Human Papilloma Virus infections and HPV vaccine acceptability in persons from diverse ethnic backgrounds in Amsterdam

In 2009, two years after the registration of two prophylactic vaccines against Human Papilloma Virus (HPV) types 16 and 18, the Dutch Ministry of Health offered HPV vaccination free of charge to all 13-16 year old girls in the Netherlands. From 2010 onwards HPV vaccination will routinely be offered to 12-year old girls. HPV infections are the cause of invasive cervical cancer (ICC), as well as of penile cancer and some head- and neck cancers. HPV vaccination is offered in order to reduce the incidence and mortality of ICC. Unfortunately, the introduction of the HPV vaccine in the Dutch National Immunisation Program (RVP) was less successful than was anticipated, and the expected health benefits may therefore be less than foreseen. The incidence of ICC is high in certain ethnic groups, which are disproportionately poorer and medically underserved. This high incidence is corroborated by a higher seroprevalence to HPV, a surrogate measure of lifetime HPV exposure. Unfortunately ethnic groups that can most benefit from HPV vaccination, may have lower acceptability and uptake of vaccine than the indigenous Dutch population. Research that provides estimates of HPV vaccine acceptability and uptake, and the factors associated with vaccine uptake are needed so that effective public health interventions can be designed focused on decreasing this health disparity. In order to guide future public health practice related to vaccine dissemination, more information is needed about the prevalence of HPV, as measured by serology, among both females and males. Specifically, there is a need to estimate the age and sex specific prevalence of antibodies to high risk (hr) HPV, types of infection that result in cancer morbidity and mortality. The overall goal of this research project is to inform public health vaccine practice, in order to prevent morbidity and mortality due to hrHPV infections. The specific aims are: 1.To estimate the seroprevalence of hrHPV infections, by age group and sex, among six ethnic groups in Amsterdam and analyse associated factors; 2.To assess the HPV vaccination acceptability among adolescents and parents of six ethnic groups in Amsterdam, by age and sex, and analyse reasons for non-uptake; 3.To establish a cohort and conduct baseline measurements that will be linked to HPV incidence and clearance, and to HPV vaccination and cervical screening uptake and outcome in later studies (after runtime of this project). Migrants comprise a large and increasing proportion of the Amsterdam population and appear to have poorer health. Against that background a large cohort study is planned, that aims to unravel the causes (and the unequal burden) of chronic diseases across ethnic groups. The so-called HELIUS cohort aims to include 10,000 individuals from each of 6 ethnic groups (indigenous Dutch; Surinamese [Hindustani & Creole], Turkish, Moroccans and West Africans). This provides a unique opportunity to investigate the epidemiology of hrHPV in association with participation in two programs to prevent cervical cancer, i.e. vaccination uptake of girls and screening uptake of women aged 30-60 years. The cohort will start recruitment in May 2010. After obtaining informed consent, participants will be interviewed about their health and undergo a medical examination. Biological specimens will be obtained, analysed and stored (biobank, including DNA) for future use. Every five years, all participants will be invited for a follow-up health examination. In addition, data of participants will be linked with registry data (e.g. vaccination register; cancer register; cervical cancer screening program register) at the individual level. The proposed project on HPV and vaccine acceptability will be nested within the Helius cohort. For the first study aim, mapping the sero-epidemiology of hrHPV, we will recruit 1760 participants per ethnic group. HPV type-specific antibodies against 8 hrHPV types will be measured in the serum of these participants, and age- and sex-specific prevalences estimated. Associations between possible risk factors and HPV will be assessed using logistic regression. For the second aim, the study into vaccine acceptability, we will recruit 600 parents of children aged 7-12 years, 600 parents of girls aged 16-17, and 600 adolescent girls aged 16-17, all randomly selected from across the six ethnic groups. These participants will be invited for a separate, more detailed interview, in which social-psychological factors related to vaccine acceptability will be assessed. The proposed project is a cross-sectional study design, but will form the baseline for future studies examining the incidence of HPV, uptake of vaccination and ICC screening, and examine associations between these outcomes and baseline measurements. The research team consists of experienced researchers and key actors in the Dutch immunisation policy, ensuring a direct link of results to the relevant institutions.