Karolina Raczkowska-Łabuda, Anna Gorzelnik, *Lidia Zawadzka-Głos
Why is a laryngologist interested in cervical cancer? Summary information about HPV vaccination
Czemu laryngolog interesuje się rakiem szyjki macicy? Podsumowanie informacji dotyczących szczepień przeciwko HPV
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Szczepionki przeciwko HPV dostępne są na światowym rynku od ponad 10 lat. W Polsce pierwsze preparaty pojawiły się w aptekach w 2007 roku, choć zostały wymienione w PSO dopiero rok później. Obecnie w naszym kraju szczepienia przeciwko wirusowi brodawczaka ludzkiego można przeprowadzić w schemacie 3-dawkowym preparatami 2-walentnymi, 4-walentnymi oraz 9-walentnym. Badania kliniczne podsumowujące 10 lat doświadczeń udowadniają wysoką skuteczność szczepionki względem obniżenia częstości występowania infekcji HPV oraz raka szyjki macicy. Artykuł porównuje politykę programów szczepień przeciwko HPV w Polsce i na świecie i przedstawia najnowsze zalecenia co do stosowania różnych preparatów, przybliża ich charakterystykę. Podkreśla się prewencyjną rolę szczepień w przypadkach HPV-zależnych nowotworów głowy i szyi oraz potrzebę profilaktyki immunologicznej zarówno u dziewcząt, jak i u chłopców. Praca kładzie nacisk na spodziewane korzyści wdrożenia programów populacyjnych, zarówno w wymiarze społecznym, jak i finansowym, na przykładzie Państw, gdzie zastosowano takie rozwiązanie. Celem artykułu jest spopularyzowanie tematu szczepień przeciwko HPV w Polsce i wsparcie inicjatywy włączenia szczepionki przeciwko brodawczakowi ludzkiemu do PSO.
Human papillomavirus (HPV) vaccines have been available on the world market for more than 10 years. They became available in Polish pharmacies in 2007, although they were only included in the National Vaccination Program almost one year later. Currently in our country, the vaccination against human papillomavirus can be performed in a 3-dose schedule with a 2-valent, 4-valent or 9-valent vaccine. Clinical studies after 10 years of the presence of the vaccine in the market indicate that these vaccinations are an efficient measure for reducing the risk of HPV infection and of cervical cancer. The article compares HPV vaccination programs in Poland and around the world, presents the newest guidelines for the use of particular products, and discusses the characteristics of the products. The preventive role of vaccinations in HPV-dependent head and neck tumors, as well as the need for immunoprophylaxis in both girls and boys is underlined. The paper emphasizes the expected benefits of the implementation of population programs, both in social and financial aspects, on the example of countries which had already implemented such a solution. The aim of the article was to popularize the topic of vaccination against HPV in Poland and to support the initiative of the inclusion of HPV vaccination to the obligatory part of the National Vaccination Program.
Human papillomavirus (HPV) belongs to the Papillomaviridae family. It is characterized by a tropism towards the epithelial cells of the skin and mucous membranes. The invasion of the epithelium results from skin injuries. Viral propagation is coupled with epithelial cell differentiation process. According to the latest reports, there are over 200 types of HPV viruses, classified in a few groups: α, β, γ, μ, and v. Group α consists of 60 viruses attacking, among others, the cervical epithelium, which can lead to cervical cancer. Type β viruses infect the skin, are responsible for the formation of warts and are usually not oncogenic. Viruses can be further divided into groups with low, medium and high oncogenic potential. HPV types 16 and 18 are responsible for 70% of cases of cervical cancer. In addition, their key role in the formation of head and neck cancers is underlined. Over the past two decades, it has been proven that HPV infection is particularly common in oropharyngeal cancers. In the light of this information, the great interest of medical specialists from different fields in HPV vaccine is not surprising.
