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WELLNESS AND AGE
CHAPTER X
Department of Anatomy of the University of Medicine in Wrocław
Katedra i Zakład Anatomii Prawidłowej Człowieka
Uniwersytet Medyczny we Wrocławiu
AGNIESZKA PINKOWSKA, ANNA ROHAN-FUGIEL, BOHDAN GWORYS
Knowledge of cervix cancer and human papilloma infection
in 13-year-old females in relation to conducted protective
vaccination. A preliminary study
Poziom wiedzy 13-letnich dziewcząt dotyczący raka szyjki macicy
i zakażeń brodawczakiem typu ludzkiego
w kontekście wykonywanych szczepień ochronnych. Badania wstępne
Key words: cervical carcinoma, vaccination, HPV
Słowa kluczowe: rak szyjki macicy, szczepienia, wirus HPV
INTRODUCTION
Human papillomavirus (HPV) belongs to the family Papillomaviridae of DNA
viruses. HPV infects stratified epithelial tissues, most commonly in the anogenital
region, and follows an intraepithelial life cycle. More than 100 HPV types have been
identified, of which types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and
73 show high-risk of carcinogenicity [5]. Highest risk are types 16 and 18, attributable to 80% of cervical cancer cases. Besides oncogenic HPVs, other types are responsible for a variety of clinical conditions albeit the majority are benign in nature
(e.g. types 6 and 11) and most HPV infections (80%) are naturally cleared by the
immune system without outside intervention.
WELLNESS AND AGE
HPV is primarily transmitted through sexual contact, with the incidence of infection most common in the early years of sexual activity (50% of infections occurring
within 2 years of sexual debut). Contrary to popular belief, HPV affects both men
and women, with epidemiological data indicating that 50–80% of individuals regardless of sex will be infected at some point in their lives. Besides the high contraction
rate, there is a risk of becoming infected with one or more types of HPV at multiple
time points during one's lifetime. Among associated risk factors, a relationship exists
between the prevalence of infection and number of sexual partners. For example,
estimates of HPV prevalence in the American population are 54% in young women
who have had more than one sexual partner but 34% among those who have had
only one sexual partner [22].
Viral load is relatively low during HPV infection, hence immunogenicity of the
virus is small. However, a persistent infection of over 2 years is most commonly
associated with high-risk oncogenic HPV types and may lead to cancers of the cervix, vulva, anus, and in rare cases, the penis. HPV infection is considered to be the
leading cause of cervical cancer. Every year, an estimated 500000 new cervical
cancers occur across the world. In Europe alone the number of new cases is
approximately 60000, with nearly half ending in death. Poland is considered a black
spot on the map of Europe, where cervical cancer is the second-most common cause
of cancer. Irrespective of awareness campaigns, incidence and mortality rates have
remained stable at 20.6 per 100000 and 9.7 per 100000 individuals per year, respectively [25]. The highest incidence of cervical cancer is among women aged 35–55
years. The danger of cervical cancer lies in the fact that it develops slowly over time
(average 5–10 years) and is frequently asymptomatic at its early stages.
While treatment options for HPV are limited, there exist a wide range of preventive options including vaccination. A quadrivalent vaccine under the trade name
Gardasil® (Merck & Co. – MSD) was first licensed in 8 June 2006 by the American
Food and Drug Administration and recommended for females between the ages of 9
and 26 [2]. By 2007, the European Medicines Agency approved the use of Gardasil® under the name of Silgard® (MSD) and the alternative bivalent vaccine Cervarix® (GlaxoSmithKline – GSK) [25]. Both Cervarix® (GSK) and Silgard® (MSD)
are inactivated vaccines, where the former is effective against HPV types 16 and 18
while the latter elicit antibody response to types 6, 11, 16, and 18. While there exist
differences between the vaccines in antigen and adjuvant composition and administration schedule, both follow a similar mechanism of action.
