Innovations in HPV Vaccination and Roles of Nurses in Cervical Cancer Prevention

Abstract

The human papilloma virus (HPV) is the main aetiological agent for cervical cancer, one of the most frequent cancers observed in women throughout the world. There are effective programs for reducing the incidence of cervical cancer with HPV vaccination. The objective of this study was to discuss the applicability of the HPV vaccination and the role of nurses in prevention of cervical cancer. Use of bivalent and quadrivalent vaccines has been initiated against the types of HPV which are the primary cause of cancer. The quadrivalent HPV vaccination has entered into the routine vaccination schedule in many European countries for use in children and adolescents between 9-15 years of age and for women between 16-26 years of age, whereas it has been proposed that the bivalent vaccination should be given to girls between 9-18 years of age. While cervical cancer is among the cancers that can be prevented, it is essential to continue screening tests while introducing vaccination in a systematic manner for protection. On this subject, among the most important roles of nurses is to implement the screening programs by fulfilling the caregiving, training and consultancy roles for the society and especially, for high risk groups and to increase the awareness of the people.

Full text

Asian Pacic Journal of Cancer Prevention, Vol 15, 2014 10053
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.23.10053
Innovation in HPV Vaccine and Nurse Roles in Cervical Cancer Prevention
Asian Pac J Cancer Prev, 15 (23), 10053-10056
Introduction
Cancers are major public health problems because of
the high incidence of mortality and morbidity (Bilir, 2007;
Al-Darwish et al., 2014). Cervical cancer is caused by the
sexually transmitted Human Papilloma Virus (HPV) and is
the fourth most common life-threatening cancer in women
and the seventh worldwide, with an estimated 528,000
new cases in 2012. Women can particularly benefit
from the HPV vaccine. It was estimated that globally
cervical cancer accounted for 7.5% of the female cancer
deaths in 2012 and almost 87% of the deaths occurred
in low-income countries (IARC, 2012). Turkey’s rate of
incidence is 4.3/100,000 people, which is a low prevalence
of cervical cancer among the countries (IARC, 2012).
In developed countries, the incidence of cervical cancer
is mostly observed in the 45-69 years of age group and
the mortality rate occurs at 70 years of age and older.
The incidence and mortality rate in developing countries
are more frequent in the group 70 years of age and older
(TNSCCS, 2007). The World Health Organization (WHO)
noted that the HPV vaccine has reduced the incidence of
cervical cancer and the WHO recommended girls 9-13
years of age who have not yet become sexually active as
the target group for vaccination (WHO, 2013). Nurses
and other health professionals can implement effective
screening programs and cost-effective vaccinations to
1Department of Community Health Nursing, Faculty of Nursing, Ege University, Izmir, 2Department of Home Care Ventilatory,
Kastamonu University, Kastamonu, Turkey *For correspondence: julidegulizaryildirim@hotmail.com
Abstract
The human papilloma virus (HPV) is the main aetiological agent for cervical cancer, one of the most frequent
cancers observed in women throughout the world. There are effective programs for reducing the incidence of
cervical cancer with HPV vaccination. The objective of this study was to discuss the applicability of the HPV
vaccination and the role of nurses in prevention of cervical cancer. Use of bivalent and quadrivalent vaccines
has been initiated against the types of HPV which are the primary cause of cancer. The quadrivalent HPV
vaccination has entered into the routine vaccination schedule in many European countries for use in children and
adolescents between 9-15 years of age and for women between 16-26 years of age, whereas it has been proposed
that the bivalent vaccination should be given to girls between 9-18 years of age. While cervical cancer is among
the cancers that can be prevented, it is essential to continue screening tests while introducing vaccination in a
systematic manner for protection. On this subject, among the most important roles of nurses is to implement
the screening programs by fullling the caregiving, training and consultancy roles for the society and especially,
for high risk groups and to increase the awareness of the people.
Keywords: HPV vaccines - uterine cervical cancer - screening - nurse’s roles - awareness
MINI-REVIEW
Innovations in HPV Vaccination and Roles of Nurses in Cervical
Cancer Prevention
Julide Gulizar Yildirim1*, Zeynep Arabaci2
reduce the rates of cervical cancer (Bilir, 2007; Brabin et
al., 2011). In this study, we evaluated the role of nurses
in order to ensure the feasibility and effectiveness of the
HPV vaccine in protecting against cervical cancer.
Background
In recent years, the knowledge, awareness, attitude,
behaviors and beliefs of youths were examined in the
studies on the effectiveness of the HPV vaccination
(Waller et al., 2003; Akyuz et al., 2006; Uysal and Birsel,
2009; Wong et al., 2009; Ak et al., 2010; Duran, 2011;
Arabaci and Ozsoy, 2012; Ortashi et al., 2014; Al-Darwish
et al., 2014; Wang et al., 2014; Yilmazel and Duman,
2014).
Educational needs
Various studies showed the importance of the role of
nurses and have assessed the awareness and knowledge of
HPV among adolescents, young adults, students (Waller
et al., 2003; Al-Darwish et al., 2014; Wang et al., 2014;
Yilmazel and Duman, 2014) and women who have past
experience with abnormal Pap test results and colposcopy
(Waller et al., 2005; Akyuz et al., 2006; Uysal and Birsel,
2009; Wong et al., 2009; Ak et al., 2010; Duran, 2011;
Arabaci and Ozsoy, 2012; Ortashi et al., 2014).
Some studies showed the importance of insufcient