Material and Methods
A review of the literature on HPV vaccination, with particular reference to the publications from the last 4 years (2014-2017). The main focus was put on national guidelines of organizations such as: Centers for Disease Control and Prevention of the United Stated, American Food and Drug Administration, English National Health Service, Public Health Agency of Canada, Immunize Australia Program, Information Centre on HPV and Cancer of the Catalan Institute of Oncology, Norwegian Cervical Cancer Screening Programme, Polish Ministry of Health, and Chief Sanitary Inspector in Poland.
HPV vaccines have been available on the American market for more than 10 years. In Poland, they first appeared a little later – in 2008, the first recommendations of the Minister of Health and the Chief Sanitary Inspector regarding HPV vaccination were issued (1). Unfortunately, unlike multiple countries in the world, including United States, Great Britain, Norway, as well as Philippines and Malaysia, where a full reimbursement of HPV vaccination has been introduced (tab. 1), in Poland, the vaccinations are recommended, but the costs are not reimbursed by the National Health Fund. In August 2016, the Ministry of Health announced that funding for the inclusion of HPV vaccination into the National Vaccination Program was not currently possible, and in the perspective of the coming years, the Department of Mother and Child had no possibility of planning the expense of 250-300 million Polish zlotys in order to buy the HPV vaccine and include it in the obligatory vaccines (2).
Tab. 1. List of countries where HPV vaccination is compulsory and reimbursed
Luckily, under the Article 48 of the Health Care Act of 27th August 2004, it is also possible for local governments to develop their own health programs, and some of them taking the initiative to finance the HPV vaccination. In the years 2009-2011, only 3% of the target population in Poland was vaccinated in such programs (3), however, the local government’s activity is popularizing the problem and raising public awareness.
The incidence of cervical cancer in Poland is 15% higher than the European Union average and mortality is 70% higher (3, 4). This translates into 3,000 new cases and nearly 1,750 premature deaths every year (data from 2010) (3, 4). However, it should be borne in mind that cervical cancer is not the only neoplasm caused by HPV. Unfortunately, there is no comprehensive data for all HPV-related cancers in the National Cancer Registry. HPV has been shown to be directly related to cancers of the vagina, vulva, penis, anus, oral cavity, tonsils, pharynx and larynx. Recurrent laryngeal papillomatosis, present in both children and adults, must also be enumerated among the HPV-related diseases (5).
The most available data in the literature concerns cervical cancer (6-8). The scale of the problem is presented in table 2.
Tab. 2. Incidence and mortality due to cervical cancer in the year 2017 (data concerning USA from the year 2016)
|Country||Incidence [pers./year]||Mortality [pers./year]||Lethality|
The relationship of cervical cancer and HPV is unquestionable. Viral DNA is detected in 95-100% of the patients affected with cervical cancer (9).
HPV is one of the most common human pathogens. There are over 200 types of the virus, over 40 of which are sexually transmitted. The latter are classified in two groups:
1. low risk – usually do not induce oncogenesis, but cause mild condylomata acuminata in the genital and anal area, as well as respiratory papillomas. This group consists primarily of HPV types 6, 11, 42, 43, 44;
2. high risk (oncogenic) – promote oncogenesis. This group includes HPV types 16 and 18, as well as 31, 33, 35, 39, 40, 43, 51, 52, 53, 54, 55, 56, and 58. Viral DNA is detected in:
– 95-100% of cases of cervical cancer, 70% of the DNA detected is HPV-16 and -18;
– 95% of rectal cancer – mainly HPV-16;
– 70% of the oral and pharyngeal cancers (pharynx, soft palate, tongue, tonsils) – more than 50% caused by HPV-16;
– 65% of vaginal cancers – HPV-16 predominates;
– 50% of vulvar cancers – HPV-16 predominates;
– 35% of penile cancers – HPV-16 predominates (10, 11);
– 20% of laryngeal cancers – HPV-16 predominates (12).
It is estimated that over 90% of men and 80% of women will be infected with at least one HPV type in their lifetime (13, 14). Half of these infections will be caused by oncogenic types (high-risk types) (13, 14). The course of the infection is asymptomatic and often self-limiting (lasting between 1 and 2 years), therefore, it is possible for a person to unknowingly transmit the virus to their partners.
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