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.

Abstract

Human papillomavirus (HPV)-6/11/16/18 vaccine reduces the risk of HPV-6/11/16/18-related cervical intraepithelial neoplasia (CIN) 1-3 or adenocarcinoma in situ (AIS). Here, its impact on CIN1-3/AIS associated with nonvaccine oncogenic HPV types was evaluated.
We enrolled 17,622 women aged 16-26 years. All underwent cervicovaginal sampling and Pap testing at regular intervals for up to 4 years. HPV genotyping was performed for biopsy samples, and histological diagnoses were determined by a pathology panel. Analyses were conducted among subjects who were negative for 14 HPV types on day 1. Prespecified analyses included infection of 6 months' duration and CIN1-3/AIS due to the 2 and 5 most common HPV types in cervical cancer after HPV types 16 and 18, as well as all tested nonvaccine types.
Vaccination reduced the incidence of HPV-31/45 infection by 40.3% (95% confidence interval [CI], 13.9% to 59.0%) and of CIN1-3/AIS by 43.6% (95% CI, 12.9% to 64.1%), respectively. The reduction in HPV-31/33/45/52/58 infection and CIN1-3/AIS was 25.0% (95% CI, 5.0% to 40.9%) and 29.2% (95% CI, 8.3% to 45.5%), respectively. Efficacy for CIN2-3/AIS associated with the 10 nonvaccine HPV types was 32.5% (95% CI, 6.0% to 51.9%). Reductions were most notable for HPV-31.
HPV-6/11/16/18 vaccine reduced the risk of CIN2-3/AIS associated with nonvaccine types responsible for approximately 20% of cervical cancers. The clinical benefit of cross-protection is not expected to be fully additive to the efficacy already observed against HPV-6/11/16/18-related disease, because women may have >1 CIN lesion, each associated with a different HPV type.
ClinicalTrials.gov identifiers: NCT00092521 , NCT00092534 , and NCT00092482.

Full text

Page 1

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
Darron R. Brown, Susanne K. Kjaer, Kristján Sigurdsson, Ole-Erik Iversen, Mauricio Hernandez-Avila,
Cosette M. Wheeler, Gonzalo Perez, Laura A. Koutsky, Eng Hseon Tay, Patricía Garcia, Kevin A. Ault,
Suzanne M. Garland, Sepp Leodolter, Sven-Eric Olsson, Grace W. K. Tang, Daron G. Ferris, Jorma Paavonen,
Marc Steben, F. Xavier Bosch, Joakim Dillner, Elmar A. Joura, Robert J. Kurman, Slawomir Majewski,
Nubia Muñoz, Evan R. Myers, Luisa L. Villa, Frank J. Taddeo, Christine Roberts, Amha Tadesse, Janine Bryan,
Lisa C. Lupinacci, Katherine E. D. Giacoletti, Heather L. Sings, Margaret James, Teresa M. Hesley, and Eliav Barra
(See the editorial commentary by Herrero and the article by Wheeler et al., on pages 919–22 and 936–44,
respectively.)
Background.
Human papillomavirus (HPV)–6/11/16/18 vaccine reduces the risk of HPV-6/11/16/18–related
cervical intraepithelial neoplasia (CIN) 1–3 or adenocarcinoma in situ (AIS). Here, its impact on CIN1–3/AIS asso-
ciated with nonvaccine oncogenic HPV types was evaluated.
Methods.
We enrolled 17,622 women aged 16–26 years. All underwent cervicovaginal sampling and Pap testing
at regular intervals for up to 4 years. HPV genotying was performed for biopsy samples, and histological diagnoses
weredeterminedbyapathologypanel.Analyseswereconductedamongsubjectswhowerenegativefor14HPVtypes
on day 1. Prespecified analyses included infection of ?6 months’ duration and CIN1–3/AIS due to the 2 and 5 most
common HPV types in cervical cancer after HPV types 16 and 18, as well as all tested nonvaccine types.
Results.
Vaccination reduced the incidence of HPV-31/45 infection by 40.3% (95% confidence interval [CI],
13.9% to 59.0%) and of CIN1–3/AIS by 43.6% (95% CI, 12.9% to 64.1%), respectively. The reduction in HPV-31/
33/45/52/58 infection and CIN1–3/AIS was 25.0% (95% CI, 5.0% to 40.9%) and 29.2% (95% CI, 8.3% to 45.5%),
respectively. Efficacy for CIN2–3/AIS associated with the 10 nonvaccine HPV types was 32.5% (95% CI, 6.0% to
51.9%). Reductions were most notable for HPV-31.
Conclusions.
HPV-6/11/16/18vaccinereducedtheriskofCIN2–3/AISassociatedwithnonvaccinetypesrespon-
sible for ?20% of cervical cancers. The clinical benefit of cross-protection is not expected to be fully additive to the
efficacy already observed against HPV-6/11/16/18–related disease, because women may have ?1 CIN lesion, each
associated with a different HPV type.
Trial registration.
ClinicalTrials.gov identifiers: NCT00092521, NCT00092534, and NCT00092482.
Human papillomavirus (HPV) infection is a necessary
risk factor for cervical cancer [1]. Worldwide, cervical
cancer is the second most common cancer in women
andthethirdmostfrequentcauseofdeathduetocancer,
accounting for nearly 300,000 deaths annually [2].
Received 29 May 2008; accepted 2 September 2008; electronically published 23
February 2009.
Potential conflicts of interest are listed at the end of the text.
Presented in part: International Papillomavirus Congress and Clinical Workshop,
Beijing, 3–9 November 2007 (abstract 5B-02); EUROGIN, Monaco, 4–6 October
2007 (abstract SS2–2); Interscience Conference on Antimicrobial Agents and
Chemotherapy, Chicago, 17–20 September 2007 (abstract 1915); Australian Soci-
ety for Colposcopy and Cervical Pathology, Gold Coast, Australia, 27–30 Septem-
ber 2007.
The Journal of Infectious Diseases
© 2009 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2009/19907-0003$15.00
DOI: 10.1086/597307
2009; 199:926–35
Financial support: Merck Research Laboratories, a division of Merck & Co. The studies
weredesignedbythesponsor(Merck&Co.)incollaborationwithexternalinvestigatorsand
anexternaldataandsafetymonitoringboard.Thesponsorcollatedthedata,monitoredthe
conduct of the study, performed the statistical analysis, and coordinated the writing of the
manuscript with all authors. The authors were actively involved in the collection, analysis,
orinterpretationofthedataandintherevisingofthemanuscriptforintellectualcontentand
approved the final manuscript. The sponsor provided funding for page charges.
aAuthor affiliations are listed at the end of the text.
Reprints or correspondence: Dr. Darron R. Brown, Prof. of Medicine, Microbi-
ology, and Immunology, Indiana University School of Medicine, 545 Barnhill Dr.,
Indianapolis, IN 46202 (darfrow@iupui.edu).
M A J O R A R T I C L E
926
● JID 2009:199 (1 April)
● Brown et al.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 2

