Shao-Kai Zhang

Perceptions and acceptability of HPV vaccination among parents of young adolescents: A multicenter national survey in China

Prophylactic HPV vaccines target young adolescents to prevent related cervical lesions and even genital warts prior to onset of sexual activity. Parental consent is often essential for success of vaccination program for this age group. We conducted a national multicenter study to explore the acceptability of HPV vaccination among parents of young adolescents and associated factors in relevant parent decision making in China. A total of 2899 parents of young adolescents (11-17 years) participated in the survey between November 28, 2011 and May 9, 2012, but four were excluded from analysis because of inconsistencies in their given information in the questionnaire. Mothers accounted for 62.8% of the parent participants. The mean age of the parents was 40.40 (standard deviation, 4.68) years. Only 36.2% of the parents accepted the vaccine for their children. Knowledge about HPV and HPV vaccine was a positive correlate with HPV vaccination acceptability (Ptrend=0.003). Grade of child (Ptrend=0.015), prior vaccination experience outside the National Expanded Program on Immunization (OR: 1.43; 95%CI: 1.19-1.72), fear of cervical cancer and/or genital warts (OR: 2.47; 95%CI: 2.00-3.05), and prior consultation regarding HPV vaccine information (OR: 2.35; 95%CI: 1.57-3.52) were also positively associated with higher HPV vaccine acceptability. The acceptability was lower in mothers (OR: 0.45; 95%CI: 0.37-0.54) and who had better education (Ptrend=0.009). 57.3% of the parents agreed that the most appropriate venue for HPV vaccination was the local center for disease prevention and control. In conclusion, our study indicates a low acceptability of HPV vaccination among parents of young adolescents in China. We understand there are many challenges in implementing HPV vaccination program. Our findings will serve as valuable references for future HPV vaccination policies and campaigns after HPV vaccines are approved in China.

p16INK4A immunohistochemical staining and predictive value for progression of cervical intraepithelial neoplasia grade 1: a prospective study in China.

p16INK4A is strongly expressed in tissues diagnosed as cervical intraepithelial neoplasia (CIN) and cancer in women infected with human papillomavirus (HPV), but few prospective studies have evaluated p16INK4A as a marker for the risk of low‐grade CIN (CIN1) progression. We investigated the prevalence of p16INK4A immunostaining by CIN grade and whether overexpression of p16INK4A in CIN1 predicts future risk for high‐grade CIN in Chinese women. 6,557 Chinese women aged 30–49 years were screened from 2003 to 2005 using cytology and carcinogenic HPV test. Colposcopy was performed on women with any abnormal result. p16INK4A Immunostaining was performed on biopsies from all women with CIN1, as well as randomly selected women with normal or CIN grade 2 and worse (CIN2+) biopsies. Women with CIN1 were followed up without treatment. Colposcopy was performed on all untreated women at a 2‐year interval. The prevalence of p16INK4A staining was 2.7%, 42.7%, 75.5%, 79.6% and 100% among women with normal, CIN1, 2, 3 and cancer biopsies, respectively (p < 0.001). HPV positivity was strongly associated with p16INK4A staining [odds ratios (OR) = 12.8; 95% confidence intervals (CI): 5.2–31.6]. p16INK4A staining of CIN1 biopsies at baseline was associated with an increased risk of finding high‐grade CIN over 2 years of follow‐up (OR = 1.43; 95% CI: 0.52–3.91). The two‐year cumulative incidence of CIN2+ for p16INK4A positive women was higher at 10.71% than for p16INK4A negative women at 1.30% (crude RR = 8.25, 95% CI: 1.02–66.62). p16INK4A overexpression is strongly associated with grade of CIN and risk of progression to high‐grade CIN in women with low‐grade lesions.

Human Papillomavirus Vaccine Awareness, Acceptability, and Decision-Making Factors among Chinese College Students

BACKGROUND College students are recommended as the target groups for catch-up human papillomavirus (HPV) vaccination. Systematical exploration of awareness, acceptability, and decision-making factors of HPV vaccination among Chinese college students has been limited. MATERIALS AND METHODS A multi-center survey was conducted in mainland China between November 2011 and May 2012. College students aged 18-22 years were stratified by their grade, gender, and major for sampling. Socio-demographic and HPV-related information such as knowledge, perceptions, acceptability, and attitudes were collected through a questionnaire. RESULTS A total of 3,497 undergraduates completed the questionnaire, among which 1,686 were males. The acceptability of the HPV vaccine was high (70.8%). Undergraduates from high-level universities, at lower grade, or with greater prior knowledge of HPV vaccines showed higher acceptability of HPV vaccination (ptrend <0.001). Additionally, undergraduates with vaccination experience outside the National Expanded Program on Immunization (OR=1.29; 95%CI: 1.10-1.51) or fear of HPV-related diseases (OR=2.79; 95%CI: 2.28-3.41) were more willing to accept HPV vaccination. General knowledge of HPV vaccine was low among undergraduates, and safety was a major concern (71.05%). The majority of students wished to pay less than 300RMB for HPV vaccine and chose the Chinese Center for Disease Control and Prevention as the most appropriate venue for vaccination. CONCLUSIONS Although most undergraduates demonstrate positive attitudes towards HPV vaccination, challenges pertaining to introduction exist in China. Corresponding proactive education and governmental subsidy to do so are urgently needed by this age-group population. Suggestions and potential strategies indicated may help shape the future HPV vaccination program in China.

