). CONCLUSIONS: HPV-vaccine uptake was low among school girls in Berlin. Both, physicians and parents were influential regarding their HPV-vaccination decision even though personal perceptions played an important role as well. School programs could be beneficial to improve knowledge related to HPV and vaccines, and to offer low-barrier access to HPV vaccination.

Risk of yellow fever vaccine-associated viscerotropic disease among the elderly: a systematic review.

Yellow fever vaccine-associated viscerotropic disease (YEL-AVD) is a rare and serious adverse event of the yellow fever (YF) vaccine that mimics wild-type YF. Research shows there may be an increased risk of YEL-AVD among the elderly population (≥ 60-65 years old), however this research has yet to be accumulated and reviewed in order to make policy recommendations to countries currently administering the YF vaccine. This paper systematically reviewed all information available on YEL-AVD to determine if there is an increased risk among the elderly, for both travelers and endemic populations. Age-specific reporting rates (RRs) were re-calculated from the literature using the Brighton Collaboration case definition for YEL-AVD and were then analyzed to determine if there was a significant difference between the RRs of younger and older age groups. Two out of the five studies found a significantly higher rate of YEL-AVD among the elderly population. Our findings suggest unexposed elders may be at an increased risk of developing YEF-AVD, however the evidence remains limited. Therefore, our findings for YF vaccination of elderly populations support the recommendations made by the Strategic Advisory Group of Experts (SAGE) in their April 2013 meeting, mainly vaccination of the elderly should be based on a careful risk-benefit analysis.