HPV types are organized into genera and species on the basis
of homology in the sequence of the L1 gene [3]. With rare ex-
ception, most of the known HPV types that infect the genital
tractaremembersoftheAlphapapillomavirus(orA)genus(table
1). Eighteen have been classified as oncogenic on the basis of
epidemiologicand/orgeneticevidence.HPV-16istheprototype
of the A9 species, which includes 6 cancer-causing types (16, 31,
33, 35, 52, and 58). HPV-18 is the prototype of the A7 species,
whichincludes5cancer-causingtypes(18,39,45,59,and66).A
pooled analysis of 11 studies conducted in 9 countries showed
that the 12 most common HPV types in cervical cancer were, in
descending order of frequency, 16, 18, 45, 31, 33, 52, 58, 35, 59,
51, 56, and 39 [4]. Together, HPV-16 and -18, as single infec-
tions or combined with other HPV types, are responsible for up
to 70% of all invasive cervical cancers. The members of the A9
andA7speciesotherthanHPV-16and-18areresponsibleforup
to20%ofallcervicalcancersandalargeproportionofhigh-and
low-grade cervical lesions [6, 7].
Recently, a quadrivalent HPV-6/11/16/18 vaccine was ap-
proved for prevention of cervical, vulvar, and vaginal intraepi-
thelial lesions and genital warts associated with vaccine HPV
types [8–11]. Given the polyclonal nature of the immune re-
sponse to vaccination, it is hypothesized that anti–HPV-16 and
anti–HPV-18 generated by vaccination may be able to bind to
andpossiblyneutralizevirionsofHPVtypescloselyrelatedto16
and/or 18, thereby preventing infection and disease associated
with these other types (cross-protection). Such a capability
could potentially increase the expected reduction in cancer that
this vaccine will generate. Given that there is currently no estab-
lished definition for cross-protection, the World Health Orga-
nization (WHO) Expert Committee on Biological Standardiza-
tion recommends that demonstration of cross-protection be
established by observed reductions in the incidence of cervical
intraepithelialneoplasia(CIN)ofanygrade(abbreviatedhereas
CIN1–3/adenocarcinoma in situ [AIS]), CIN2–3 or AIS (abbre-
viated here as CIN2–3/AIS) due to the types in question, and/or
viral persistence, defined as detection of the same HPV type in
cervicovaginal samples obtained 6, 12 or 18 months apart [12].
In the present prospective evaluation of cross-protective effi-
cacyofthequadrivalentvaccine,wefocusedon5commonHPV
types whose L1 protein share at least 80% amino acid homology
withtheL1proteinofHPV-16and-18andthatareindividually
responsibleforatleast2%ofcervicalcancers:31,33,45,52,and
58. In addition, evaluation of cross-protection was conducted
Table 1.
regions of the world).
Distribution of human papillomavirus (HPV) in cervical cancer (variations exist among the
Category
Contribution
to cancer, %
Homology
to HPV-16, %a
Homology to
HPV-18, %a
By species
A9 (HPV-16, -31, -33, -52, -58, and -35)
A7 (HPV-18, -45, -59, and -39)
By HPV typeb
HPV-16 (A9)
HPV-18 (A7)
HPV-45 (A7)
HPV-31 (A9)
HPV-33 (A9)
HPV-52 (A9)
HPV-58 (A9)
HPV-35 (A9)
HPV-59 (A7)
HPV-51 (A5)
HPV-56 (A6)
HPV-39 (A7)
HPV-26, -53, -66, -68, -73, and -82 (A5, A6, A7, A11)
HPV-6 and -11 (A10)
Other intermediate and low-risk types (various)
Nontypeable and infections with ?3 types
70.9
18.6
. . .
. . .
. . .
. . .
58.7
12.2
4.7
3.8
2.3
2.2
2.2
1.4
1.2
0.7
0.6
0.5
0.9
0.2
1.3
7.2
. . .
. . .
67
83
81
80
80
82
65
NA
63
64
. . .
. . .
. . .
. . .
. . .
. . .
88
66
66
66
66
65
78
NA
66
77
. . .
. . .
. . .
. . .
NOTE.
based on the known pathogenicity of HPV types was used (16?18?31/45?52/58?33?all others). Adapted from Muñoz
et al. [4]. The data-analysis plan was based on information about the distribution of HPV types in cervical cancers that was
available at the time [4]. However, a recent meta-analyses suggests that, worldwide, HPV-33 is the fourth most common
type in invasive carcinomas [5].
aBased on the evaluation of predicted amino acid sequences, using gene sequences provided by GenBank.
bHPV types are listed on the basis of their contribution, from highest to lowest. Species are given in parentheses.
For calculations of the contribution of HPV types in the context of infection with 2 or more types, a hierarchy
Cross-Protective Efficacy of Quadrivalent HPV Vaccine
● JID 2009:199 (1 April)
● 927
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 3

for 5 HPV types whose homology to HPV-16 and -18 at the L1
amino acid level was ?80% (35, 39, 51, 56, and 59). Together,
these 10 nonvaccine HPV types account for up to 20% of all
cervical cancers after excluding cases for which infection with
other HPV types is present. Following the WHO guidelines, we
conducted prespecified evaluations of the impact of the vaccine
on the rates of infection and disease associated with these 10
nonvaccine HPV types in a population that was naive (seroneg-
ative and DNA negative) to HPV-6, -11, -16, and -18 and DNA
negative to all of these 10 nonvaccine HPV types at enrollment.
However, because ?40 HPV types are known to infect the ano-
genital tract, our analysis only approximates vaccination of
HPV-naivefemales[13].Analysesconductedinanintention-to-
treat (ITT) population including women who, before vaccina-
tion, may have been infected with 1 of the 14 HPV types of
interest (approximating catch-up vaccination) are reported in
the companion article by Wheeler et al. [14].
METHODS
End-point definitions.
endpointscanbefoundintheaccompanyingarticlebyWheeler
et al. [14]. The 6-month infection end point was validated using
clinical trial data of the quadrivalent vaccine (see appendix A,
which appears only in the electronic edition of the Journal).
Data sources.
The analysis of disease end points used the
combined database of 2 phase 3 efficacy trials: protocol 013
(NCT00092521) [8] and protocol 015 (NCT00092534) [9],
termed FUTURE I and FUTURE II, respectively. Both were
phase 3, randomized, double-blind, placebo-controlled clinical
trials designed to investigate the prophylactic efficacy of the
quadrivalent vaccine (Gardasil; Merck and Co.), as described
elsewhere[8,9].Datafortheanalysisofinfectionendpointswas
derived from protocol 012 (NCT00092482), a substudy of pro-
tocol 013 [15]. The studies were designed to be of 4 years’ dura-
tion. Because of the high efficacy seen in FUTURE I and II, the
independent data and safety monitoring board recommended
vaccination of women in the placebo arm earlier than planned.
The end-of-study data reported here includes ?3.6 years of
post–dose 1 follow-up.
Although baseline samples were collected at enrollment, the
trials allowed the enrollment of subjects who had been previ-
ously infected with or were currently infected with ?1 vaccine
HPV type or ?1 of the 10 nonvaccine types analyzed here.
Populations.
Between December 2001 and May 2003,
17,622 women aged 16–26 years (there were two 15-year-olds)
were enrolled in FUTURE I (n ? 5455, including the protocol
012 substudy [n ? 3578]) and FUTURE II (n ? 12,167). The
trials enrolled women who reported having had 0–4 sex part-
nersduringtheirlifetime,exceptinFinland,wheretherewasno
such restriction. Subjects with a history of an abnormal Pap test
result or treatment for genital warts (FUTURE I) were not en-
Definitions for infection and disease
rolled.Onday1,subjectsunderwentadetailedgenitalexamina-
tion, Pap testing, cervicovaginal sampling to detect HPV DNA,
and serology for anti–HPV-6/11/16/18 testing. Subjects were
randomly assigned (1:1) to receive intramuscular injections of
HPV-6/11/16/18 vaccine or visually indistinguishable adjuvant-
containing placebo on day 1 and at 2 and 6 months. Each pro-
tocol was approved by the institutional review boards.
Clinical follow-up and laboratory testing.
tyc) cytology samples for Pap testing were collected on day 1, at
month 7, and at 6-month (FUTURE I) or 12-month (FUTURE
II) intervals thereafter. Cytology samples were classified using
the Bethesda System 2001 [16]. Procedures for algorithm-based
cytology, colposcopy, and biopsy referral have been described
elsewhere [8, 9]. Biopsy material was first read for clinical man-
agement by pathologists at a central laboratory (Diagnostic Cy-
tologyLaboratories)andthenreadforend-pointdetermination
byapanelofupto4blindedpathologists,asdescribedelsewhere
[9].
Cervical biopsy samples, endocervical curettage samples, and
samples from loop electrosurgical excision procedures and con-
ization procedures obtained at any time during the studies were
tested for 14 types (6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58,
and 59), using a polymerase chain reaction (PCR)–based assay
[17–19].
The following genital swab samples were obtained at each
scheduledvisit:anendo/ectocervicalswab(onespecimen)anda
combined labial/vulvar/perineal swab plus a perianal swab
(pooled to become a second specimen). Ascertainment of HPV
infectioninvolvedHPVPCRanalysisperformedonthesegenital
swab samples. All subjects were tested for the above 14 HPV
types on day 1. At months 3, 7, 12, 18, 24, 30, 36, and 48, swab
samples from subjects enrolled in protocol 012 were tested for 9
HPV types (16, 18, 31, 33, 35, 45, 52, 58, and 59).
Case definition and study objectives.
tive was to determine whether administration of HPV-6/11/
16/18 vaccine reduces the combined incidence of infection or
disease associated with HPV-31 and -45 (the 2 most common
types found in cervical cancer after HPV-16 and -18) and with
HPV-31, -33, -45, -52, and -58 (the 5 most common HPV types
found in cervical cancer after 16 and 18) [20]. Other end points
were the incidence of infection or disease associated with non-
vaccineA9speciesmembers(31,33,35,52,and58),nonvaccine
A7 species members (39, 45, and 59), and the 10 nonvaccine
HPV types for which testing was available (31, 33, 35, 39, 45, 51,
52, 56, 58, and 59). The type(s) of HPV associated with each of
the combined end points was based on genotyping HPV DNA
detected in lesional tissue.
Statistical methods.
Prespecified analyses were done in a
population that approximates sexually naive females. This anal-
ysis was restricted to subjects who received ?1 vaccination and,
at enrollment, were seronegative and DNA negative for each of
the quadrivalent HPV vaccine types (6, 11, 16, and 18); were
ThinPrep (Cy-
The primary objec-
928
● JID 2009:199 (1 April)
● Brown et al.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 4

