Supplementary Appendix
MedCheck Editorial team2024/5/29

Appendix１: History of HPV vaccination
Year
2006'

Event
The world's first Human Papillomavirus vaccine (Gardasil, quadrivalent) has been put on sale in the UnitedStates for women aged 9 to 26.

2009'

Cervarix (bivalent) was approved and launched in Japan for women aged 10 years and older.
Gardasil vaccination was approved for men in the USA.

2010'

A vaccination promotion programme for women aged 13-16 was launched in Japan at public expense.

2011'

Gardasil (quadrivalent) was approved and launched in Japan for women aged 9 years and older.

2013'

The HPV vaccine has become a routine vaccination (publicly funded) and vaccination was actively recommended.
A number of serious adverse reactions following HPV vaccination were noted and active recommendations for
vaccination were withheld(routine immunisation＝public funding maintained).

2014'

Nine-valent Gardasil 9 for men and women was approved in the USA.

2015'

A survey of 70 000 vaccinated and non-vaccinated people was conducted in Nagoya, Japan.

2018'

The indication for the 9-valent vaccine was extended in the USA from 9-26 years to 9-45 years for both sexes [b].

2020'

In Japan, Gardasil was also approved for the prevention of HPV infection in men [6].

2021'A 9-valent HPV vaccine (Silgard 9) was approved and launched in Japan [7].

2022'

Active recommendation of the HPV vaccine has been resumed in Japan [5,8].

a) Haupt RM, Sings HL. “The Efficacy and Safety of the Quadrivalent Human Papillomavirus 6/11/16/18 Vaccine Gardasil” J Adolesc Health. 2011 Nov;49(5):467-75. doi:10.1016/j.jadohealth.2011.07.003. PMID 22018560
b) Gardasil Wikipedia： https://en.wikipedia.org/wiki/Gardasilc) https://www.mhlw.go.jp/bunya/kenkou/other/dl/101209i.pdf (in Japanese)d) https://www.mhlw.go.jp/stf/houdou_kouhou/kouhou_shuppan/magazine/202205_00001.html (in Japanese)

Appendix 2:
Meta-analysis results by age using data of Cochrane review(A) 9 to 26 years of age(B) 24 to 45 years of age

Gardasil

Cervarix

Chinese (4)P = 0.9385, I2＝0％

3.00 (0.19, infinity)

VIVIANE (20)

2.60 (0.87,

FUTURE III(20)7.01 (0.90, 316.32)

Combined

3.31 (1.38,

9.33)

7.97)

P = 0.0082, I2＝0％*a: reference number in the Cochrane review.
*b: AAHS: amorphous aluminium hydroxyphosphate sulphate*c: This means AAHS which has toxicity. Therefore it is not suitable to call “placebo” but thisis just the same expression as in the published peer review paper.

Appendix 3: Characteristics of epidemiological studies claiming HPV vaccine

prevented cervical cancer or other HPV-related cancer

Figure 3： Data claiming that vaccine reduced HPV-related invasive cancers

Finnish study 1 [13]Incidence rate of all
HPV-related invasivecancers are compared.

Only individual rates
are compared for
HPV-unrelated cancers.

Incidence rate of all HPV-unrelated cancers is compared
All HPV-unrelated cancers
8 12.2(5.3, 24.0)
35 28.2(19.6, 39.2)

Incidence rate ratio
0.43 (0.20, 0.93), P=0.0277*a：Because HPV vaccine is not effective in suppressing HPV-unrelated cancers, significantly low incidence rate ratio for HPV-unrelated cancers in the vaccinatedgroup compared with that in the unvaccinated group (0.43) should be considered as healthy-vaccinee effect.