Acceptability of human papillomavirus vaccine among parents of junior middle school students in Jinan, China

OBJECTIVE To determine the level of awareness on human papillomavirus (HPV) vaccine and acceptance of HPV vaccination among parents of junior middle school students. METHODS A cross sectional survey employing cluster sampling was conducted in Jinan, Shandong Province of China in January of 2013. RESULTS A total of 400 parents of junior middle school students participated in the questionnaire survey, among whom 360 (90%) completed valid questionnaires. About 88 (22.63%) parents had ever heard of HPV. Only one in ten (10.2%) knew about HPV vaccine. Parents willing to accept HPV vaccination for children accounted for 40.8%. Factors associated willing to accept HPV vaccination for children among parents were: female parent (AOR: 0.38, 95%CI: 0.21-0.67), having ever heard of HPV vaccine (AOR: 2.38, 95%CI: 1.01-5.61), thinking HPV vaccination should commence before sexual debut(AOR: 2.16, 95%CI: 1.21-3.85), thinking HPV vaccination should commence before 12 years old (AOR: 2.76, 95%CI: 1.02-7.46) or 13-15 years old (AOR: 4.75, 95%CI: 1.79-12.61), concern about suffering from cervical cancer and/or genital warts (AOR: 2.43, 95%CI: 1.31-4.50). About 60% of parents were in favor of future HPV vaccination promoting in China believing that HPV vaccine could efficiently prevent cervical cancer, anal cancer or genital warts, 37.4% of parents with expectation of governmental subsidy and price regulation. CONCLUSION Parental awareness level of HPV vaccine and willingness to accept HPV vaccination for children was low. However, the general attitude of many participants toward future promoting of HPV vaccination in China was encouraging, particularly if certain expectations were met.

Evaluation of p16/Ki-67 dual staining in detection of cervical precancer and cancers: a multicenter study in China

Purpose To analyze the clinical performance of p16/Ki-67 dual-stained cytology identifying high-grade cervical intraepithelial neoplasia (CIN2+) in Chinese women. Methods 1079 women attending ongoing cervical cancer screening and 211 “enriched” women aged ≥30yrs with biopsy-confirmed CIN2+ from five Chinese hospitals were enrolled during year 2014-2015. Cervical specimens were collected for high-risk human papillomavirus (HR-HPV) DNA analysis, Liquid-based cytology (LBC) and p16/Ki-67 dual staining. Colposcopy and biopsy were performed on women with any abnormal result. Results p16/Ki-67 positivity increased with histologic severity. It was 18.4%(183/996) in normal histology, 54.0%(34/63) in CIN1, 81.0%(34/42) in CIN2, 93.3%(111/119) in CIN3, 71.4% (5/7) in adenocarcinoma and 95.2%(60/63) in squamous cell carcinoma. Compared with the HR-HPV negatives, p16/Ki-67 expression was significantly higher in the HPV16/18 positive (OR: 35.45(95%CI: 23.35-53.84)) and other 12 HR-HPV types positive group (OR: 8.01(95%CI: 5.81-11.05). The sensitivity and specificity of p16/Ki-67 to detect CIN2+ in the entire population were 90.9% and 79.5%, respectively. In women with ASC-US and LSIL, sensitivity and specificity for detection of CIN2+ were 87.5% and 66.4%, respectively, with a referral rate of 43.8%. In women who tested positive for HR-HPV, sensitivity and specificity of dual-staining for detection of CIN2+ were 92.7% and 52.7%, respectively, and the referral rate was 68.7%. Conclusions p16/Ki-67 dual-stained cytology provided a high sensitivity and moderate specificity to detect underlying cervical precancer and cancers in various settings, and might be considered as an efficient screening tool in China.

