Prevalence of Genital HPV Infection in Males Following Introduction of Universal Male HPV Vaccination
Conditions: Human Papillomavirus
Sponsor: The Alfred

 
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Merck Investigator Studies Program (MISP) Protocol 
 
Fall in prevalence of genital HPV infection in males following 
introduction of universal male HPV vaccination  
 
Section 1: MISP Protocol Identification 
 
Principle Investigator  
 
Associate Professor Marcus Chen*  
 
Institution name: 
University of Melbourne and Melbourne Sexual Health Centre 
 
 
Co-Investigators 
 
Professor Christopher Fairley 
University of Melbourne and Melbourne Sexual Health Centre 
 
Associate Professor Catriona Bradshaw 
University of Melbourne and Melbourne Sexual Health Centre 
 
Professor John Kaldor 
University of New South Wales 
 
Associate Professor Sepehr Tabrizi,  
University of Melbourne and Royal Women’s Hospital 
 
Professor Suzanne Garland  
University of Melbourne and Royal Women’s Hospital 
 
Associate Professor Jane Hocking  
University of Melbourne 
 
Dr David Regan  
University of New South Wales 
 
Dr Julia Brotherton 
National HPV Vaccination Program Register 
 
Associate Professor Anna McNulty 
Sydney Sexual Health Centre 
 
Associate Professor David  
Templeton RPA Sexual Health 
 
Dr Catriona Ooi 
Western Sydney Sexual Health Service 

 
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Associate Professor Darren Russell 
Cairns Sexual Health Service 
 
Dr Charlotte Bell 
Clinic 275, Royal Adelaide Hospital 
 
Dr Lewis Marshall 
Department of Infectious Diseases, Freemantle 
 
Dr Louise Owen,  
Tasmania State wide Sexual Health Service 
 
*Principle Investigator contact details: 
 
Marcus Chen 
Melbourne Sexual Health Centre, 
580 Swanston Street, Carlton, Victoria, Australia, 3053. 
Telephone: +61 3 9341 6260. Fax: +61 3 9347 6757 
Email: mchen@mshc.org.au 
 
Current version: 4, 21st April 2015 
 
Section 2 
 
2.1: Objective and hypothesis 
 
The aim of this study is to demonstrate a fall in the prevalence of genital HPV 
infection among teenage males as a result of the implementation of a 
universal male vaccination program. Our hypothesis is that in a setting where 
there is already a female vaccination program in place and where herd 
immunity has resulted in a fall in male HPV prevalence, introduction of a male 
vaccination program will result in further falls in the prevalence of HPV in 
males. 
 
 
2.2 Background 
 
Rationale for study  
 
The provision of HPV vaccination to females through universal vaccination 
programs has resulted in a fall in prevalence of HPV infection and HPV 
related lesions among females in countries where this has been introduced. 
This has been shown in several countries including Australia, which was one 
of the first countries to roll out free, universal vaccination in females. In 
Australia studies have shown a significant decline in the prevalence of HPV 
infection, genital warts and HPV related cervical lesions among females.1-4  

 
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While such direct benefits have been shown in females, they have not been 
shown among males as no country to date has rolled out universal, free 
vaccination of males on a national level. Rather, what has been shown to date 
are falls in the prevalence of genital warts as a result of herd immunity from 
female vaccination.1-2 Mathematical models predict that extending the 
vaccination program to males will provide incremental benefit.5 While this is 
predicted to be occur, there have to date been no data from any countries 
demonstrating this as no countries have thus far implemented universal 
vaccination of both males and females. 
 
As the Australian Government has announced that a universal male 
vaccination program will be introduced in Australia beginning in 2013 we 
believe we are uniquely placed in Australia to document a fall in HPV 
prevalence among males that is additional to falls that have already occurred 
because of female vaccination. 
 
If this study is to be undertaken it is critical that it begins as soon as possible 
given that vaccination is being rolled out in Australia in 2013. Without this we 
cannot establish the baseline prevalence of HPV among males prior to male 
vaccination. 
 