Appendix 4：Analysis of data claiming that vaccine reduced HPV-related invasive cancers

BA(/100,000 person years)

Incidence rate

25
20
15
10

12.2

Unvaccinated
非接種

p=0.019p=0.3060.43

50

Vaccinated
接種

28.2

30

HPV-unrelated
HPV
cancer
非関連癌
Risk ratio: 0.43,
p=0.028

C

0.43

8.0

0.0

3.5
0.0

HPV-related
HPV-related invasive
HPV
HPV関連癌invasive cancers:
cancers: adjusted by
Not adjusted

HPV-unrelated cancer

調整

Incidence of HPV-related invasive cancer(un adjusted) 0.0 (0/65,656 pys) vs 8.0 (10/124,245 pys (p=0.0188）
HPV-unrelated cancer(/100,000 pys):12.2(8/65,656 pys) vs 28.2 (35/124,245 pys) (p=0.0277）
Risk ratio = 0.43（95％confidence interval : 0.20-0.93), P=0.0277
HPV vaccine is not effective in suppressing HPV-unrelated cancers. Therefore, the reduction in cancer incidence in the vaccinated group in ‘A: HPV-unrelated
cancers’ indicates that unvaccinated individuals are ‘cancer-prone’ by nature. For fair comparison considering the original health status (cancer susceptibility) of
the unvaccinated and vaccinated groups, the HPV-related cancer incidence rate of the unvaccinated group should be multiplied by 0.43 (10/124,245 pys×0.43, or
8.0/100,000 pys ×0.43). When the cancer incidence rates of the unvaccinated group (3.5/100,000 pys) subsequently obtained were compared with those of thevaccinated group (0/65,656 pys), significant difference was disappeared between both groups (P=0.306).

Table 5：Incidence rate ratio of HPV-unrelated cancers indicate Healthy vaccinee effect:

After adjusting the healthy vaccinee effect, reported effectiveness on HPV-related
invasive cancer prevention disappear.

*a：Therefore, the number of HPV-related cancers in unvaccinated group (10) is multiplied by 0.43 to reach 4.3. Then theincidence rate of vaccinated group (0/65,656 pys) and unvaccinated group (4.3/124,245 pys) were compared yielding no
significance (P=0.306). See Supplementary Appendix 4-8 for details. See Supplementary Appendix 4-8 for details.

Appendix 5：Increase in HPV-unrelated cancers from 1st to 2nd period (vaccinated vs. unvaccinated)
・The data for the 1st period are from Finnish
study 1 (FS1) [13]. The data for 1st and 2nd
period are from Finnish study 2 (FS2) [14].
・The person-years and number of events forthe revised first period of the vaccinated groupin order to compare the incidence rate of thesame cohort in the 2nd period were obtained byproportionally distributing 9,529 (FS1) and
3,331 for the 1st period of FS2. Slightdifferences in the number of RCT subjects wereignored.
・The unvaccinated group for the 2nd periods
includes the subjects of the 1st period plus 861
adjuvant control subject in FUTURE II trial.

*a：HPV-related cancer：Cervical cancer, vulvar cancer, pharyngeal cancer, etc.

・FS2 [14] is a continuation of FS1 [13], but as
mentioned in Appendix 3, it violated theprinciple of cohort studies for both vaccinatedand unvaccinated cohort. Therefore, thestatement “0 HPV-related cancers” cannot be
trusted.