DNAnegativeforeachof10nonvaccinetypes(31,33,35,39,45,
51, 52, 56, 58, and 59); and had a normal Pap test result. In this
article, this population is referred to as being negative for 14
HPV types. Protocol violators were included. Case counting be-
gan after day 1.
A point estimate of vaccine efficacy (VE) and the 95% confi-
dence interval (CI) were calculated on the basis of the observed
split between vaccine and placebo recipients, adjusted for the
accrued person-time in each study arm. The statistical criterion
for success (P ? .05) was equivalent to requiring that the lower
bound of the CI for VE exclude 0%. An exact conditional pro-
cedure was used to evaluate VE under the assumption that the
numbersofcasesinthevaccineandplaceboarmswereindepen-
dent Poisson random variables.
We evaluated VE for combined HPV types (i.e., HPV-31/45–
related CIN1–3/AIS), and for individual HPV types (i.e., HPV-
31–related CIN1–3/AIS). For each analysis, including those
which combined multiple HPV types, a woman was counted as
having an end point only once. For example, in the analysis of
HPV-31/45–related disease, a woman detected with an HPV-
31–related CIN2 lesion at month 12 and an HPV-45–related
CIN1 lesion at month 18 would be counted once toward HPV-
31/45–related CIN1–3/AIS. When VE for individual HPV types
was calculated, she would count once toward HPV-31–related
CIN2–3/AIS and once toward HPV-45–related CIN1–3/AIS.
Time-to-event plots shown were based on the Kaplan-Meier
estimator[21].Theplotswerenotpartofaformalsurvivalanal-
ysis;rather,theygiveavisualdemonstrationofthedivergenceof
incidence rates between the 2 vaccination arms over time. No
direct estimation of VE should be inferred by extrapolating data
from these plots.
RESULTS
FUTURE I and II enrolled 17,622 women, 99.9% of whom re-
ceived ?1 dose of vaccine or placebo (98.4% received 2 doses
and 97.2% received 3 doses). Baseline demographics for the in-
dividual studies [8, 9] and the combined studies [22] have been
described elsewhere. In previously reports of VE [8, 9], the pri-
mary analysis population was per protocol. For the analyses of
cross-protection, the prespecified primary analysis was done in
type-specificpopulationsthatrequiredwomentobenegativefor
the type being analyzed on day 1 only (unrestricted susceptible)
rather than from day 1 through 1 month after receipt of dose 3
(per protocol) [8, 9]. Similar to the per-protocol analysis,
womenintheunrestricted susceptiblepopulation couldbepos-
itive for other HPV types. In this primary analysis population,
efficacy for HPV-31/45–related CIN1–3/AIS and high-grade le-
sions (CIN2–3/AIS) was 37.3% (95% CI, 17.0% to 52.8%) and
43.2% (95% CI, 12.1% to 63.9%), respectively. Efficacy for
HPV-31/33/45/52/58–related CIN1–3/AIS and CIN2–3/AIS
was26.4%(95%CI,12.9%to37.8%)and25.8%(95%CI,4.6%
to 42.5%), respectively. Although the primary results were fa-
vorable, the magnitude of benefit was confounded by cases of
CIN2–3 associated with mixed prevalent/incident coinfection;
therefore, prespecified supportive analyses were done in a pop-
ulation that was negative for the 14 tested HPV types, thus ap-
proximating sexually naive females. Reasons for exclusion from
the efficacy analyses and baseline characteristics of the efficacy
populationthatwasnegativefor14HPVtypesarelistedintable
2 and in figure 1. Baseline characteristics were generally well
balanced between the vaccine and placebo arms. The placebo
arm had a slightly higher proportion of black women (2.6% in
thevaccinearmand3.5%intheplaceboarm)andvirgins(9.3%
in the vaccine arm and 10.4% in the placebo arm).
Subjects were followed for a mean of 3.6 years after dose 1,
with 2068 (57.8% of enrolled subjects in protocol 012) in-
cluded in the analyses of infection. Vaccination reduced the
incidence of HPV-31/45 infection by 40.3% (95% CI, 13.9%
to 59.0%) and HPV-31/33/45/52/58 infection by 25.0% (95%
CI, 5.0% to 40.9%) (table 3). For individual HPV types, a
significantreductionininfectionwasobservedforHPV-31.A
positive percent reduction was observed for the other 6 types
analyzed, although the data did not reach statistical signifi-
cance. We performed a post-hoc analysis where HPV-31 was
removedfromthecompositeendpoints(table4).Efficacy for
HPV-33/45/52/58 infection was 14.9% (95% CI, ?11.3 to
35.0).
A total of 9296 subjects (53% of enrolled subjects in FUTURE I
and II) were included in the analyses for cervical disease (tables 5
and6).EfficacyforCIN1–3/AISandforhigh-gradelesions(CIN2–
3/AIS) associated with the 10 tested nonvaccine HPV types was
23.4% (95% CI, 7.8% to 36.4%) and 32.5% (95% CI, 6.0% to
51.9%), respectively. Vaccination reduced the incidence of HPV-
31/45–related CIN1–3/AIS by 43.6% (95% CI, 12.9% to 64.1%)
and of HPV-31/33/45/52/58–related CIN1–3/AIS by 29.2% (95%
CI,8.3%to45.5%).Efficacywasdrivenprimarilybyreductionsin
HPV-31,-33,-52,and-58.Noefficacyfordiseasewasobservedwith
respect to HPV-45, although of the 10 nonvaccine HPV types ex-
amined,HPV-45wastheleastlikelytobedetectedinCINlesions.A
post-hocanalyseswhereHPV-31wasremovedisshownintable4.
SignificantreductionsinCIN1–3/AISwereobservedwhenonlythe
remaining 9 nonvaccine HPV types for which testing was con-
ductedwereconsidered.
To address any potential ascertainment bias resulting from
the higher frequency of colposcopy, biopsy, and definitive ther-
apy among placebo recipients or from the inclusion of cervical
biopsy samples in the analysis of infection, we did supportive
analyses whereby infection was restricted to detection of HPV
DNA in cervicovaginal/anogenital swab samples only. Here, the
observed efficacy for HPV-31/33/45/52/58 infection was 23.1%
(95% CI, 2.1% to 39.7%).
Figure2showsthedivergenceofincidenceratesovertimefor
CIN1–3/AISandCIN2–3/AISforthe10testednonvaccineHPV
Cross-Protective Efficacy of Quadrivalent HPV Vaccine
● JID 2009:199 (1 April)
● 929
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 5