Cervarix®

Vaccine antigens against HPV types 16
and 18

Adjuvant AS04 (hydrated aluminum
hydroxide and monophosphoryl lipid A)
Dosing schedule
0-1-6 months

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Silgard®
 Vaccine antigens against HPV types 16
and 18
 Vaccine antigens against HPV types 6
and 11
 Adjuvant AAHS (amorphous aluminum
hydroxyphosphate sulfate)
 Dosing schedule
0-2-6 months
Agnieszka Pinkowska, Anna Rohan-Fugiel, Bohdan Gworys
in 13-year-old females in relation to conducted protective vaccination.
A preliminary study
Qualification criteria for the HPV vaccine are relatively minor (typical vaccination-based contraindications), while females who are not sexually active do not need
gynecological examination. While HPV vaccination has been found to be effective
in preventing cervical cancer, it cannot offer 100% protection against its development nor does it have any therapeutic effect on HPV or cervical cancer alone.
The efficacy of the vaccine was found to be age-dependent, being two-fold in younger girls compared with older women [25]. After dosing, seroconversion among
individuals for oncogenic HPVs is nearly 100%. While the literature suggests that
these vaccines protect against HPV for at least 6 years, the long-term benefits are
unknown and the efficacy of future booster doses uncertain. While the health benefits of HPV vaccination in younger females are well established, vaccination in
males is not universally recommended due to the a paucity of clinical data [24].
Country
Australia
United States of American
Canada
Austria
France
Germany
Italy
Norway
Age of HPV vaccination
12–13 years
11–12 years
9–26 years
9–15 years
14–15 years
12–17 years
12 years
11–12 years
To reduce the risk of precancerous or cancerous changes of the cervix, contemporary primary prevention has focused on administering the HPV vaccination and
promoting a healthy lifestyle. Secondary prevention has focused on the early detection of precancerous lesions by cytology and visual screening whereas tertiary
prevention on outright diagnosis and treatment of confirmed cases.
National health authorities across the world have stressed the efficacy of HPV
vaccination prior initial contact with the virus and therefore strongly recommend or
even require its administration to young females [5]. Many have enacted universal
vaccination programs, such as in the United States, Canada, Australia, and certain
European Union member nations. The Vaccine European New Integrated Collaboration Effort reports that 29 European Union countries had implemented HPV vaccinations for girls aged 11–12 years already by 2010. Among the member states, 18
have integrated HPV vaccinations as part of national immunization schedules whereas 15 countries cover the cost in full and 2 partially refund the vaccine. In Poland,
HPV vaccination has been recommended since 2008 by the national immunization
board although it is not funded at the national level. Various local Polish governments have enacted initiatives to purchase HPV vaccines for young girls, primarily
those aged 11–12 years. One medium-sized city that has done so is Wrocław, which
from 2010 has annually vaccinated approximately 2000 13-year-old schoolgirls free
of charge. Concomitant to HPV vaccinations are education-based interventions on
HPV itself and the advisability of vaccination. The purpose of this pilot study was to
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WELLNESS AND AGE
determine the current level of knowledge on HPV and cervical cancer among 13year-old females who were to be vaccinated as part of the city of Wrocław's public
school immunization program.
MATERIAL AND METHODS
The primary research tool was a self-designed questionnaire comprising 10 closed, single-choice items. Eight of the items verified knowledge on HPV vaccination
and cervical cancer whereas the remaining two collected sociodemographic data.
The questionnaire was administered between December 2010 and May 2011. A
convenience sample was selected based on 13-year-old female patients attending a
local health clinic who were to be inoculated with the HPV vaccine. On the day of
vaccination a medical examination was performed and the participants, accompanied
with a parent or guardian, were informed of the procedures including background
information on HPV and cervical cancer. All of the participants received the vaccination free of charge as part of the city of Wrocław's immunization program. The
participants completed the questionnaire anonymously.
RESULTS
In response to the first item querying the source of their information on cervical
cancer, thirteen answered that they had no interest in the matter (43.3% of the sample), ten responded that they had talked with their doctor before being vaccinated
(33.3%), four had read about it on the Internet (13.3%), and three had a conversation
with their mother (10%).
33%
44%
10%
13%
Not intersted
Internet
From my mother
From my doctor before vaccination
Figure 1. Item 1 – Where did you get your knowledge on cervical cancer?