Appendix 6：Rationale for setting Healthy vaccinee effect at 0.43 (from Finnish study 1)• Finnish study 2 (FS2) [14] followed only the RCT subjects (extremely healthy HPV vaccinees), about one-third of the HPV vaccinatedpopulation among Finnish study 1 (FS1) [13], excluding cluster RCT subjects (moderately healthy HPV vaccinees) which occupied almost
two third of vaccinated group of FS1 [13] for an additional 3 years beyond the originally followed 7 years. On the other hand, aluminum
adjuvant control population of the RCT “FUTURE II” (hence aluminum adjuvant toxicity could occur) was added as control population of
the FS2 [14] and followed for an additional 3 years beyond the originally followed 8 years and then compared between the vaccinated andunvaccinated groups.
• The 3-year period of this extended part of the study is designated as period 2, and the original period of the FS1 [13] is designated as period
1. FS2 [14] reported period 1 + 2. Appendix 5 shows incidence rates and incidence rate ratios calculated using data from FS1[13] andFS2[14]. Incidence of HPV-unrelated cancers in period 2 compared with period 1 in unvaccinated group increased 2.8-fold which may becorresponding to the age increased. On the other hand, incidence of that in the vaccinated group increased 11-fold which isdisproportionately large. The increase in HPV-unrelated cancers in the second period of the vaccinated group may be related to the HPV
vaccination.
① At the latter part of the period 1, for example 5 years or more, the HPV-unrelated cancers in the vaccinated group may have begun toincrease steeply and the incidence rate ratio of HPV-unrelated cancers might have increased rapidly. Hence, healthy vaccinee effect may beunderestimated (0.43 is too large) : i.e. vaccinated women originally may have been more healthy than the apparent incidence rate ratio forwhole period 1.
②On the other hand, because the vaccinated group began follow-up at a younger age and had a shorter mean follow-up period than theunvaccinated group, the incidence of HPV-unrelated cancers is lower than that of the unvaccinated group at the beginning. Hence, healthyvaccinee effect may be overestimated (0.43 is too small.
③ In addition, about one-third of the vaccination group in FS1 [13] and all the vaccinated group in FS2 [14] are RCT subjects, and they are
extremely healthy population, strictly excluding persons with abnormal cervical cytology, immunosuppressant drug users,
immunocompromised persons, and persons with chronic diseases. However, the unvaccinated group is a population in which such sick people
were not excluded but not were added as seen in the usual observational study. Therefore, the healthy vaccinee effect may be underestimate(0.43 is too large).
• ① and ② may compensate each others, it is reasonable to consider 0.43 (incidence rate ratio of HPV-unrelated cancers) as healthy-vaccinee
effects (Appendix 7). However, even this 0.43 may underestimate the healthy-vaccinee effects because of the effect of ③ But we adopt 0.43
as healthy vaccinee effect.
• Note that the Finnish study used the entire population prior to the start of vaccination as the unvaccinated group, so the healthy vaccinee
effect only affects the vaccinated (➂). Therefore, the correction is somewhat lenient for the Swedish study [15] and for the Female analcancer study [18]. See Appendix 9-14 for adjustment of the England [16] and Scotland [17] study).

Appendix 7：
Another evidence of
healthy-vaccinee effect (1)①②Scottish study[17]: 0.36③④⑤

Incidence rate ratio(IRR) aged 14 years and older（ complete vs. incomplete ）＝（20.4/754,122.3 pys）/（6.8/103,627.4 pys）（⑤/④）＝2.71/6.56＝0.412（95%CI: 0.17, 0.98),ｐ＝0.0387
IRR for all ages（complete vs. incomplete）＝[(20.4+0)/(754,122.3+134,299.8)pyrs]/[(6.8+0）/（103,627.4+1847.9)pyrs][(③＋⑤）/(②＋④)]＝2.30/6.45＝0.356（95%CI: 0.15, 0.85),ｐ＝0.0148
The cervical cancer incidence rate ratio (IRR, 0.412) for ages 14 and older is greater than that for all ages (0.356). Thus, the IRR for ages 12-13 is estimated to be smaller thanthat for all age groups (let's assume it is about 0.30)(See Appendix 9-B).
Pooled risk ratio of cervical lesion with CIN 3+ associated with HPV 16/18 was 0.07 (95%CI: 0.02, 0.27) for 3 dose and 0.06 (0.01, 0.24) for 1 and 2 dose of vaccine comparedwith control according to the Cochrane review [21]. These data suggest that the complete and incomplete vaccination do not differ in the apparent effectiveness suppressing
sustained HPV infection. Hence the significantly smaller IRR for completely vaccinated compared with the incompletely vaccinated may not be due to the completeness of
vaccination but due to the healthy-vaccinee effect. The level 0.36 as healthy-vaccinee effect is not largely different from 0.43 obtained from the Finnish study 1.
Incomplete vaccination is defined as not having been vaccinated after the first or second dose. One of the most important reasons for this is that any health problem would
cause a person to refrain from vaccination, The percentage of incomplete vaccinations reflects the percentage of unhealthy persons. The percentage of incomplete vaccinations
is 1.4%: 411/(411+29,144) for 12-13 years old and 11.5%: 14,234/(14,234+109,835) for 14 years and older. The ratio was 0.12 (95% confidence interval: 0.11, 0.13),
p<0.0001, suggesting that the 12-13 age group was originally healthier than the 14+ age group (See also Appendix 9-B)..