types. Over the course of follow-up, reductions in the incidence
of disease became increasingly apparent for the 10 tested non-
vaccine HPV types. As shown in figure 2, the censoring of sub-
jectswhoreachanendpointmarkedlydecreasesthesamplesize;
therefore, the 95% CIs for the incidence rates grow wider with
longer follow-up. Direct estimation of VE cannot be inferred by
extrapolating data from these plots. Efficacy (tables 3–6) was
calculated on the basis of a fixed-event design with the analysis
performed at a single point in time at the end of follow-up, with
all subjects in the analysis population providing data.
The cross-protective efficacy was most apparent and consis-
tent for members of the A9 species. The combined incidence of
HPV-31/33/35/52/58–related CIN1–3/AIS was reduced by
31.9% (95% CI, 11.8% to 47.6%). For the A7 species, a positive
percent reduction was observed with respect to HPV-39– and
HPV-59–related end points, although the reductions were not
statistically significant. There was no evidence for efficacy with
respect to HPV-51–related CIN (A5 species). A positive percent
reduction (not statistically significant) was observed for HPV-
56–related CIN (A6 species).
EfficacyfindingsforCIN1–3/AISwereconsistentbetweenthe
individualprotocols,withtheexceptionofHPV-35–,HPV-51–,
and HPV-59–related end points, for which nonsignificant re-
ductions were observed in protocol 013 but not protocol 015
(data not shown).
Although subjects were required to be DNA negative for all 14
HPV types on day 1 in order to be included in the efficacy evalua-
tions,thepresenceof?1typeinincidentCINlesionswascommon,
consistentwithpriornaturalhistorystudies.Atotalof308incident
CIN2–3/AIS lesions were observed in the placebo arm during the
follow-up period (note: a women may have developed more than
onelesionduringthecourseofthestudies,butforeachrowinthe
analyses of VE, each woman was counted only once). Of the 308
incident CIN2–3/AIS lesions observed in the placebo arm, 138
(44.8%) were associated with HPV-16–related A9 species, with 99
(32.1%)beingassociatedwithHPV-31/33/35/52and/or58withno
coinfectionwithvaccineHPVtypesandwith39(12.7%)beingas-
sociated with HPV-31/33/35/52 and/or 58 with coinfection with
vaccineHPVtypes.Inthevaccinearm,lesionsassociatedwithamix
of vaccine and nonvaccine HPV types were rare, because the pro-
phylactic efficacy against disease due to vaccine HPV types ap-
proaches100%[8,9].
Table 2.
human papillomavirus (HPV) types.
Baseline demographics of the efficacy population that was negative for 14
Characteristic Vaccine (n ? 4732) Placebo (n ? 4778)
Age, mean ? SD, years
Race
Asian
Black
Hispanic American
Native American
White
Other
Lifetime no. of sex partners at enrollment
0 (virgin)
1
2
3
4
?4
Prevalence of Chlamydia trachomatis
Prevalence of Neisseria gonorrhoeae
Past pregnancy
19.8 ? 2.119.8 ? 2.1
215/4732 (4.5)
122/4732 (2.6)
550/4732 (11.6)
6/4732 (0.1)
3,437/4732 (72.6)
402/4732 (8.5)
225/4778 (4.7)
166/4778 (3.5)
521/4778 (10.9)
3/4778 (0.1)
3443/4778 (72.1)
420/4778 (8.8)
441/4732 (9.3)
1913/4732 (40.4)
1124/4732 (23.8)
747/4732 (15.8)
473/4732 (10.0)
34/4732 (0.7)
99/4651 (2.1)
15/3389 (0.4)
885/4732 (18.7)
495/4778 (10.4)
1899/4778 (39.7)
1107/4778 (23.2)
734/4778 (15.4)
498/4778 (10.4)
42/4778 (0.9)
92/4679 (2.0)
5/3404 (0.1)
879/4778 (18.4)
NOTE.
subjects who received ?1 vaccination and, at enrollment, were seronegative and DNA negative for
each of the quadrivalent HPV vaccine types (6, 11, 16, and 18); were DNA negative for each of 10
nonvaccine types (31, 33, 35, 39, 45, 51, 52, 56, 58, and 59); and had a normal Pap test result.
Selected baseline demographics of the overall population can be found in reference 22. Percentages
were calculated as (no. of subjects with indicated characteristic/no. of subjects with a known
response or satisfactory test result) ? 100.
Data are no. (%) of subjects, unless otherwise indicated. This population was restricted to
The figure is available in its entirety in the online
edition of the Journal of Infectious Diseases.
Figure 1.
negative for 14 human papillomavirus (HPV) types (infection and disease
end points).
Reasons for exclusion from the efficacy population that was
930
● JID 2009:199 (1 April)
● Brown et al.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 6

DISCUSSION
HPV types other than 6, 11, 16, and 18 that cause a substantial
proportionofcervicalHPVdisease,includingcancer,arestructur-
allyrelatedtoHPV-16and-18.Itisimportanttoexaminethepro-
phylacticefficacyoftheHPV-6/11/16/18vaccineinpreventingthe
acquisitionofinfectionandrelatedcervicaldiseaseassociatedwith
these nonvaccine types in populations approximating those tar-
getedbymostHPVvaccinationprograms.Thus,thepresentstudy
evaluated the cross-protective efficacy of the vaccine in a subset of
the clinical trial population that, before vaccination, was negative
for the 14 HPV types tested and had a normal Pap test result, ap-
proximatingsexuallynaivefemales.Thisallowedforanassessment
of cross-protective efficacy in the absence of prevalent infections.
Weobserveda32.5%reductioninCIN2–3/AISassociatedwith10
nonvaccineHPVtypesthatcollectivelycause?20%ofcervicalcan-
cers.Thesefindingsarethefirstdemonstrationofcross-protection
for any HPV vaccine against CIN2–3/AIS, disease end points that
are cervical cancer precursors and that formed the basis of vaccine
licensure. Reductions of similar magnitudes were observed for the
combinedendpointsofCIN1–3/AIS.Thecross-protectiveefficacy
was driven by the A9 species members, particularly HPV-31, -33,
-52,and-58.
Although we observed significant reductions in cervical disease
duetoHPVtypesnotincludedinthevaccine,theclinicalbenefitof
cross-protection(intermsofnumbersoflesionsprevented)should
notbeexpectedtobefullyadditivetotheefficacyalreadyobserved
against HPV-6/11/16/18–related disease, because many women
have ?1 CIN lesion and each lesion may be associated with a dif-
ferentHPVtype.Forexample,amongplacebosubjects,thecumu-
lative incidence of CIN2–3/AIS for the A9 species (HPV-31, -33,
-35,-52,and-58)was14.7eventsper1000subjects.Ofthe69cases
intheplaceboarm,22(31.9%)occurredinwomenwhoalsohadan
HPV-16– or HPV-18–related CIN2–3/AIS lesion. Had these
women been immunized before exposure, the HPV-16/18 dis-
ease would have been prevented. In the absence of cross-
protection, the prevention of HPV-16/18 infection would not
haveendedtheirriskofdevelopingCIN2–3duetoanonvaccine
type. However, with our observed cross-protection, the risk of
CIN2–3duetoanonvaccineHPVtypewasreduced.Asshownin
figure 3, the added benefit of cross-protection resulted in the
prevention of an additional 3 cases of CIN2–3, an increment of
4.3%. Despite an observed benefit, as with any vaccine the long-
term reductions in the overall burden of disease—including re-
ductions in Pap testing and abnormalities, colposcopy, and de-
finitive therapy—have yet to be determined.
Table 3.
human papillomavirus (HPV) types (prespecified analyses).
Analysis of cross-protection against infection in the efficacy population that was negative for 14
Category
Vaccine
(n ? 1036)
Placebo
(n ? 1032)
Efficacy
(95% CI), % Cases Ratea
Cases Ratea
HPV-31 or -45
HPV-31, -33, -45, -52, or -58
Individual HPV typesb
HPV-31
HPV-33
HPV-45
HPV-52
HPV-58
Other HPV types testedb
HPV-35
HPV-59
Nonvaccine A9 species (HPV-31, -33, -35, -52, and -58)
Nonvaccine A7 species (HPV-45 and -59)
491.4
3.8
812.3
5.0
40.3 (13.9 to 59.0)
25.0 (5.0 to 40.9)127167
31
15
24
50
35
0.9
0.4
0.7
1.4
1.0
57
21
26
61
37
1.6
0.6
0.7
1.7
1.0
46.2 (15.3 to 66.4)
28.7 (?45.1 to 65.8)
7.8 (?67.0 to 49.3)
18.4 (?20.6 to 45.0)
5.5 (?54.3 to 42.2)
14
45
124
66
0.4
1.3
3.7
1.9
17
55
157
77
0.5
1.6
4.7
2.2
17.8 (?77.1 to 62.5)
18.7 (?22.8 to 46.4)
21.9 (0.6 to 38.8)
14.8 (?19.9 to 39.6)
NOTE.
negative for each of the quadrivalent HPV vaccine types (6, 11, 16, and 18); were DNA negative for each of 10 nonvaccine types (31,
33, 35, 39, 45, 51, 52, 56, 58, and 59); and had a normal Pap test result. Infection is defined as detection of the same HPV type on
2 consecutive visits spaced ?6 months apart (?1-month visit windows) or the presence of cervical/genital disease associated with
the relevant type (with DNA for the type found in a swab sample at the visit directly before or after the biopsy). A subject is counted
only once within each applicable row. CI, confidence interval.
aCases per 100 person-years at risk.
bThe study was not powered to assess efficacy against individual types.
This population was restricted to subjects who received ?1 vaccination and, at enrollment, were seronegative and DNA
Table 4.
ease excluding human papillomavirus (HPV)–31 (post-hoc analyses).
Analysis of cross-protection against infection and dis-
The table is available in its entirety in the online
edition of the Journal of Infectious Diseases.
Cross-Protective Efficacy of Quadrivalent HPV Vaccine
● JID 2009:199 (1 April)
● 931
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 7