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A preliminary study
In response to the second item on cervical cancer prevention methods, the majority were found to be underinformed – eight cited only cytological screening
(26.6%), seven indicated HPV vaccination (23.3%), and 1 chose delayed sexual
debut (3.3%). Of the seven participants who selected the true or false, three indicated that only cytological screening was effective (10%) while four believed that a
combination of vaccination, cytological screening, and early sexual debut prevented
against cervical cancer (13.3%).
Figure 2. What are known methods of preventing cervical cancer?
The following item on sex and its consequences revealed that this issue was rarely addressed. Nearly 70% of the participants had never conversed with their parents
on sexuality, in which twelve declared that neither side had wanted to pursue such a
discussion (40%) and eight were not yet able to comfortably discuss sex with their
parents (26.6%). More than 20% had discussed sexuality with their mothers, of
which five had such a conversation before being vaccinated against HPV (16.6%)
and two before menarche (6.6%). Three of the participants admitted that their parents avoided the subject despite having inquired about sex (10%).
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WELLNESS AND AGE
Figure 3. Have you discussed sex and its consequences with your parents?
The next item questioned if the participants had discussed the reason for needing
another HPV dose, in which fourteen declared they had not been informed by their
parents (46.6%), five responded that they had been informed by their parents but just
before vaccination (16.6%), and only five had discussed the issue with both their
parents and family physician before vaccination (16.6%). Only six indicated that
they had discussed the issue in detail with their parents (20%).
126
A preliminary study
20%
46%
17%
17%
Yes, by my mother
Yes, by my mother just before HPV vaccination
Yes, with my mother and doctor before HPV vaccination
No, I did not
Figure 4. Were you informed about the reasons for a subsequent HPV dose?
The fourth item focused on the transmission of HPV, in which half identified
sexual activity as the main source. Seven declared that it was by general contact
(23%), four by blood transmission (13.3 %), and four participants stated they did not
know what HPV was (13.3 %). None selected intravenous infusions.
23%
13%
13%
51%
By blood
By sex
I don't know what HPV is
By touch
By infusion
Figure 5. Transmission routes of HPV
The item on HPV affliction found that twenty-one participants believed that only
women could be infected (70%), nine declared that both males and females can be
carriers of HPV (30%), whereas none identified as boys and men as the sole carriers
of HPV.
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WELLNESS AND AGE
30%
70%
Only women
Only boys and men
Women and men
Figure 6. Carriers of HPV
The next item addressed the typical age of cervical cancer onset, finding that the
majority were either not interested in the matter (nine participants, 30%) or did not
know at what age it may occur (nine participants, 30%). Eight girls (30%) believed
that cervical cancer affects only women aged over 50 and four women aged over 40
(13.3%).
30%
30%
13%
27%
At any age
Above 40
Above 50
I'm not interested
Figure 7. At what age can cervical cancer occur?
In terms of interest in matters pertaining to health and preventive healthcare, none of the participants indicated that they had discussed the subject with interest,
whereas eleven declared they had more interesting topics to discuss (35%), nine said
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A preliminary study
that health and preventive healthcare does not concern them (30%), and ten girls
admitted that they discussed such issues only when presented in mass media (33%).
33%
37%
30%
I have more interesting topics to talk about
This doesn't concern us
Sometimes after it's mentioned in the media
Yes, this is important
Figure 8. Have you discuss health and preventive healthcare issues
with anyone?
The remaining two items pertained to sociodemographic characteristics, with the
first asking the participant to assess what type of student they are. Here, twenty-one
girls stated they were good students (70%), seven described themselves as average
(23.3%), and only two as very good students (6.6%).
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WELLNESS AND AGE
7%
23%
70%
Average
Good
Very good
Figure 9. What kind of student are you?
The last item asked the participants to describe their mother's education level,
finding that fifteen had mothers with a secondary education (50%), ten with higher
education (33%), and five with a vocational education (16%).