Appendix 8：Another evidence for the existence of healthy-vaccinee effect (2)Incidence rate

8B. Proportion of incomplete vaccinees
among all vaccinees by age

6.6

6.4

(/100,000 pys)

6
4

2.7

2.3
2
0

Age

12 to 13

All ages
complete

IRR (95％CI)

P valueabout 0.1-0.3 ?

≧14
Incomplete

0.36 (0.15,0.85)
0.0148Proportion（％）

A: Incidence rate and ratio of cervical cancer
by vaccination status and by age

12
10
8
6
4
2
0

11.5

1.4

12 to 13

≧14

Age at the start of the study

0.4 1(0.17, 0.98)
0.0387・ The results from Cochrane review indicate that the complete and incomplete vaccination do
not differ in the apparent effectiveness suppressing sustained HPV infection. And the Finnish 1st
study robustly demonstrates a healthy-vaccinee effect (0.43). The value (0.43) and the cervicalcancer incidence rate ratio (IRR: 0.36) are almost the same, therefore, this IRR (0.36) should beconsidered healthy-vaccinee effect.
The cervical cancer IRR (complete vs. incomplete) for 12-13 years old cannot be calculated precisely
because the observed cervical cancer cases is zero, but the IRR is estimated to be even lower than
0.356 in 12-13 years old because the IRR is smaller for all age groups (0.356) including 12–13-yearolds than for 14 years and older (0.412) (See Appendix 9-B).

The ratio of proportions of incompletely vaccinated of 12-13
years of age to those aged 14 and older is 0.12 (95% CI:
0.11,0.13), P<0.00001.
Incomplete vaccinee include those who avoided vaccination due
to some health problem (left panel A). Therefore, it is possiblethat a stronger healthy-vaccinee effect was at work in the
12–13-year-olds, who had a smaller percentage of incomplete
vaccinee than those 14 years and older (See Appendix 9-B).

Appendix 9-A： Apparent cervical cancer prevention effect of HPV vaccine disappears after

adjusting for healthy-vaccinee effect (adjusted by data from Scottish study [17])*a：37×0.356 *b： In the English study [16], the incidence rate ratio (IRR) according to Model 3 in Table 3 is 0.13 (95%CI: 0.06-0.28).
This is adjusted by healthy-vaccinee effect [IRR=0.36 (95%CI: 0.15-0.85) for all ages in the Scottish study]. As a result, the upper limitof the 95% confidence interval exceeded 1 (1.16) and was no longer significant.

Mortality rate ratio

0.17

0.13
0.10
0.27
0.10

0.20

0.40

(95％CI)(0.14,0.24)

2-23 mo(0.10,0.16)

2-5 yrs(0.08,0.13)

6-15 yrs(0.13,0.17)≧15 yrs
0.80

Mortality rate ratio (MRR: Log scale)

Age

Appendix 9-B：Healthy-vaccinee effectby age (natural causes)(95％信頼区間)

・ The left panel shows the comparison of mortality rate ratio
from natural causes by age (mortality during 0-184 days after
meningococcal vaccine to that of unvaccinated subjects [a].
This represents a healthy-vaccinee effect because
meningococcal vaccine can not reduce other cause of death.
・Healthy-vaccinee effect in the 6-15 age group seems larger
than the 15+ age group, and the 95% confidence interval isstatistically significant because there is almost no overlap.
From the above, it can be inferred that the incidence rate ratiofor 12–13-year-olds in the England study is even closer to 1.0
than the data in the above table.
Reference [33] De Wals, P. et al. Vaccine 2009: 27, 3223-3227
https://doi.org/10.1016/j.vaccine.2009.02.055

Table 6: Original and healthy-vaccinee effect adjusted incidence rate ratios of HPV-related cancers (1)The bold are the adjusted IRR and 95％CIs for the data by which the authors claimed and strengthened
the effectiveness of the HPV vaccine on the grounds that the number of cases was zero or very small.
Bold italicized data suggest that the HPV vaccine may increase cancer after adjustment for healthyvaccinee effect.
See next page for the explanation of *a to *I