TheWHOrecommendsthatdemonstrationofcross-protection
be established by observed reductions in CIN and/or viral persis-
tence.Thereiscurrentlynointernationalconsensusonadefinition
forHPVpersistencebasedontype-specificdetectionofHPVDNA
byPCR[12].Weconsidered6-monthinfectionforthesameHPV
genotype. Single-time detection of HPV was not an end point, be-
causeasinglepositiveHPVDNAtestresultmaybeduetotransient
infection,contamination,orearlypersistentinfection.Previousre-
ports of a bivalent HPV vaccine showed some level of cross-
protection against infection with HPV-45, -31, and -52; however,
disease end points were not reported [23]. Efficacy analyses using
diseaseendpointsratherthaninfectionalonearenecessarytomea-
suretheclinicalbenefitofcross-protection.
In the present study, when excluding the vaccine types, the cu-
mulative incidence of CIN1–3/AIS through 3.6 years of follow-up
washighestforHPV-56,-51,-31,-52,and-58,indescendingorder.
LesionsassociatedwithHPV-45wererare.Weobservedreductions
intheincidenceofCINlesionsassociatedwithA9speciesmembers,
particularly HPV-31. It is likely that second-generation HPV vac-
cinestargetingabroaderspectrumofoncogenicHPVtypesmaybe
available within the next decade and would include those HPV
types that cause the highest proportion of cervical cancers. Given
thatsomeofthesetypes,suchasHPV-56,contributeto?1%ofthe
worldwide cervical cancer burden, it is noteworthy to observe re-
ductions in HPV types that may not be included in second-
generationvaccines.
The present study has some limitations. Our combined end
points included lesions with strong malignant potential (CIN3/
AIS).However,thestudywasnotdesignedwithsufficientpowerto
detect reductions in CIN2–3/AIS due to nonvaccine types or to
measure reductions in individual nonvaccine HPV types, explain-
ing why a posteriori there is not sufficient power to measure these
reductions. Our analyses also required that women be DNA nega-
tive for nonvaccine types on day 1 only; thus, some women may
havebecomeinfectedbeforereceivingall3doses.Inaddition,sub-
jects in the placebo arm were more likely to be referred for colpo-
scopic examination, biopsy, and definitive therapy, because of the
lackofprotectionfromHPV-6/11/16/18infection.Thiscouldlead
to potential ascertainment bias. It was therefore important to cor-
roboratetheobservedreductionsincervicaldiseaseassociatedwith
nonvaccine types with infection data from swab samples only,
whichwouldnotbesubjecttothispotentialbias.
BecausewomenremainatriskforHPVinfectionaslongasthey
remain sexually active, it will be important to determine the dura-
tionofprotectionagainstHPV-relateddiseaseforbothvaccineand
nonvaccine types. It has not been possible to establish a minimum
protective antibody titer for vaccine types; however, the quadriva-
lentvaccineelicitsimmunememory,ahallmarkoflong-termpro-
Table 5.
situ (AIS) due to human papillomavirus (HPV) types other than 16 and 18 in the efficacy population that was
negative for 14 HPV types (prespecified analyses).
Analysis of cross-protection against cervical intraepithelial neoplasia (CIN) 1–3 or adenocarcinoma in
Category
Vaccine
(n ? 4616)
Placebo
(n ? 4680)
Efficacy
(95% CI), %CasesRatea
Cases Ratea
HPV-31 or -45
HPV-31, -33, -45, -52, or -58
HPV-31, -33, -35, -39, -45, -51, -52, -56, -58, or -59
Nonvaccine A9 species (HPV-31, -33, -35, -52, or -58)b
HPV-31
HPV-33
HPV-35
HPV-52
HPV-58
Nonvaccine A7 species (HPV-39, -45, or -59)b
HPV-39
HPV-45
HPV-59
HPV-51b
HPV-56b
340.2
0.6
1.3
0.6
0.1
0.1
0.1
0.2
0.2
0.3
0.2
0.1
0.1
0.4
0.4
610.4
0.9
1.6
0.9
0.3
0.2
0.1
0.3
0.3
0.5
0.3
0.1
0.2
0.4
0.5
43.6 (12.9 to 64.1)
29.2 (8.3 to 45.5)
23.4 (7.8 to 36.4)
31.9 (11.8 to 47.6)
56.9 (28.6 to 74.8)
39.2 (?12.6 to 68.1)
20.4 (?88.8 to 67.3)
30.6 (?8.9 to 56.2)
17.1 (?31.7 to 48.2)
27.3 (?4.6 to 49.7)
32.6 (?11.4 to 59.8)
?11.3 (?192.2 to 57.1)
22.3 (?44.7 to 58.9)
?4.3 (?49.5 to 27.2)
27.6 (?2.6 to 49.3)
103
205
101
23
18
11
35
36
54
28
11
20
66
58
147
270
150
54
30
14
51
44
75
42
10
26
64
81
NOTE.
negative for each of the quadrivalent HPV vaccine types (6, 11, 16, and 18); were DNA negative for each of 10 nonvaccine types (31, 33,
35, 39, 45, 51, 52, 56, 58, and 59); and had a normal Pap test result. Disease was defined as the diagnosis of a tissue sample as CIN,
AIS, or cervical cancer by a pathology panel with DNA detected in tissue from the same lesion. A subject is counted only once within
each applicable row. CI, confidence interval.
aCases per 100 person-years at risk.
bThe study was not powered to assess efficacy against individual types.
This population was restricted to subjects who received ?1 vaccination and, at enrollment, were seronegative and DNA
932
● JID 2009:199 (1 April)
● Brown et al.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 8