17%
33%
50%
Vocational
Secondary
Higher
Figure 10. Mother's education level
130
A preliminary study
DISCUSSION AND CONCLUSIONS
Based on the questionnaire items addressing cervical cancer prevention methods,
transmission routes of HPV, infection vectors, and the age of cervical cancer diagnosis, we found that our sample of 13-year-olds answered a mean 30% of the items
correctly (23.3%, 50%, 30%, and 30%, respectively). This discouraging result was
compounded by the reported low interest in health issues, where approximately 44%
of the sample expressed a lack of interest in cervical cancer and HPV and nearly
75% declared to show no interest in health and preventive healthcare. Of interest is
the fact that 33% of the sample did discuss health when addressed in the media. This
appears to provide a promising form of communication with teenagers who evidently show minor interest in health issues that may be very significant in later life.
There is some history of awareness campaigns that have used this approach, such as
the Polish Society for the Prevention of HPV's “Saving lives in the fight against
cervical cancer” which involved famous Polish women and their daughters as well
as teen-focused magazines. Such social initiatives are an excellent step in the right
direction, as the use of celebrities popular among teenage girls can facilitate discussion in this regard. As the results attest, there appears to be a significant disconnect
in discussion between teenage girls and their parents. As reported by their daughters,
slightly more than 20% of mothers attempted to discuss issues surrounding sex and
its consequences. Similarly, only 20% of parents explained what HPV is, why vaccination is needed, and what are possible health outcomes. Instead, 50% of parents
had not yet broached the topic of sex and that over 45% had brought their child to be
vaccinated without discussing the issue beforehand.
Surprisingly, while 76% of the 13-year-olds declared they performed well or very well in school, none admitted that they considered health and preventive healthcare an important issue in their lives. Based on our results, the health professional can
posit a number of questions. Are we expecting too much from a 13-year-old girl? Is
the language used to discuss such a weighty issue too complex? Is there some way
to genuinely promote interest in a health issue that may have serious life consequences? Is the lack of communication due to intergenerational differences? Should the
proliferation of such knowledge be, first and foremost, targeted to the mothers of
teenage girls?
Unfortunately, the limited scope of this study as well as its small sample size do
not allow us to provide any explicit recommendations concerning the lack of
knowledge on HPV vaccination and prevention of cervical cancer in 13-year-olds.
Additional psychometric investigation is needed.
The available literature has demonstrated an insufficient level of knowledge on
cervical cancer and HPV vaccination among a wide cross-section of Polish females
regardless of age. A study by Podlińska, Biernacka, and Gotlib analyzed public
opinion research from 1998 and 2002 and revealed growing awareness of gynecological cancers, albeit still a decidedly low level [17]. A study by Ulman-Włodarz et
al. involving women aged 18–60 years also found a lack of adequate knowledge and
motivation in regards to preventive examination (including cytology-based scree131
WELLNESS AND AGE
ning) [23]. Charążka and Bieńkiewicz also demonstrated unawareness in cervical
cancer prevention in a population of female university students, with significantly
greater knowledge among medical students than those attending a liberal arts
university [4]. Nonetheless, Drosdzol et al. reported an insufficient level of
knowledge in cancer prevention also among female medical students [6].
In Poland, demographic information on HPV vaccination in 2007 indicates that
5694 females were vaccinated (2909 below 10 years of age and 2785 above 20 years
of age) [12]. By 2008 this increased to 13863 females (9173 and 4690, respectively)
[13] and to 30749 females by 2009 (24933 below 19 years of age and 5816 above 20
years of age) [14]. In 2010, a slight decrease in HPV vaccinated females was observed to 27138 females (24231 and 2907, respectively) [15].
While the data indicate a progressive increase in HPV vaccination, the Polish
Coalition Against Cervical Cancer unequivocally states that more needs to be done
in abating cervical cancer. They have raised issues related to the financing and promotion of vaccination programs, especially in light of the lack of national-level
funding (Communiqué 51/15/2009 from 3 August 2009). The dilemma in regards to
funding may be a key issue in this regard, as local governments are able to provide
only 90% vaccination coverage and not all provide such a service [19].