Table 6: Original and the healthy-vaccinee effect adjusted incidence rate ratios of HPV-related cancers (2)Explanation of *a to *i.
*a: When the number of cases in the vaccinated group was 0 (Finnish study [13,14] and 12-13 years in the Scottish
study) [17], the incidence rate ratio (IRR) was calculated by multiplying the total number of HPV-related cancer
cases in the unvaccinated group by 0.43 and 0.36. The other IRRs or hazard ratios (HRs) were adjusted for healthyvaccinee effect by dividing 0.43 (95%CI) and 0.36 (95%CI) (See Table and Appendix 11-13).
*b：Original IRR and its 95%CI were calculated from the data for vaccine effectiveness data as described“Intention-to-treat vaccine efficacy against all HPV-positive cancers was 100% (95%CI: 2 to 100, p<0.05).”*c: The lower limit of the 95%CI reported in the literature was 0.00, which precluded adjustment calculation.
Therefore, instead of 0.00, we used 0.00499 which is the maximum possible value with three significant digits.
*d: Upper limit of the 95% CI of IRR adjusted by 0.43 was lower than 1.0 but that by 0.36 was higher than 1.0.
However, it should be noted that the healthy vaccinee effect is maximized (IRR is the lowest as low as 0.10, 95%CI: 0.08,0.13) in the age of 6 to 15 years according to De Wals et al.[33] (See the column of "About Healthy vaccinee effect as key
confounding bias in the observational study" in this issue)*e：Incidence rate ratios were calculated. using the unadjusted data for vaccine effectiveness (VE) on Table 2 of Ref[17], except *f and *g.
*f：Incidence rate ratios were calculated from the number of weighted person-years, which is the sum of incomplete
vaccinee and complete vaccinee of all ages, and the number of weighted observed events.
*g：Since the follow-up period for the 12–13-year-old group is essentially 5 years, the number of events inunvaccinated group during the 5-year follow-up period was read from the graph and estimated to be 34 (Appendix
18) to estimate the incidence rate ratio.
*h：High-grade Squamous Intraepithelial Lesion*i： It is suggested that HPV vaccination at the age of 17 to 32 years increased risk of developing anal cancer
according to the data adjusted for healthy-vaccinee effect.

Appendix 10: Estimated number of cancer cases in the unvaccinated group at the 5th year of follow-up（ Scottish study[17]）0.3
The unvaccinated group had 34 cancer cases per 1,228,000 person-years, and the vaccinated group had 0 cancer
cases per 119,000 person-years (p=0.087). Multiplying the 34 in the unvaccinated group by 0.43 or 0.36 andconsidering health-vaccine effect, the number is 15 or 12. Comparing the two groups based on these results yields
a p-value of 0.634 or 0.617 (not significant).

Vaccinated status（％）
Proportion of cancer
by vaccinated status

0.2

Estimated number of events in the unvaccinated group at
the 5-year follow-up (read from Fig.)

Unvaccinated

0-2.5years：(251,126+247,106)/2×0.0008/100＝２
5.0years：(247,106+237,040)/2×0.014/100 ＝34
2.5-5.0years:
32

0.1

The part comparing the- -year-old vaccinated groupwith the unvaccinated group has no meaning.

Incomplete aged over 14 years

12
13

0.000008(2） 0.00014(34）Complete aged 12-13 years

0.0
Number of follow-up

Unvaccinated12-13years old incomplete
12-13years old complete≥14 years incomplete≥14 years complete

Complete aged over 14 years

Years since screening eligible or first screenAppendix 11： Number of follow-up persons by period after HPV vaccination (after starting point) （ Scottish study[17]）300,000

A.

Number of follow-up in cohort

B. Percentage of follow-up persons from start of follow-up
100

200,000

150,000

100,000

50,000

0

0.0

非接種者
No
Vacine

2.5

5.0

接種者
≧14歳
Vaccinated≧14

7.5

10.0

12.5

Years of follow-up

接種者
12-13歳Vaccinated
12-13

Percent of subjects followed (％）

Number of subjects

250,000100

98 98 99

94 94

80

75

60

50

48
38

40
20

0

0
0.0

非接種者
No Vax

2.5

5.0

接種者
≧14歳
Vaccinated≧14

7.5

1 0

10.0

3

0 0

12.5

Years of follow-up

接種者 12-13歳
Vaccinated
12-13

Among those who received the HPV vaccine at the age of 12-13 years, only 38% were followed up at the fifth
year of the study. In the unvaccinated group, 94% were still being followed at 5 years, and the average age at
the start of the follow-up was older than vaccinated group. Differences in age groups at the start of the study
make the risk of cervical cancer in the vaccinated group appear lower in the first place.