tection[24].Follow-upoflargecohortswillberequiredtoestablish
the duration of efficacy of the vaccine for both vaccine and non-
vaccinetypes.
The efficacy of the vaccine among 16–26-year-old women
with a lifetime history of ?4 sex partners was not evaluated.
Although the present analysis focused on cross-protection in
a population that was representative of an HPV-naive popu-
lation, an ITT analysis of all women entering the FUTURE I
and II trials regardless of baseline HPV status also demon-
strated statistically significant cross-protective reductions in
both HPV infections and CIN1 or greater due to nonvaccine
oncogenic HPV types [14].
Figure 2.
adenocarcinoma in situ (AIS) (A) and HPV-31/33/35/39/45/51/52/56/58/59–related CIN2–3/AIS (B) in the efficacy population that was negative for 14
HPV types. This population was restricted to subjects who received ?1 vaccination and, at enrollment, were seronegative and DNA negative for each
of the quadrivalent HPV vaccine types (6, 11, 16, and 18); were DNA negative for each of 10 nonvaccine types (31, 33, 35, 39, 45, 51, 52, 56, 58, and
59); and had a normal Pap test result. CI, confidence interval.
Time to detection of human papillomavirus (HPV)–31/33/35/39/45/51/52/56/58/59–related cervical intraepithelial neoplasia (CIN) 1–3 or
Table 6.
(AIS) due to human papillomavirus (HPV) types other than 16 and 18 in the efficacy population that was negative
for 14 HPV types (prespecified analyses).
Analysis of cross-protection for cervical intraepithelial neoplasia (CIN) 2–3 or adenocarcinoma in situ
HPV type
Vaccine
(n ? 4616)
Placebo
(n ? 4680)
Efficacy
(95% CI), %Cases Ratea
CasesRatea
HPV-31 or -45
HPV-31, -33, -45, -52, or -58
HPV-31, -33, -35, -39, -45, -51, -52, -56, -58, or -59
Nonvaccine A9 species (HPV-31, -33, -35, -52, or -58)b
HPV-31
HPV-33
HPV-35
HPV-52
HPV-58
Nonvaccine A7 species (HPV-39, -45, or -59)b
HPV-39
HPV-45
HPV-59
HPV-51b
HPV-56b
11
44
62
44
8
12
4
17
16
11
4
3
5
16
12
0.1
0.3
0.4
0.3
27
66
93
69
27
16
4
23
20
21
10
2
9
15
16
0.2
0.4
0.6
0.4
0.2
0.1
58.7 (14.1 to 81.5)
32.5 (?0.3 to 55.0)
32.5 (6.0 to 51.9)
35.4 (4.4 to 56.8)
70.0 (32.1 to 88.2)
24.0 (?71.2 to 67.2)
?1.5 (?444.9 to 81.1)
25.2 (?46.4 to 62.5)
18.9 (?64.7 to 60.7)
47.0 (?15.0 to 76.9)
59.6 (?40.2 to 90.7)
?51.9 (?1717.8 to 82.6)
43.8 (?86.9 to 85.2)
?8.1 (?134.7 to 50.0)
24.1 (?71.1 to 67.2)
?0.1
0.1
?0.1
0.1
0.1
0.1
?0.1
?0.1
?0.1
0.1
0.1
?0.1
0.1
0.1
0.1
?0.1
?0.1
?0.1
0.1
0.1
NOTE.
negative for each of the quadrivalent HPV vaccine types (6, 11, 16, and 18); were DNA negative for each of 10 nonvaccine types (31, 33,
35, 39, 45, 51, 52, 56, 58, and 59); and had a normal Pap test result. Disease was defined as the diagnosis of a tissue sample as CIN,
AIS, or cervical cancer by a pathology panel with DNA detected in tissue from the same lesion. A subject is counted only once within
each applicable row. CI, confidence interval.
aCases per 100 person-years at risk.
bThe study was not powered to assess efficacy against individual types.
This population was restricted to subjects who received ?1 vaccination and, at enrollment, were seronegative and DNA
Cross-Protective Efficacy of Quadrivalent HPV Vaccine
● JID 2009:199 (1 April)
● 933
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 9

In conclusion, the results of the HPV-6/11/16/18 vaccine pro-
gram provide strong evidence that implementation of HPV vacci-
nation campaigns in HPV-naive preadolescent girls and young
adultwomenhasthepotentialtoreducecervicalcancerratesworld-
wide. The demonstrated cross-protection against additional onco-
genic HPV types may provide an extra measure of protection for
youngwomenimmunizedwiththequadrivalentHPVvaccine.
Author affiliations.
Department of Medicine, Indiana Uni-
versity School of Medicine, Indianapolis (D.R.B.); Department of
Virus, Hormones, and Cancer, Institute of Cancer Epidemiology,
Danish Cancer Society/Rigshospitalet, Copenhagen, Denmark
(S.K.K.); National Cancer Detection Clinic, Reykjavik, Iceland
(K.S.);DepartmentofClinicalMedicine,UniversityofBergen,and
Department of Obstetrics and Gynecology, Haukeland University
Hospital, Bergen, Norway (O.-E.I.); Institute of Public Health,
Cuernavaca, Morelos, Mexico (M.H.-A.); Department of Molecu-
lar Genetics and Microbiology and Department of Obstetrics and
Gynecology, University of New Mexico, Albuquerque (C.M.W.);
UniversidaddelRosario,Bogotá,Colombia(G.P.);Departmentof
Epidemiology, University of Washington, Seattle (L.A.K.); KK
Women’sandChildren’sHospital,Singapore(E.H.T.);Epidemiol-
ogy HIV and STD Unit, Universidad Peruana Cayetano Heredia,
Lima, Peru (P.G.); Department of Gynecology and Obstetrics,
Emory University School of Medicine Atlanta, Georgia (K.A.A.);
Microbiology and Infectious Diseases Department, Royal Wom-
en’sHospital,andDepartmentofObstetricsandGynecology,Uni-
versityofMelbourne,Melbourne,Victoria,Australia(S.M.G.);De-
partment of Gynecology and Obstetrics, Medical University of
Vienna, Vienna, Austria (S.L. and E.A.J.); Karolinska Institute at
Danderyd Hospital, Stockholm, Sweden (S.-E.O.); Department of
ObstetricsandGynecology,UniversityofHongKong,HongKong
Special Administrative Region, China (G.W.K.T.); Department of
Family Medicine and Obstetrics and Gynecology, Medical College
of Georgia, Augusta, Georgia (D.G.F.); Department of Obstetrics
and Gynecology, University Central Hospital, Helsinki, Finland
(J.P.);DirectionRisquesBiologiques,EnvironnementauxetOccu-
pationnels, Institut National de Santé Publique du Québec,
Montréal, Québec, Canada (M.S.); Institut Catala d’Oncologia,
IDIBELL, Barcelona, Spain (F.X.B.); Department of Medical Mi-
crobiology,LundUniversity,Lund,Sweden(J.D.);Departmentsof
GynecologyandObstetrics,Pathology,andOncology,JohnsHop-
kins University School of Medicine, Baltimore, Maryland (R.J.K.);
DepartmentofDermatologyandVenereology,CenterofDiagnos-
ticsandTreatmentofSexuallyTransmittedDiseases,WarsawMed-
ical University, Warsaw, Poland (S.M.); National Institute of Can-
cer, Bogotá, Colombia (N.M.); Department of Obstetrics and
Gynecology, Duke University Medical Center, Durham, North
Carolina (E.R.M.); Department of Virology, Ludwig Institute for
CancerResearch,SaoPaulo,Brazil(L.L.V.);MerckResearchLabo-
ratories, West Point, Pennsylvania (F.J.T., C.R., A.T., J.B., L.C.L.,
K.E.D.G.,H.L.S.,M.J.,T.M.H.,andE.B.).
Figure 3.
papillomavirus.
Illustration of the added benefit of cross-protection. AIS, adenocarcinoma in situ; CIN, cervical intraepithelial neoplasia; HPV, human
934
● JID 2009:199 (1 April)
● Brown et al.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 10

