HPV vaccination in Egypt

El-Said Abdel-Hady,

PhD, FRCOG,

Former Dean of Mansoura Faculty of Medicine,

President of Horus University,

President of EGOS.

declaration

• No conflict of interest,

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• Diagrams and photos in this presentation are downloaded from the internet.

Objectives:

• HPV related cancers,
• Epidemiology of cervical cancer,
• Natural history of cervical cancer,
• Human Papilloma Viruses,
• HPV vaccines: cost/effectiveness,
• Screening after vaccination,
• Do we need HPV vaccines in Egypt?
• Can we achieve the WHO targets for cervical cancer?
• Conclusion.

HPV oncogenesis:

Epidemiology of cervical cancer:

• Globally, cervical cancer is the fourth most common cancer in women.

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• In the developing countries, cervical cancer is the most common gynecological cancer,

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• In 2022, an estimated 660,000 new cases of cervical cancer occurred, with 350,000 deaths.

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• 94% of the 350,000 death-related cervical cancers occurred in low and middle-income countries.

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WHO. 5 March 2024. Cervicl cancer.

Global incidence rates of Cervical cancer

Global mortality rates

In Egypt:�HPV and related cancers, fact sheet 2023, HPV information center March 2023.

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• 36.7 million women aged ≥15 years are at risk.

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• 1320 women are diagnosed with cervical cancer and 744 women die of the disease.

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• Cervical cancer ranks (all years) as the 13^th among women and 12^th cause of death.

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• The 9^th among women aged 15-44 and 11^th cause of death.

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In Egypt:�HPV and related cancers, fact sheet 2023, HPV information center March 2023.

• Data is not yet available on the HPV burden in the general population of Egypt.

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In the North African region,

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• 3% of women in the general population harbor HPV 16/18,

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• 78.9% of invasive cervical cancer are attributed to HPV 16 or 18.

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In Egypt:�HPV and related cancers, fact sheet 2023, HPV information center March 2023.

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Burden of cervical HPV infection in Egypt

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• HPV 16/18 prevalence No tested 95% CI
• Normal cytology - -
• Low grade CIN - -
• High grade CIN - -
• Cervical cancer - -

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• WWW.hpvcenter.net

The prevalence of HPV among Egyptian women and its impact : an observational study

• M. Elazab et al. open journal of obstetrics and gynecology. 2021; 11 (7), 879-884.

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• Between June 2019-August 2020.
• Comprehensive health insurance authority,
• Women between 20-65 years,

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• Among 1000 women underwent the LBC test, 143 women were positive to HPV DNA (14.3%).
• HPV 16 was the most common subtype (73.2%) .
• More than one subtype were found in 26.8% of positive cases.

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Natural History/prevention strategy of cervical cancer

HPV

CIN I-III

Cancer

10 years

5-10 years

HPV vaccines

Eradication

�persistent infection with high-risk HPV can cause CIN and can cause cancer.

Human Papilloma Viruses (HPVs)

• HPV was first detected by transmission electron microscopy as the causal organism of cutaneous and anogenital warts but the association between HPV and cervical cancer was proposed by Zur-Hausen et al in 1974.

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• The Nobel Prize in Physiology or Medicine 2008 Herold Zur Hausen HPV is the necessary or the key cause of cervical cancer.

DNA viruses

• >150 types of DNA viruses

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• The HPV DNA genome consists of approximately 8000 base pairs (8 kb) in double-stranded (circular) form.

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• It includes 8 protein -coding genes called open reading frames (ORF) and a regulatory region called the upstream regulatory region (URR).

HPV genome

Early and late genes

• The HPV early (E) proteins are involved in viral transcription and replication.

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• The late (L) proteins are required for viral assembly and make up the capsid found in the mature virus particle.

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• E6 inactivates p53 gene

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• E7 inactivates Rb gene

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J Clin Virol. 2000 Oct;19(1-2):57-66.

• Natural HPV immunity and vaccination strategies.
• Stern PL¹, Brown M, Stacey SN, Kitchener HC, Hampson I, Abdel-Hady ES, Moore JV.

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Cancer Res. 2001 Jan 1;61(1):192-6.

• Immunological and viral factors associated with the response of vulval intraepithelial neoplasia to photodynamic therapy.
• Abdel-Hady ES¹, Martin-Hirsch P, Duggan-Keen M, Stern PL, Moore JV, Corbitt G, Kitchener HC, Hampson IN.

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FASEB J. 2001 Jun;15(8):1445-7.

• The HPV16 E6 and E7 proteins and the radiation resistance of cervical carcinoma.
• Hampson L¹, El Hady ES, Moore JV, Kitchener H, Hampson IN.

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HPV carcinogenesis

HPV vaccines

HPV vaccines (WHO March 2024).

• The first HPV vaccine became available in 2006.

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• As of 2023, globally, there are 6 HPV vaccines available (WHO).

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• HPV vaccines should be given to all girls aged 9-14 years, before they become sexually active.

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• The vaccine may be given in 1 or 2 doses.

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• People with reduced immunity should receive 2 or 3 doses.

WHO global strategy for elimination of cervical cancer by 2030,

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All countries have made a commitment to eliminate cervical cancer as a public health problem.