Appendix12： Age at start of follow-up and mean age at the end of follow-up（ Unvaccinated group and vaccinated group by age at vaccination ： Scottish study[17] ）
26

25.8

Age (year)

24
22
20

23.3

8.0 years

9.3
7.3

17.8

18
16

16.5

14
12

2.5years

16

4.8
13

Unvaccinated
非接種

≧14
12,13
≧14歳
12-13歳Vaccinee（age at vaccination）

The age at the start of the survey for the HPV vaccination group was not clear, then, 12-13 age group was 13 years old,
and the 14 and older age group consisted of 14-22 years old, and the average of these ages was taken to be 16 years old.
The HPV unvaccinated group was estimated to have started the survey at least 16.5 years of age.
The unvaccinated group would have been followed until they were about 2.5 years older than the vaccinated group aged 14 years or older,
and 8.0 years older than the 12–13-year-old vaccinated group.

Column Figure 1: Theoretical influence of the healthy vaccinee effect by vaccine coverage,
if a vaccine has no beneficial and harmful effect:
Odds ratio of frailty after vs before exclusion A. in vaccinated, B. in unvaccinatedOdds ratio of frailty in vaccinated vs in unvaccinated at the start of vaccination: C.

See text for explanation

Column Figure 2: Healthy vaccinee effect by factor
A: By severity of outcome disease

Incidence rate rat ratios (IRRs) and their 95% CI were calculated by using
the data from Dagan N et al. for asymptomatic SARS-CoV-2 infection andclinical COVID-19. IRRs for severer disease are estimated by the numberof death and the person-days at risk during calculable period of as short
as possible after receiving vaccine using the data from Dagan N et al.
As the outcomes become more severe (asymptomatic infection, clinicalillness, hospitalization, severe illness and death), the risk ratio of thevaccinated group to the unvaccinated group on the first day of vaccination(healthy-vaccinee effect) becomes more pronounced.
From MedCheck in English No25 p40-52 Fig 4
MedCheck made this Figure using the Data from Dagan N et al.
N Engl J Med 2021; 384(15):1412-23. doi: 10.1056/NEJMoa2101765

B: By follow up period after vaccination

Mortality rate ratio (MRR) immediately after vaccination (duringdays 0 to 6)is the lowest and the most directly reflects the healthyvaccinee effect than the MRR during thereafter.
MedCheck made this Figure using the Data from
De Wals, P. et al. Vaccine 2009: 27, 3223-3227
https://doi.org/10.1016/j.vaccine.2009.02.055

Column Figure 2: Healthy vaccinee effect by various factor
C: By age

D: By cause of death
Age

1.0

・ The upper panel shows the comparison of mortality rate ratio
from natural causes by age (MRR during 0-184 days after
meningococcal C vaccination to that of unvaccinated subjects.
This represents a healthy-vaccinee effect because
meningococcal vaccine can not reduce other cause of death.
・Healthy-vaccinee effect in the 6-15 age group seems larger
than the 15+ age group, and the 95% confidence interval isstatistically significant because there is almost no overlap.
From the above, it can be inferred that the incidence rate ratiofor 12–13-year-olds in the England study is even closer to 1.0
than the data in the above table.
MedCheck made this Figure using the Data from
De Wals, P. et al. Vaccine 2009: 27, 3223-3227
https://doi.org/10.1016/j.vaccine.2009.02.055

Among many cause of death, malignancies (mostly malignant
tumors) are the most seriously influenced by the healthy vaccinee
effect (MRR during 0-184 days after meningococcal C vaccination to thatof unvaccinated subjects)

MedCheck made this Figure using the Data from
De Wals, P. et al. Vaccine 2009: 27, 3223-3227
https://doi.org/10.1016/j.vaccine.2009.02.055