Potentialconflictsofinterest.
advisory board fees, and consultancy fees from Merck and Sanofi
Pasteur MSD. S.-E.O. has received lecture fees from Merck.
M.H.-A. has received lecture fees and grant support from Merck.
O.-E.I. has received lecture fees from Merck and GlaxoSmithKline
(GSK). C.M.W. has received funding through her institution to
conductHPVvaccinestudiesforGSK.K.A.A.hasreceivedconsul-
tancyandadvisoryboardfeesfromMerckandhasreceivedfunding
through his institution to conduct HPV vaccine studies for Merck
and GSK and nonvaccine clinical trials for Gen-Probe. F.X.B. has
receivedlecturefeesfromMerckandGSKandhasreceivedfunding
through his institution to conduct HPV vaccine studies for
GSK. J.P. has received consultancy fees, advisory board fees, and
lecture fees from Merck. J.D. has received consultancy fees, lecture
fees,andresearchgrantsfromMerckandSanofiPasteurMSD.S.L.
has received lecture fees from Merck and Sanofi Pasteur
MSD. E.A.J. has received lecture fees from Merck, Sanofi Pasteur
MSD, and GSK. S.K.K. has received consultancy fees and funding
through her institution to conduct HPV vaccine studies for Sanofi
Pasteur MSD and Digene. S.M.G. has received advisory board fees
and grant support from Commonwealth Serum Laboratories and
GSKandhasreceivedlecturefeesfromMerck.D.G.F.hasreceived
consultancy fees and funding through his institution to conduct
HPVvaccinestudiesforGSKandlecturefeesandconsultancyfees
from Merck. K.S. has received consultancy fees from Merck. S.M.
has received lecture fees and advisory board fees from Merck. G.P.
has received lecture fees and consultancy fees from Merck and
Sanofi Pasteur MSD. D.R.B. has received lecture fees, advisory
board fees, and intellectual property fees from Merck. M.S. has re-
ceived lecture fees and grant support from Merck. Additionally,
S.-E.O., C.M.W., M.H.-A., L.L.V., O.-E.I., G.W.K.T., F.X.B., J.P.,
J.D.,E.H.T.,S.L.,E.A.J.,S.K.K.,G.P.,D.G.F.,K.S.,M.S.,L.A.K.,and
D.R.B.havereceivedfundingthroughtheirinstitutionstoconduct
HPV vaccine studies for Merck. F.J.T., C.R., A.T., J.B., L.C.L.,
K.E.D.G., H.L.S., M.J., T.M.H., and E.B. are employees of Merck
andpotentiallyownstockand/orstockoptionsinthecompany.
N.M.hasreceivedlecturefees,
Acknowledgments
WethankKathyHarkins,ShuangLu,CarolynMass,andMaryAnneRut-
kowski for statistical and programming support.
References
1. WalboomersJMM,JacobsMV,ManosMM,etal.Humanpapillomavi-
rus is a necessary cause of invasive cervical cancer worldwide. J Pathol
1999; 189:12–9.
2. National Cancer Institute. Cancer advances in focus: cervical cancer.
Available at:http://www.cancer.gov/aboutnci/cancer-advances-in-
focus/cervical. Accessed 2 August 2007.
3. de Villiers E-M, Fauquet C, Broker TR, Bernard H-U, zur Hausen H.
Classification of papillomaviruses. Virology 2004; 324:17–27.
4. Muñoz N, Bosch FX, de Sanjosé S, et al. Epidemiologic classification of
human papillomavirus types associated with cervical cancer. N Engl
J Med 2003; 348:518–27.
5. Smith JS, Lindsay L, Hoots B, et al. Human papillomavirus type distri-
bution in invasive cervical cancer and high-grade cervical lesions: a
meta-analysis update. Int J Cancer 2007; 121:621–32.
6. Clifford GM, Smith JS, Aguado T, Franceschi S. Comparison of HPV
type distribution in high-grade cervical lesions and cervical cancer: a
meta-analysis. Br J Cancer 2003; 89:101–5.
7. Clifford GM, Rana RK, Franceschi S, Smith JS, Gough G, Pimenta JM.
Human papillomavirus genotype distribution in low-grade cervical le-
sions: comparison by geographic region and with cervical cancer. Can-
cer Epidemiol Biomarkers Prev 2005; 14:1157–64.
8. GarlandSM,Hernandez-AvilaM,WheelerCM,etal.Quadrivalentvac-
cine against human papillomavirus to prevent anogenital diseases.
N Engl J Med 2007; 356:1928–43.
9. The FUTURE II Study Group. Quadrivalent vaccine against human
papillomavirus to prevent high-grade cervical lesions. N Engl J Med
2007; 356:1915–27.
10. JouraEA,LeodolterS,Hernandez-AvilaM,etal.Efficacyofaquadrivalent
prophylactic human papillomavirus (types 6, 11, 16 and 18) L1 virus-like-
particle vaccine against high-grade vulval and vaginal lesions: a combined
analysisofthreeclinicaltrials.Lancet 2007; 369:1693–702.
11. TheFUTUREIIStudyGroup.Effectofprophylactichumanpapilloma-
virusL1virus-like-particlevaccineonriskofcervicalintraepithelialneo-
plasiagrade2,grade3andadenocarcinomainsitu:acombinedanalysis
of four randomised clinical trials. Lancet 2007; 369:1861–8.
12. World Health Organization Expert Committee on Biological Standardiza-
tion. Guidelines to assure the quality, safety and efficacy of recombinant
human papillomavirus virus-like particle vaccines. http://www.who.int/
biologicals/publications/trs/areas/vaccines/human_papillomavirus/
HPVg%20Final%20BS%202050%20.pdf.Accessed2August2007.
13. Saslow D, Castle PE, Cox JT, et al. American Cancer Society guidelines
forhumanpapillomavirus(HPV)vaccineusetopreventcervicalcancer
and its precursors. CA Cancer J Clin 2007; 57:7–28.
14. Wheeler CM, Kjaer SK, Sigurdsson K, et al. The impact of quadrivalent
human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like par-
ticlevaccineoninfectionanddiseaseduetooncogenicnonvaccineHPV
types in sexually active women aged 16–26 years. J Infect Dis 2009;
199:936–44 (in this issue).
15. Garland SM, Steben M, Hernandez-Avila M, et al. Noninferiority of
antibody response to human papillomavirus type 16 in subjects vacci-
natedwithmonovalentandquadrivalentL1virus-likeparticlevaccines.
Clin Vaccine Immunol 2007; 14:792–5.
16. Henry MR. The Bethesda System 2001: an update of new terminology
for gynecologic cytology. Clin Lab Med 2003; 23:585–603.
17. International patent numbers WO 2003/019143 A2, WO 2006/116276
A2,andWO2006/116303A2.Availableat:http://www.wipo.int/portal/
index.html.en. Accessed 4 August 2008.
18. VillaLL,CostaRLR,PettaCA,etal.Prophylacticquadrivalenthumanpap-
illomavirus (types 6, 11, 16 and 18) L1 virus-like particle vaccine in young
women:arandomiseddouble-blindplacebo-controlledmulticentrephase
IIefficacytrial.LancetOncology 2005;6:271–8.
19. MaoC,KoutskyLA,AultKA,etal.Efficacyofhumanpapillomavirus-16
vaccine to prevent cervical intraepithelial neoplasia: a randomized con-
trolled trial. Obstet Gynecol 2006; 107:18–27.
20. Bosch FX, Muñoz N. The viral etiology of cervical cancer. Virus Re-
search 2002; 89:183–90.
21. KaplanEL,MeierP.Nonparametricestimationfromincompleteobser-
vations. J Am Stat Assoc 1958; 53:457–81.
22. The FUTURE II Study Group. Prophylactic efficacy of a quadrivalent
human papillomavirus (HPV) vaccine in women with virologic evi-
dence of HPV infection. J Infect Dis 2007; 196:1438–46.
23. PaavonenJ,JenkinsD,BoschFX,etal.Efficacyofaprophylacticadjuvanted
bivalent L1 virus-like-particle vaccine against infection with human papil-
lomavirustypes16and18inyoungwomen:aninterimanalysisofaphase
IIIdouble-blind,randomisedcontrolledtrial.Lancet 2007; 369:2161–70.
24. Olsson S-E, Villa LL, Costa R, et al. Induction of immune memory following
administration of a prophylactic quadrivalent human papillomavirus (HPV)
types6/11/16/18L1virus-like-particlevaccine.Vaccine2007;25:4931–9.
Cross-Protective Efficacy of Quadrivalent HPV Vaccine
● JID 2009:199 (1 April)
● 935
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 11