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• 90% of girls vaccinated by age 15.

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• 70 % of women screened with a high- quality test (HPV detection) by ages 35 and 45.

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• 90% of women with cervical disease receiving treatment.

HPV vaccine inclusion in national immunization programmes

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• As of November 2024, at least 144 countries (74% of WHO-member states) provided the HPV vaccine in their national immunization schedule for girls.

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• The figures for boys is around 24% of member states.

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• https://en.Wikipedia.org. HPV Vaccine-Wikipedia

Mechanism of action

• The HPV vaccines are based on hollow virus-like particles (VLPs) assembled from recombinant HPV coat proteins L1 and L2.

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• Gardasil are designed to elicit virus-neutralizing antibody responses that prevent initial infection with the HPV types represented in the vaccine.

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Lowy DR, Schiller JT (May 2006). "Prophylactic human papillomavirus vaccines". Journal of Clinical Investigation. 116 (5): 1167–73. doi:10.1172/JCI28607. PMC 1451224. PMID 16670757

Virus-like particles (VLPs) assembled from the L1 protein of human papillomavirus 16 and 18 (bivalent)

efficacy

• All HPV vaccines have been found to have high efficacy (close to 100%) for prevention of HPV vaccine type-related persistent infection.

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• HPV vaccine efficacy-CDC. https://www.cdc.gov

HPV vaccine effectiveness by age at vaccination: a systematic review

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• The highest vaccine effectiveness were found in the younger age groups.

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• 9-14 years: 74-93%

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• 15-18 years: 12-90%

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• Ellingson MK et al. Human vaccin immunother. 2023;19 (2): 2239085.

Efficacy in preventing cancer:

It is estimated that vaccination might prevent:

• 70% of cervical cancer,
• 80% of anal cancer,
• 60% of vaginal cancer,
• 40% of vulvar cancer, and possibly some mouth cancer.

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• They additionally prevent some genital warts with the vaccines against 4 and 9 HPV types providing greater protection.

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• "Human papillomavirus vaccines: WHO position paper, October 2014." (PDF). Weekly Epidemiological Record. 89: 465–492. Oct 24, 2014. PMID 25346960.

safety

• HPV vaccines are very safe.
• Pain at the site of injection occurs in about 80% of people.
• Redness and swelling at the site and fever may also occur.
• No link to Guillain–Barré syndrome has been found.

Cost effectiveness

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• Vaccination is cost effective in developed nations.

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• Vaccination may be cost effective in the developing world.

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• Fesenfeld, M; Hutubessy, R; Jit, M (20 August 2013). "Cost-effectiveness of human papillomavirus vaccination in low and middle income countries: a systematic review.". Vaccine. 31 (37): 3786–804. doi:10.1016/j.vaccine.2013.06.060. PMID 23830973

Vaccination is not an alternative to screening

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• Since the vaccine only covers some high-risk types of HPV, cervical cancer screening is recommended even after vaccination.

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• In the US, the recommendation is for women to receive routine Pap smears beginning at age 21.

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• "Human Papillomavirus (HPV) Vaccines: Q & A". Fact Sheets: Risk Factors and Possible Causes. National Cancer Institute (NCI). 2009-10-22. Retrieved 2008-07-18.

Do we need the vaccine in Egypt?

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Yes we need the vaccine,

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• In the National screening programme.

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• In a selected group of the community,

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• For those who can afford it,

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• For those who ask for it.

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Can we afford the vaccine?

• Probably yes!!

A national campaign

• In August 2023, a government- backed campaign was lunched to raise awareness around cervical cancer.

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• Journey of a Thousand Kilometers sponsored by the ministry of social solidarity value of 27 million Egyptian pounds.

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• Rotary-funded project: worth of 2 million US dollars for greater Cairo area.

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The presidential initiative for cancer prevention

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• Breast cancer
• Cervical cancer
• Lung cancer
• Prostate cancer
• Colon cancer

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Can we screen for cervical cancer?

• Yes we can.

Int J Gynaecol Obstet. 2006 May;93(2):118-22

• Screening for cervical carcinoma using visual inspection with acetic acid.
• Abdel-Hady ES¹, Emam M, Al-Gohary A, Hassan M, Farag MK, Abo-Elkheir M.

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In my view, Egypt needs,�Visual inspection with acetic acid (VIA test)�

• Negative Positive

Can we reduce the high false positive rate?

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• Can Revised Visual Inspection with Acetic Acid (VIA) Test Improve the Performance of Crude VIA Test of in Low-Resource-Setting Countries?

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• Indian Journal of Gynecologic Oncology, 2017;15:65.

Can we achieve the WHO target for cervical cancer prevention by 2030?

• Probably yes!

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• ?? 90%HPV vaccination,

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• √√ 70% screening by age 35 and 45,

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• √√ 90% treatment.

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Thank you

El-Said Abdel-Hady,

PhD (Manchester), FRCOG,

Professor of Obstetrics and Gynecology,

Former Dean of Mansoura School of Medicine,

President of Horus University,

President of EGOS (Egyptian Gynecologic Cancer Society).

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