Reflections on the role of the vaccine against human papillomavirus (HPV) in Sexually Transmitted Diseases (STDs)

Dear Editor,

Sexually Transmitted Diseases (STDs) cause serious damage; among other, gynecological and anal cancers, in that HPV is the carcinogen in 90% of cases. The prevention of these diseases is based on people's education, but their treatment and vaccination occupy an increasingly greater space. In this context, are particularly important (www.aids.gov.br and www.dst.uff.br):

1. Hygiene, particularly peri-intercourse hygiene;

2. Responsibility with respect to one's partners, for instance, the correct use of condoms and care with extramarital sex;

3. A correct and early treatment of STDs and the partner's protection during this period;

4. General preventive care, such as a regular gynecological review;

5. Access to diagnosis, treatment and information about STDs, and

6. Vaccination, currently available for some STDs, such as HPV.

Concerning HPV vaccination, ANVISA currently recommends the tetravalent vaccine for men and women aged 9-26 years; and the bivalent vaccine for women over 9 years old (www.anvisa.gov.br). On the other hand, some studies discuss the benefits of expanding the indication for other age groups, and also for people already infected with HPV. There is even a project of law moving through Brazilian Congress (PLS 238/11) mandating the vaccination for women between 9 and 40 years. The extent of this benefit for a larger number of Brazilian people also depends on public awareness, costs, side effects and benefits of the vaccine.

The awareness of the population depends on informative campaigns to clarify about STDs, especially the benefits of HPV vaccination, vaccine indications and location of vaccination posts. The vaccine costs will decrease with the development of a national technology aiming to a large-scale vaccine production. The vaccine has minor side effects, compared to its benefits, and these side effects should decrease with vaccine improvement.^{1 - 6}

Some facts emphasize the benefits of the vaccine, leading to reflections on the possibility of expanding its indications for other age groups and for people already infected with HPV, such as:

1. HPV vaccines cover part of viral types. In an individual, the infection can occur by types different from those that constitute the viral vaccine, in which case the vaccinated individual would be protected, if a new infection caused by any of HPV types targeted by the vaccine occurs.⁷ In addition, some studies suggest that the vaccine can improve immunity against viral types not present in the vaccine, influencing the treatment and the resistance against disease.^{8 - 11}

2. STDs are entry points for other STDs or for different viral types of the same STD. When the body's immunity is improved with the vaccine and when infections by those HPV types present in the vaccine are prevented, we are improving the protection of the body from being infected by new STDs, or by other viral types.⁹

3. There is a better chance that a STD-infected individual do not follow those preventive care measures above mentioned, therefore being at greater risk of recontamination. In this case, the vaccine protects against diseases caused by those HPV types that make up the vaccine, notwithstanding this behavior.

In conclusion, we believe that demonstrating the advantages of expanding the indication of ANVISA towards vaccinating people of other age groups and also those who have had HPV disease, together with an appropriate investment in research, production and distribution of the vaccine by the Ministry of Health, cancer mortality, absence from work, poor quality of life and the cost of Health will be diminished.^{12 - 14}

REFERENCES

• ¹
  Future II Study Group. Prophylactic efficacy of a quadrivalent human papillomavirus (HPV) vaccine in women with virological evidence of HPV infection. J Infect Dis. 2007;196:1438-46.
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  Szarewski A, Poppe WA, Skinner SR, et al. Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women aged 15-25 years with and without serological evidence of previous exposure to HPV-16/18. Int J Cancer. 2012;131:106-16.
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  Schwarz TF, Spaczynski M, Schneider A, et al. Persistence of immune response to HPV-16/18 AS04-adjuvanted cervical cancer vaccine in women aged 15-55 years. Hum Vaccine. 2011;7:958-65.
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  Muñoz N, Manalastas R Jr, Pitisuttithum P, et al. Safety, immunogenicity, and efficacy of quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine in women aged 324-45 years: a randomised, double-blind trial. Lancet. 2009;373:1949-57.
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  Verstraeten T, Descamps D, David MP, et al. Analysis of adverse events of potential autoimmune aetiology in a large integrated safety database of AS04 adjuvanted vaccines. Vaccine. 2008;26:6630-8.
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  Villa LL, Costa RLR, Petta CA, et al. High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up. Br J Cancer. 2006;95:1459-66.
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  Ho GY, Studentsov Y, Hall CB, et al. Risk factors for subsequent cervicovaginal human papillomavirus (HPV) infection and the protective 32 33 FEBRASGO - Manual de Orientação de Vacinação da Mulher FEBRASGO - Manual de Orientação de Vacinação da Mulher role of antibodies to HPV-16 virus-like particles. J Infect Dis. 2002;186:737-42.
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  Brown DR, Kjaer SK, Sigurdsson K, et al. The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in generally HPV-naive women aged 16-26 years. J Infect Dis. 2009;199:926-35.
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  Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report [internet]. Available from: http://www.cdc.gov/mmwr/pdf/wk/mm5920.pdf [cited 28.5.10].
  » http://www.cdc.gov/mmwr/pdf/wk/mm5920.pdf
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  Wheeler CM, Castellsagué X, Garland SM, et al. Cross-protective efficacy of HPV-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by non-vaccine oncogenic HPV types: 4-year end-of study analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012;13:100-10.
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  Lehtinen M, Paavonen J, Wheeler CM, et al., for the HPV PATRICIA Study Group. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012;13:89-99.
• ¹²
  Sasagawa T, Takagi H, Makinoda S. Immune responses against human papillomavirus (HPV) infection and evasion of host defense in cervical 4 cancer. J Infect Chemother. 2012;18(December):807-15, http://dx.doi.org/10.1007/s10156-012-0485-5 [Epub 2012 Nov 3].
  » http://dx.doi.org/10.1007/s10156-012-0485-5
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  WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World. Summary Report 2010. Available from: http://www.who.int/hpvcentre
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  Instituto Nacional de Câncer. Estimativa 2012: incidência de câncer no Brasil. 2011. Available from: http://www1.inca.gov.br/estimativa/2012/estimativa20122111.pdf [accessed 15.2.13].
  » http://www1.inca.gov.br/estimativa/2012/estimativa20122111.pdf

Publication Dates

• Publication in this collection
  Apr-Jun 2015