 
 
 
 
In Victoria the male vaccination program will be provided through:  
 
 An ongoing school based program to boys in year 7 (mainly 12 and 13 
year olds with some 11 year olds) with a time limited program for boys in 
year 9 (mainly 14 and 15 year olds with some 13 year olds) in 2013 and 
2014 only.  
 
 An ongoing community based program for boys aged 12 and 13 years 
together with a time limited program for boys aged 14 and 15 in 2013 and 
2014 only.  
 
This means that by 2014, 2015, 2016 and 2017, the oldest cohort of males to 
have been offered vaccination as part of the Victorian program will be aged 
16, 17, 18 and 19 years respectively. The age of boys who will have been 
offered vaccination by year from 2013 through to 2017 is shown in Table 1. In 
period 1 (2014-2015), 200 boys will be recruited. The same number, 200, will 
be recruited in period 2 (2016-2017). 
 
 
Significance of study outcomes 
 
As Australia is the first country to implement a universal male vaccination 
program we have the opportunity to be among the first to demonstrate a fall in 
HPV prevalence among males as a result of male vaccination. While there is 

 
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evidence that the prevalence of genital warts among males in Australia has 
fallen as a result of female only vaccination, falls in the prevalence of HPV 
infection including high risk HPV types among males in response to universal 
male vaccination have not thus far been documented in any country but is 
expected to occur.5  
 
This would provide evidence and argue for the introduction of universal male 
HPV vaccination programs in countries which have already introduced 
universal vaccination of females. 
 
 
 
2.3 Study design 
 
Study population and sample size 
 
This study will determine the prevalence of genital HPV among males aged 
17-19 years using two cross sectional samples, the first obtained over 2014-
2015 (period 1) and the second over 2016-2017 (period 2) (Table 1). Given 
the differing age groups that will have been offered vaccination over the four 
years, period 1 will provide baseline prevalence among males prior to the 
vaccination program – a prevalence that reflects herd immunity from pre-
existing vaccination of females. In period 1, most 17-19 year old males will not 
have been offered the vaccine (Table 1). By contrast, in period 2, most 17-19 
year old males will have been offered vaccination as part of the male 
vaccination program (Table 1). 
 
 
2.4 Study flowchart 
 
 
 
 ↓ 
 
 
 
 
 ↓ 
 
 
 
 
 ↓ 
 
 
 
 
 
Screened by nurse 
Consent obtained 
Questionnaire completed 
Self sampling for HPV 

 
5
 
 
2.5 Study procedures 
 
This study will recruit 17 to 19 year old males from universities and other 
sources including sexual health services. Potential participants will be 
identified by a nurse or doctor if they present to a health service or if they 
become aware of the study through advertising will discuss the study with a 
research nurse. 
 
 
Eligibility criteria 
 
 Male 
 
 Aged 17 to 19* 
 
 Residing in Australia from 12 years of age# 
  
 Able to complete study requirements 
 
Exclusion criteria  
 
 Males who report sex with men in the past 12 months 
 
 
*Must be aged 17, 18 or 19 years during the four year study period, that is, 
January 1 2014 through to December 30 2017. 
 
#This is to ensure that males included in the study were present in Australia at 
the time HPV vaccination was offered. 
 
Men who agree to the study will be asked to provide informed, written consent 
and undertake self-testing for genital HPV and a questionnaire will be 
obtained. Self-collection of the swab will be completed at the participants 
convenience using postal specimens that include a self-testing kit that is 
either given to participants attending services or posted out if recruitment is 
via advertising.  
 
The questionnaire will capture:  
 
 Demographic information such as age and education level.  
 
 Detailed sexual history including: age at first sex; number and gender of 
sexual partners over different time periods; sexual practices including oral, 
anal and vaginal sex; and condom use. 
 