Julide Gulizar Yildirim and Zeynep Arabaci
Asian Pacic Journal of Cancer Prevention, Vol 15, 2014
10054
knowledge levels and awareness about cervical cancer
(Wong et al., 2009; Duran, 2011; Yilmazel and Duman,
2014); that academic grades were an efcient factor for
dening their knowledge levels about cervical cancer
and HPV vaccination (Yilmazel and Duman, 2014); and
that knowledge was insufcient among undergraduates
(71.05%). Undergraduates from high-level universities,
at a lower year of study or with greater prior knowledge
of the HPV vaccines displayed higher acceptability
(p<0.001) of the HPV vaccination (Wang et al., 2014).
Al-Darwish et al., (2014) found that 43.7% of the male
and 56% of the female students were not aware of the early
warning signs, symptoms and risk factors.
Of the students, 67% were not aware and only 27.2%
of the female students and 52.5% of the fth year students
were aware about the availability of vaccine against
cervical cancer. Ortashi et al., (2014) indicated in their
research that 37% of women were aware of the HPV
vaccination.
Behavior
Yilmazel and Duman (2014), indicated that university
students displayed risky behaviors, such as unsafe sexual
intercourse, which cause health problems and sexually
transmitted diseases (e.g., HIV, HPV, syphilis, gonorrhea
and chlamydia). It was observed that students’ beliefs
about risk factors, vaccination protection and condom use
differed among the academic departments and these beliefs
were higher/stronger among students who studied in the
health department. Ortashi et al., (2014) reported adjusting
for some factors affected the behaviors about vaccination.
Of the women, 80% would consider getting vaccinated
themselves and 87% would recommend vaccination to
relatives or friends. Of the women, 69% had a positive
attitude towards vaccination and nationality and husband’s
education was effective in associating with a positive
attitude towards the HPV vaccine.
Beliefs
Women have almost no fear about the prevention
and early diagnosis of cervical cancer due to insufcient
awareness (Duran, 2011). The acceptability rates for
the HPV vaccination among women were found to be
similar to those in the vaccination programs of developed
countries (Haesebaert et al., 2012; Molokwu et al., 2013;
Ortashi et al., 2014). Ortashi et al., (2014) indicated that
overall, 69% of women had a favorable opinion about the
HPV vaccination. Some of them (17%) reported that it
might not be culturally acceptable and 1% felt that there
might be religious objections to the HPV vaccination.
Only 18% of women dened uptake of culture as a barrier
to the HPV vaccination. Wang et al., (2014) reported that
undergraduate students were more willing to accept the
HPV vaccination due to fear of HPV-related diseases.
HPV vaccine
Currently, two types of HPV vaccines are marketed
internationally. Both vaccinations are obtained with
the purification of major capsule (L1) proteins by
implementing the recombinant technology, which does not
contain viral DNA, but contains particles (VPL) similar
to the specic virus. These vaccinations that are inorganic
and do not have infectious attributes are for prevention,
but do not have curative attributes (Alhan, 2009). The
rst cancer vaccine, a quadrivalent HPV vaccine called
Gardasil (Merck & Co., Inc.), which protects against HPV
types 6, 11, 16 and 18, was approved by the US Food and
Drug Administration (FDA) in 2006. However, other than
cervical cancer, Gardasil is licensed for protection against
lesions, such as vaginal and vulvar intraepithelial neoplasia
and genital warts. Worldwide, HPV vaccination has now
been implemented in more than 150 countries (Alhan,
2009; Schiller et al., 2012). Subsequently, Cervarix(®)
(GlaxoSmithKline Biologicals, Rixensart, Belgium), a
bivalent HPV vaccine containing VLP for types 16 and
18, was approved and licensed in 2007. This vaccine is
used for the prevention of pre-cancer and cancer lesions
in adolescent girls as of 10 years of age. The efcacy
of both vaccines are reported to be more than 98% for
protection against cervical cancer in females (Saslow et
al., 2007; Brabin et al., 2011; Schiller et al., 2012). HPV
vaccines must take their place as a part of a coordinated
strategy constituted to prevent cervical cancers. These
strategies should include education (increased risk of HPV
infection, which is transmitted by the reduction behavior),
diagnosis and knowledge about treatment of pre-cancerous
lesions. In Kothari’s (2014) study, it was reported that a
three-dose HPV vaccination program in 2008 from the
Joint Committee on Vaccination and Immunization was
recommended to be offered routinely to girls 12-13 years
of age and a time-limited catch-up vaccination for females
13-18 years of age. The quadrivalent vaccination was
given to over 20,000 women between 16-26 years of age
and the bivalent vaccination was given to 18,000 women.
It was found that it was 92% protective for new infections
connected to 16/18 of HPV and that it was 100% protective
in the prevention of persistent infections (WHO, 2013).
Protection against cervical cancer, HPV programs and
nurses’ roles
It is important for women to protect themselves against
carcinogenic factors for primary prevention of cervical
cancer and can be provided with individual preferences
and by changing lifestyle. The purpose of secondary
prevention is to prevent mortality and morbidity that can
be provided by using screening tests for early diagnosis
(e.g., Pap test) and should be applied for early treatment
(Fidaner, 2007; Ardahan and Temel, 2011). Nevertheless,
nurses have rather important roles in making the public
conscious by communicating with people for protecting
against sexually-transmitted diseases (STDs) through the
use of contraception, such as condoms and diaphragms,
which constitute a barrier between the cervix and penis.
It was found that the risk of cervix cancers in women who
protected against pregnancy by using hormones was high
compared to women who did not use any method. Since
the cause of cervical cancers are due to an HPV infection
caught sexually, the elimination of factors should be
recommended, such as the regulation of sexual life, a
decrease in multi-partners, sexual activity at an early age
and not having a safe sexual life, a decrease in prolicacy
and an improvement in nutrition (consuming vitamins A