How university students view human papillomavirus (HPV) vaccination: A cross-sectional study in Jinan, China

The acceptability of HPV vaccination among university students in China is not well understood. Our study was of cross-sectional study design. We collected a questionnaire about socio-demographic characteristics, knowledge of, attitude toward and acceptability of HPV vaccination. A total of 351 students were included in data analyses, among whom 47.6% were males and 70.0% aged 19–21. Only 10.3% had previously heard of HPV and 5.4% HPV vaccine. Male and female students were equally likely to accept HPV vaccine (71.8 vs 69.4%, p = 0.634) and recommend it to sexual partners (73.1 vs 76.7%, p = 0.441). The great majority of students could only afford RMB 300 (USD 50) or less for HPV vaccination. HPV vaccination acceptance was associated with being in year-one (Adjusted odds ratio (AOR) = 3.78, 95% confidence interval (CI): 2.12–6.75), being from a key university (AOR = 1.88, 95%CI: 1.07–3.31), having heard of HPV-related morbidities (AOR = 1.88, 95% CI: 1.05–3.35), being concerned about HPV-related morbidities (AOR = 2.23, 95% CI: 1.16–4.27) and believing the vaccine should be given before first sexual contact (AOR = 2.44, 95% CI: 1.38–4.29). Female students were more likely to anticipate a late uptake of HPV vaccination (p = 0.002). The relatively lower levels of HPV knowledge but higher levels of vaccine acceptance among undergraduates highlighted the need for education on the roles of sexual behaviors in HPV transmission.

The Natural History of Cervical Cancer in Chinese Women: Results from an 11-Year Follow-Up Study in China Using a Multistate Model

Background: It is important to understand the natural history of cervical cancer, which has implications for cancer prevention and management. However, a dearth of studies on the long-term development of cervical cancer exists in China. Methods: We investigated the natural history of cervical cancer in Chinese women by creating a multistate model using 11 years of follow-up data from the Shanxi Province Cervical Cancer Screening Study I conducted from 1999 to 2010. In 1999, a total of 1,997 eligible women, ages 35 to 45 years, were enrolled in Xiangyuan County, Shanxi Province. Participants were followed up in 2005 and 2010, respectively. Results: The average time a subject spent in CIN1 before transiting into another state was 1.4693 years [95% confidence interval (CI): 1.1215–1.9251] and the average time a subject spent in CIN2 was 2.9822 years (95% CI: 1.9790–4.4938). A subjects transition probability from CIN1 to normal increased with time. However, the transition probability from CIN1 to CIN2 was relatively lower, with 3-, 5-, and 10-year transition probabilities of 0.1415, 0.1066, and 0.0437. Comparison of 5-year transition probabilities between CIN2 to normal/CIN1 and CIN2 to CIN3+ yielded a ratio of 2.74. Conclusions: Women with CIN1 had a substantial tendency for regression. Similarly, women with CIN2 had a higher probability of regression to normal/CIN1 than progression to CIN3+. Findings in this study may have significant implications for the development and evaluation of formal cervical cancer preventive strategies in China. Impact: This study may serve as a valuable reference to future research on other multistate cancer processes. Cancer Epidemiol Biomarkers Prev; 23(7); 1298–305. ©2014 AACR.

A Real-World Feasibility Study of CareHPV assay, VIA/VILI and Pap Smear as Primary Screening in Rural China

Background: To compare the real-world performance of visual inspection with acetic acid and with Lugol’s iodine (VIA/VILI), cytology and careHPV DNA assay in rural China performed by local health providers. Methods: Eligible women living in rural areas in Xinmi County, Henan Province were invited to participate in cervical cancer screening program. Enrolled women were randomized into 3 intervention arms, screened by VIA/ VILI, pap smears, and careHPV assay respectively. Women had positive primary screening results were referred to colposcopy and/or biopsy. All the clinical and lab work was performed by local health providers. The final diagnoses of histopathology were based on the diagnosing of a senior histopathology expert from Cancer Hospital, Chinese Academy of Medical Sciences. Questionnaires about the knowledge and attitudes towards the HPV and the screening program of the health providers at village clinics were collected. Results: 894 women had careHPV DNA test, 552 underwent VIA/VILI and 547 had Pap smears. The positive rates for careHPV assay, VIA/VILI and Pap smears were 10.6%, 18.1%, and 4.9% respectively (χ2=48.647, P<0.001). The overall CIN2+ detection rate was 0.5%, the CIN2+ detection rate for the three arms were not significantly different (0.7% for careHPV assay, 0.5% for VIA/VILI, 0.2% for pap smear, χ2=1.648, P=0.439). The knowledge of the health providers about HPV, HPV assay in screening was unsatisfactory. However, their attitudes about implementing HPV assay into the national program were positive. Conclusion: Implementing careHPV assay in low resource settings and performed by simply trained lab personnel is feasible. For large population screening program, extensive training and good quality control are needed to improve the quality. Education for implementing HPV assay in local health providers are needed.