For this reason, a multipronged approach must involve not only full financing
but, in line with the conclusions of the aforementioned authors, the expansion of
educational and awareness programs that address cervical cancer. Such a strategy
must encompass family physicians, internists, pediatricians, and gynecologists whose responsibility would be to not only promote HPV vaccination but also disperse
knowledge across all generations of women.
REFERENCES
1. Bidziński M, Dębski R, Kędzia W i wsp. Stanowisko Zespołu Ekspertów Polskiego Towarzystwa Ginekologicznego na temat profilaktyki raka gruczołowego szyjki macicy; Ginekol Pol 2008;79:710-714
2. Charakterystyka Produktu Leczniczego Cervarix, sierpień 2010
3. Charakterystyka Produktu Leczniczego Silgard; 2009
4. Charążka A, Bieńkiewicz A, Profilaktyka raka szyjki macicy w świadomości
studentek. Zdr Publ.2002,112,340-344
5. Czajka H, Wysocki J; Szczepienia w profilaktyce chorób zakaźnych; Help Med.;
Kraków 2010; str 85-89
6. Drosdzol A, Nowosielski K, Skrzypulec V[et al.] Świadomość onkologiczna
studentek Śląskiej Akademii Medycznej dotycząca nowotworów żeńskich narządów płciowych. Ann Acad Med. Siles 2005, 59, 359-362
7. 7.FoodandDrugAdministration2009
http://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm094
042.htm
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8. Guidance for the introduction of HPV vaccines in EU countries; European Center of Disease Prevention and Control; Stokholm, January 2008
9. Kotarski J, Basta A, Dębski R i wsp. Uzupełnione stanowisko Polskiego Towarzystwa Ginekologicznego dotyczące szczepień przeciwko zakażeniom wirusami
brodawczaka ludzkiego (HPV) Ginekol Pol.2009, 80, 870-876
10. Krajowy Rejestr
macicy-kobiet/#e
Nowotworów
http://onkologia.org.pl/nowotwory-szyjki-
11. Martius G, Breckwoldt M, Pfleider A; Nowotwory złośliwe; Ginekologia i Położnictwo; Urban & Partner; Wrocław 1997; 524-527
12. Narodowy Instytut Zdrowia Publicznego; Państwowy Zakład Higieny; Pracownia Analizy Epidemiologicznej i Skażeń Biologicznych; Szczepienia Ochronne
w Polsce; biuletyn roczny 2007
16. Pasalska-Niewęgłowska K, Szczepienie ochronne przeciwko HPV a wiedza
pacjentek, Family Med. Prim. Care Rev 2009,11,3:456-457
17. Podlińska M, Bernacka M, Gotlib J. Próba oceny wpływu wieku na poziom
wiedzy na temat raka szyjki macicy wśród pacjentek hospitalizowanych w oddziale położniczo-ginekologicznym. Pielęgniarstwo XXI wieku Nr 1-2(3031)/2010
18. Pokorna–Kałwak D, Pinkowska A, Muszyńska A, Szczepienia przeciw wirusowi
HPV w praktyce lekarza rodzinnegoFamily Med. Prim. Care Rev. 2011;
13(3):497-500
19. Polska Koalicja na rzecz walki z rakiem szyjki macicy.Rekomendacje
http://koalicjarsm.pl/WHO Position on HPV vaccine.Vaccine,2009; 27:72367247
20. Prevention of Human Papillomavirus infection: Provisional Recommendations
for Immunization of Girls and Woman with Quadrivalent Human Papillomavirus
Vaccine. Pediatrics, vol. 120, No 3, September 2007, p.666.
21. Program szczepień ochronnych na rok 2010 – załącznik do Komunikatu Głównego Inspektora Sanitarnego Dz. Urz. MZ.09.10.47 z dnia 23.10.209 roku.
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22. Rzepka-Górska I., Ginekologia dziecięca i dziewczęca W: Bręborowicz G.H.