 Relevant medical information such as history of genital warts, circumcision 
status, and smoking.   
 

 
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 History of previous HPV vaccination 
 
 
HPV DNA sampling 
 
Each man in the study will be asked to obtain a genital specimen which will be 
self-collected by participants using a swab on the glans penis, coronal sulcus, 
foreskin (if uncircumcised), and penis.  
 
 
Laboratory testing for HPV DNA  
 
Samples will be tested at the Regional HPV Labnet Reference Laboratory, 
Molecular Microbiology Department, Royal Women’s Hospital, Melbourne. 
Cellular material will be pelleted in 1mL aliquots by centrifugation at 5, 000 ×g 
and resuspended in 200 µL PBS. Total DNA will be extracted on the MagNA 
Pure 96 using the MagNA Pure 96 DNA and Viral NA small volume kit (Roche 
Diagnostics GmbH, Penzberg, Germany).  
 
Extracted DNA will be pre-screened to assess its integrity by quantitative PCR 
amplification of a 260 base pair product of the human beta-globin gene.6  
 
Samples will subsequently be amplified for HPV L1 gene using consensus 
primers PGMY09-PGMY117 and amplicons detected using the PCR ELISA 
System (Roche Diagnostics GmbH, Penzberg, Germany). A generic probe for 
detection of the presence of any HPV sequences in the sample using biotin-
labelled probes will be used to detect all mucosal HPV types.  Samples that 
are positive by ELISA will be further genotyped by HPV Linear Array 
genotyping assay (Roche Molecular Systems, Pleasanton, California), 
involving PCR amplification of target DNA followed by nucleic acid 
hybridization and detection of 37 HPV genotypes (6, 11, 16, 18, 26, 31, 33, 
35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 
70, 71, 72, 73, 81, 82, 83, 84, 82v and 89). 
 
 
 
Ethical approval 
 
Ethical approval for this study will be obtained from each state in which recruitment is 
intended to occur. A NEAF will be submitted to the Alfred Hospital Research Ethics 
Committee, South Eastern Sydney Local health District ethics committee , Far North 
Queensland Human Research Ethics Committee, Royal Adelaide Hospital 
Committee, Tasmania Health and Medical Human Research Ethics Committee and 
South Metropolitan Health Service Human Research Ethics Committee. Site Specific 
Applications will be made for each site once NEAF approval has been given.  
 
Men will not routinely be informed of their HPV results as HPV testing is not standard 
clinical practice, HPV is mostly self-limiting, does not cause symptoms and has no 
treatment if asymptomatic. Accordingly, routine provision of results would be likely to 
induce more stress among participants that is warranted.   
 

 
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2.6 Study duration 
 
Timelines 
 
This study will require 4 years to complete: 
 
January 2014 – December 2015: approval of study and recruitment in period 
1. 
 
January 2016 – December 2017: recruitment during period 2, analysis and 
reporting. 
 
 
Feasibility 
 
Our group has a track record of successfully recruiting specific populations 
that are hard to reach for STI research. We have established strong links with 
several universities and institutions across Victoria from which 17-19 year old 
males could be recruited without difficulty and also have a network of clinical 
sites from which to recruit including the Melbourne Sexual Health Centre.  
 
 
2.7 Statistical analysis 
 
The primary outcome of interest will be the change in prevalence of 
quadrivalent vaccine types (6, 11, 16 and 18) among 17-19 year old men in 
the two time periods. The study will also provide data on the change in 
prevalence of non-vaccine types. 
 
The required sample size for each year is dependent upon the expected 
prevalence of genital HPV and affects the precision of the prevalence 
estimates (95% confidence intervals, CI) in the two cross sectional samples. 
Different prevalence rates and 95%CI are shown for various sample sizes in 
Table 1.  
 