APPENDIX A
PREDICTIVE VALUE OF DURATION OF
INFECTION
We assessed the predictive value of the duration of infection as it
relatestosubsequentprogressiontoCIN2–3/AIS.Subjectsfromthe
placeboarmofprotocol012whoreceived?1vaccinationandwho
wereseronegativeandDNAnegativefortherelevantHPVtypeon
day 1 were included in the analysis. Subjects were considered to
havedevelopedanendpointifeitherofthefollowingoccurred:(1)
1 or more episodes of infection related to a particular HPV type
occurred without the subsequent development of CIN2–3/AIS re-
latedtothesameHPVtype(inthisinstance,subjectswereclassified
according to length of the episode that had the longest duration);
(2)infectionrelatedtoaparticularHPVtypeoccurredwithsubse-
quent diagnosis of CIN2–3/AIS related to the same type. Subjects
were classified according to the duration of infection immediately
precedingthediagnosisofCIN2–3/AIS.
Table A1.
protocol 012 (unrestricted susceptible population) who developed cervical intraepithelial neoplasia (CIN)
2 or worse related to the same HPV type, by duration of infection.
Summary of subjects with human papillomavirus (HPV) infection from the placebo arm of
HPV type, duration
of infection
Subjects with subsequent
diagnosis of CIN2–3/AIS
related to the
indicated HPV typea
Subjects without
subsequent diagnosis of
CIN2–3/AIS related to the
indicated HPV typeb
PPV, point estimate
(95% CI), %c
HPV-16
?6 months
?6 to ?12 months
?12 months
HPV-18
?6 months
?6 to ?12 months
?12 months
HPV-31
?6 months
?6 to ?12 months
?12 months
HPV-33
?6 months
?6 to ?12 months
?12 months
HPV-45
?6 months
?6 to ?12 months
?12 months
HPV-52
?6 months
?6 months to 12 months
?12 months
HPV-58
?6 months
?6 to ?12 months
?12 months
6 38
59
82
13.6 (5.2 to 27.4)
14.5 (7.2 to 25.0)
8.9 (3.9 to 16.8)
10
8
3
1
1
22
26
31
12.0 (2.5 to 31.2)
3.7 (0.1 to 19.0)
3.1 (0.1 to 16.2)
5
4
3
24
37
49
17.2 (5.8 to 35.8)
9.8 (2.7 to 23.1)
5.8 (1.2 to 15.9)
1
3
3
9 10.0 (0.3 to 44.5)
23.1 (5.0 to 53.8)
13.6 (2.9 to 34.9)
10
19
0
0
0
17
16
23
0
0
0
4
2
3
20
43
50
16.7 (4.7 to 37.4)
4.4 (0.5 to 15.1)
5.7 (1.2 to 15.7)
3
1
0
21
31
26
12.5 (2.7 to 32.4)
3.1 (0.1 to 16.2)
0
NOTE.
type(s) on day 1. Cases were counted starting 30 days after day 1. AIS, adenocarcinoma in situ; CI, confidence interval; PPV,
positive predictive value.
aNo. of subjects with infection related to the indicated HPV type for the duration specified in each row who subsequently
developed a case of CIN2–3/AIS related to the indicated HPV type. Subjects are classified according to the duration of infection
related to the indicated HPV type immediately preceding the diagnosis of CIN2–3/AIS related to the indicated HPV type.
bSubjects who developed 1 or more episodes of infection related to the indicated HPV type without developing a case of
CIN2–3/AIS related to the indicated HPV type. Subjects are classified in the row that corresponds to the episode of infection
with the longest duration.
cPercentages were calculated as (no. of subjects with subsequent CIN2–3/AIS related to the same HPV type/total no. of
subjects with infection related to the indicated HPV type) ? 100.
Includes all subjects who received ?1 vaccination and were seronegative and DNA negative for the relevant HPV
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 12

The total number of subjects who had an infection end point
wascomputedasthesumofthenumberofsubjectswhoreached
either of the 2 end points. The positive predictive value of dura-
tionofinfectionasitrelatestosubsequentprogressiontoCIN2–
3/AIS was defined as the proportion of the total subjects who
developedacaseofinfectionwhosubsequentlydevelopedacase
of CIN2–3/AIS. The point estimate of the positive predictive
value was calculated as (no. of subjects with subsequent CIN2–
3/AIS related to the same HPV type/total no. of subjects with
infection related to the indicated HPV type) ? 100. The 95% CI
was calculated following the usual derivation of a 95% CI for
thepointestimateoftheprobabilitypfromabinomialdistribu-
tion.
Table A1 shows the number of cases of infection classified
according to duration of infection, along with the positive pre-
dictive value of duration of infection as it relates to subsequent
progression to CIN2–3/AIS. In summary, the observed positive
predictive value of infection that is ?12 months’ duration (i.e.,
?0to?6monthsor?6to?12months)washigherthanthatof
an infection that is ?12 months’ duration.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from

Page 13

Figure 1.
points).
Reasons for exclusion from the efficacy population that was negative for 14 human papillomavirus (HPV) types (infection and disease end
Table 4.Analysis of cross-protection against infection and disease excluding human papillomavirus (HPV)–31 (post-hoc analyses).
Category
Vaccine Placebo
Efficacy
(95% CI), % No.Cases Ratea
No. Cases Ratea
Infectionb
HPV-33, -45, -52, or -58
Nonvaccine A9 species (HPV-33, -35, -52, or -58)
CIN1–3/AIS
HPV-33, -45, -52, or -58
Nonvaccine A9 species (HPV-33, -35, -52, or -58)
HPV-33, -35, -39, -45, -51, -52, -56, -58, or -59
CIN2–3/AIS
HPV-33, -45, -52, or -58
Nonvaccine A9 species (HPV-33, -35, -52, or -58)
HPV-33, -35, -39, -45, -51, -52, -56, -58, or -59
1036
1036
105
100
3.1
2.9
1032
1032
123
114
3.6
3.4
14.9 (?11.3 to 35.0)
12.5 (?15.5 to 33.8)
4616
4616
4616
89
87
196
0.5
0.5
1.2
4680
4680
4680
114
117
251
0.7
0.7
1.5
21.0 (?5.1 to 40.8)
24.8 (?0.1 to 43.7)
21.2 (4.6 to 34.9)
4616
4616
4616
40
40
59
0.2
0.2
0.4
4680
4680
4680
50
53
83
0.3
0.3
0.5
19.0 (?25.3 to 47.9)
23.5 (?17.5 to 50.6)
28.0 (?1.7 to 49.4)
NOTE.
aCases per 100 person-years at risk.
bDefined as detection of the same HPV type on 2 consecutive visits spaced ?6 months apart (?1-month visit windows) or the presence of cervical/genital
disease associated with the relevant type (with DNA for the type found in a swab sample at the visit directly before or after the biopsy).
A subject is counted only once within each applicable row. AIS, adenocarcinoma in situ; CI, confidence interval; CIN, cervical intraepithelial neoplasia.
by guest on May 19, 2011
jid.oxfordjournals.org
Downloaded from