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DOI:http://dx.doi.org/10.7314/APJCP.2014.15.23.10053
Innovation in HPV Vaccine and Nurse Roles in Cervical Cancer Prevention
and C) are signicant measures.
Experience has shown that because the vaccine is
new, people in some countries question its efcacy or
they believe that vaccination will result in increased
sexual activity. Gynecologists or religious leaders in some
countries misunderstand the purpose or value of the HPV
vaccine (WHO, 2013).
HPV Vaccine Programs
The WHO recommends early diagnosis and screening
programs against cervical cancer and demonstrates that
it is a cancer type with negative outcomes, which can
easily be prevented through preventive medicine (Fidaner,
2007). Over 40 countries had introduced national HPV
vaccine programs and other countries had introduced or
planned to introduce pilot or demonstration programs as
of December 2012. The following play a role in the lower
uptake of some vaccines: a lack of knowledge about the
threat of vaccine-preventable diseases, risks and benets
of vaccines, mistrust of government and health workers,
poor service delivery and alternative health or religious
beliefs. These challenges emphasize the importance
of early integration and investment in immunization
programs with a thoughtful communications plan (WHO,
2013). The NHS cancer screening program cervical
screening: The facts leaet is available in 23 languages
and is useful in understanding the HPV vaccination and
can create community-awareness about the cervical
cancer screenings (NHS, 2012). Some countries within
the Gardasil Access Program used schools and clinics
and vaccination based on school-based, health facility-
based, and mixed strategies (Lander et al., 2012). Some
of the national programs (TNSCCS, 2007; Ogilvie et al.,
2010; Limia and Pachon, 2011; Binagwaho et al., 2012)
and regional level programs (Brabin et al., 2008; Watson
et al., 2009) indicated efcient vaccination to prevent
cervical cancer through a national media campaign. In
Turkey, the routine screening program for cervical cancer
started with the “National Standards for Cervical Cancer
Screening” published in 2007. In the screening, it has been
targeted that the family medicine physicians take a Pap
test a minimum of 1 time from all of the women registered
between the ages of 30-65 years of age at the community
health centers and the cancer screening centers and that
a screening program based on the society is continued
by repeating it once every ve years and that training is
given (TNSCCS, 2007).
The combined HPV vaccine coverage was 93.8%
in the school-based, 93.0% in the mixed strategies and
77.1% in the health-facility based program. In Spain, the
eleven regions administering the HPV vaccines at schools
had a 14% higher coverage compared to the eight regions
utilizing health facilities (Limia and Pachon, 2011). In
Uganda, the school-based vaccine delivery strategy was
higher than the Child Days Plus strategy (LaMontagne et
al., 2011). In Vietnam, the health facility-based programs
had higher coverage than the school-based programs
(LaMontagne et al., 2011). India’s demonstration project
utilized a mixed school and health facility-based approach.
Vaccine delivery was compared using xed-time points
based on vaccination campaigns and monthly vaccine
delivery that complements routine EPI immunizations.
Coverage was 68% in an urban setting, 83% in a rural
setting and 71% in a tribal setting for the routine approach.
Similar ndings ranging from 77 to 88% were observed