Table 1: Estimated 95% confidence intervals for differing HPV prevalent rates and 
sample sizes 
 
 
Sample size (persons) 
HPV  
prevalence  
rate (%) 
100 
200 
300 
400 
500 
5 
0.0186-0.1183 
0.0256-0.0927 
0.0293-0.0829 
0.0316-0.0774 
0.0333-0.0739 
10 
0.0516-0.1804 
0.0637-0.1523 
0.0695-0.1411 
0.0732-0.1347 
0.0758-0.1305 
 
 
 
 
 
 

 
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Previous estimates of HPV infection have been determined by investigators in 
our group for females but are not available for males.4 A sample size of 200 
males in each of the two periods would provide reasonable confidence intervals 
around expected prevalence rates for individual HPV types. This would require a 
total of 400 males for the entire four year study. 
 
 
 
2.8 Specific Drug Supply Requirements 
 
No study drugs will be used in this study. 
 
 
 
2.9 Adverse Experience Reporting 
 
Procedures for reporting will be included in the Study Agreement and be 
approved by the Alfred Hospital Research Ethics Committee.  
 
 
 
 
 
 
 
 
2.11 References 
 
 
1. 
Donovan et al. Quadrivalent Human Papillomavirus vaccination and 
trends in genital warts in Australia: analysis of national sentinel 
surveillance data. Lancet Infect Dis 2011; 11(1): 39-44. 
 
2. 
Fairley CK et al. Rapid decline in presentations of genital warts after the 
implementation of a national quadrivalent Human Papillomavirus 
vaccination programme for young women. Sex Transm Infect 2009; 85: 
499-502. 
 
3. 
Brotherton et al. Early effect of the HPV vaccination programme on 
cervical abnormalities in Victoria, Australia: an ecological study. Lancet 
2011; 377: 2085-92. 
 
4. 
Tabrizi SN et al. Fall in Human Papillomavirus prevalence following a 
national vaccination program. JID 2012; 206: 1645-51. 
 
5. 
Smith MA et al. The predicted impact of HPV vaccination on male 
infections and male HPV-related cancers in Australia. Vaccine 2011; 29: 
9112-22. 
 

 
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6. 
Resnick RM et al. Detection and typing of human papillomavirus in 
archival cervical cancer specimens by DNA amplification with consensus 
primers. J Natl Cancer Inst. 1990; 82(18): 1477-84. 
 
7. 
Gravitt PE et al. Improved amplification of genital human 
papillomaviruses. J Clin Microbiol. 2000; 38(1): 357-61. 
 
 
 
 
 
2.12 Publication Plan 
 
The findings from this research will be presented at relevant international 
conferences and published in scientific peer reviewed medical journals.  
 
 
 
 
 
2.13 CV of PI and Investigator group 
 
A CV for PI Marcus Chen is provided. 
 
 
 
 
 
2.13 Protocol Submission 
 
This protocol has been submitted to MSD Australia. 
 

 
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Table 1: Age of boys who will be offered HPV vaccination via schools and community based programs by year, Victoria 2013-2017.*  
 
Age 
 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
 
 
2013 
 
 
 
 
 
 
 
 
 
 
 
 
 
2014 
 
 
 
 
 
 
 
 
 
 
 
 
}Period 1# 
 
2015 
 
 
 
 
 
 
 
 
 
 
 
 
2016 
 
 
 
 
 
 
 
 
 
 
 
}Period 2# 
 
2017 
 
 
 
 
 
 
 
 
 
 
 
 
*Dark grey squares indicate that boys within these age groups are currently being offered vaccination in the calendar year shown in the row. Light grey 
squares indicate the age of boys who have previously been offered vaccination for HPV in previous calendar years. Time limited vaccination of year 9 
students and those aged 14 and 15 will occur in 2013 and 2014 only whereas ongoing vaccination will be offered to those in year 7 (which may include 
some 11 year olds) and those aged 12 and 13 years.  
#The boxes with hatched lines indicate the age range of boys who will be recruited in Period 1 (2014-2015, n=200) and Period 2 (2016-2017, n=200).