(red); Ginekologia i Położnictwo; tom II; PZWL; Warszawa 2005, 797
23. Ulman-Włodarz i, Nowosielski K, Romanik M, Porowski J, Jurek M
;Świadomość profilaktyki raka szyjki macicy wśród kobiet zgłaszających się do
poradni K; Ginekol Pol 2011 82,22-25
24. VENICE 2 Finalised report on the decision making process, modalities of implementation and current country status for the introduction of human papillomavirus and rotavirus vaccination into national immunization programmes in
Europe 2010
25. Zalecenia grupy ekspertów dotyczące pierwotnej profilaktyki raka szyjki macicy
u dziewcząt i młodych kobiet; Pediatria Polska; tom 85; Nr 4; 4-11
ABSTRACT
In Poland, the incidence and mortality of cervical cancer is higher than in other
European Union countries. Human papillomavirus (HPV) types 16 and 18 are etiologically linked to 70% of invasive cervical cancers. HPV is highly prevalent
worldwide and there is high risk of infection among the sexually active. The introduction of two HPV vaccines in 2006 has proffered an effective preventive measure
reducing the chance of infection as well as moderate and severe dysplasia of the
cervix. Currently, HPV vaccination is recommended but not mandatory according to
the Polish national immunization schedule. Hence, the importance of HPV vaccine
promotion particularly among young females. The aim of the present study was to
administer a self-designed questionnaire to determine the level of knowledge on
HPV and cervical cancer among 13-year-old females in a Polish city. Nearly 70% of
the participants had never conversed with their parents on sexuality. The majority
were underinformed in regards to HPV vaccination and cervical cancer prevention
methods while also declaring to show no interest in health and preventive healthcare. Although mass media campaigns appear to show some success in spreading awareness, the study concludes that family physicians, internists, pediatricians, and
gynecologists must all be involved to provide a unified front in dispersing knowledge on HPV vaccination and cervical cancer prevention.
STRESZCZENIE
W Polsce częstość zachorowań i umieralność z powodu raka szyjki macicy jest
ciągle wyższa niż w innych krajach Unii Europejskiej. Wirus brodawczaka typu
ludzkiego, a głównie jego onkotypy 16 i 18 są odpowiedzialne za blisko 70% przypadków raka szyjki macicy. Wirus jest szeroko rozpowszechniony na świecie i istnieje duże ryzyko kontaktu z wirusem wśród aktywnych seksualnie. Od 2006 roku
zarejestrowane są w Europie, a więc i w Polsce, dwie szczepionki do profilaktyki
onkogennych typów wirusa HPV. Cechuje je wysoka skuteczność w zapobieganiu
zakażeniom HPV i dysplazji szyjki macicy średniego i dużego stopnia. W Polsce
szczepionki rekomendowane są zarówno przez Polskie Towarzystwo Ginekologiczne, jak i przez Polskie Towarzystwo Pediatryczne i są w pełni zgodne z zaleceniami
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A preliminary study
WHO i Europejskiego centrum ds. Zapobiegania i Kontroli Chorób. W Polsce
szczepienia przeciwko HPV zostały wpisane do Programu Szczepień Ochronnych w
formie zalecenia. Dlatego tak ważne jest propagowanie tej formy profilaktyki. Ta
rola powinna spoczywać na lekarzach pierwszego kontaktu, lekarzach rodzinnych,
pediatrach, internistach i ginekologach. Blisko 70% ankietowanych dziewcząt nigdy
nie rozmawiała z rodzicami na tematy związane z seksualnością człowieka. Ankietowane dziewczęta wykazały się niepełną wiedzą na temat profilaktyki zakażeń
HPV i raka szyjki macicy, co więcej większość ankietowanych wyraziła brak zainteresowania sprawami zdrowia i profilaktyki zdrowotnej. Nawet najnowocześniejsze
formy profilaktyki nie przyniosą rezultatu jeśli lekarze nie przekonają do nich swoich pacjentów. Rzetelna, pełna informacja o szczepieniach, prowadzona z dużym
zaangażowaniem środowisk medycznych, musi przynieść efekty w postaci wzrostu
świadomości zdrowotnej, a co za tym idzie pełniejszego wykorzystania wszystkich
form profilaktyki.
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