for the campaign approach by geographical setting
(LaMontagne et al., 2011).
Implications for practice and nurses’ roles
Education of providers, policy-makers, parents,
adolescents and young women about cervical cancer
prevention and early detection, including the need for
regular screening even after vaccination is a critical need
(Saslow et al., 2007).
Nurses serve a key role for protecting against and
detecting cervical cancer. Screening and HPV vaccine
present nurses with exciting opportunities as well as
communication opportunities for public health nurses,
which are important roles for creating awareness of the
HPV vaccination. Nurses can recognize some factors
in women and teenage girls, such as improvement
of the perceived benefit perceptions, can recognize
socioeconomic, ethnicity factors, history of health
status and mother’s screening history, can inuence the
knowledge levels to change health behaviors, can apply
the screening program by implementing different methods,
such as the Pap test technique, acetic acid, etc. (Ardahan
and Temel, 2011; WHO, 2013; Casciotti et al., 2014;
Kothari, 2014; Paul and Fabio, 2014).
Countries considering HPV vaccine delivery strategies
that use schools can utilize the information summarized
and discussed here to move forward with planning for
HPV vaccine introduction. However, further research is
needed to develop standardized methods for estimating
coverage of adolescent immunizations, so that HPV
vaccine programs can be appropriately evaluated (Paul
and Fabio, 2014). The role of nurses is important for
primary prevention strategies and for multiple health
preventive roles that assist parents and adolescents in
making informed decisions about new preventive health
recommendations against risky sexual behaviors in the
society, such as safe sexual life, monogamy and condom
use, development and popularization of cost-effective HPV
vaccinations and prevention of smoking. Furthermore,
nurses promote messages for media use about new health
products and policies that stress areas of consensus rather
than controversy, reduce health inequalities, promote
social inclusion and raise educational standards (Kaya,
2009; Brabin et al., 2011; Casciotti et al., 2014).
Conclusion
Cervical cancer is an important public health problem
due to the fact that it is the fourth most frequently observed
type of cancer observed in women throughout the world
and that it has a rising trend in Turkey among the top ten
types of cancer. Screening programs have been proven to
be effective and cost-effective in reducing the incidence
and mortality of cervical cancer. It is necessary to continue
the Pap test and vaccination regularly for protecting against
cervical cancer and to treat the programs with integrated

Julide Gulizar Yildirim and Zeynep Arabaci
Asian Pacic Journal of Cancer Prevention, Vol 15, 2014
10056
approaches that will contribute to the improvement of
female health. In this context, the matters that should
not be forgotten by the decision-makers in particular are
giving priority to services, such as the raising of the status
of women, preventing societal sexual discrimination,
treating within a whole the reproductive health service
programs, early diagnosis and family planning and to
evaluate all of the applications with monitoring programs.
On this subject, one of the most important roles of nurses
is to increase the awareness of the public by fullling the
caregiving, training and consulting roles, especially to the
group under risk in the society.
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