Evaluation of Long Term Immunity Following HPV Vaccination
Condition: Cervical Cancer; Anogenital Warts
MeSH terms: Uterine Cervical Neoplasms
Study type: Observational

Summary: 
      In Fiji, cervical cancer is the second most frequent cancer and the highest cause of cancer
      mortality in women. In 2008/9, the Ministry of Health in Fiji accepted a donation of 110,000
      doses of quadrivalent HPV vaccine, Gardasil® based on the high cervical cancer disease
      burden. There was enough vaccine to vaccinate all girls aged 9-12 years (30,338 girls) with a
      three-dose schedule, but not all girls received three doses of the vaccine. This means those
      girls that received reduced doses may not be fully protected against the HPV genotypes
      present in the Gardasil®. While HPV vaccines are highly immunogenic and efficacious in the
      licensed three-dose schedule, there is limited information about the effectiveness of reduced
      dose schedules in terms of immunogenicity and memory. There is growing evidence from other
      studies that two doses of HPV vaccine may be sufficient for protection. Reduced schedules
      would be of benefit in Fiji due to improved costs and logistics. This study will examine
      whether one or two doses of HPV vaccine provide similar immunological evidence of long-term
      protection to the standard three-dose schedule in terms of antibody titres to the genotypes
      present in the Gardasil®. To compare immunological memory responses between dosage groups, a
      dose of Cervarix ® will be administered to all girls so that the magnitude of the memory
      responses can be measured.
    

Detailed description: 
      In 2008/9, the Ministry of Health (MoH) in Fiji accepted a donation of 110,000 doses of
      quadrivalent HPV vaccine, Gardasil® based on the high cervical cancer disease burden. There
      was enough vaccine to vaccinate all girls aged 9-12 years (30,338 girls) with a three-dose
      schedule, but not all girls received three doses of the vaccine. This means those girls that
      received reduced doses may not be fully protected against the HPV genotypes present in the
      Gardasil®. In 2013, the Fiji MoH with Australian Aid support introduced the Cervarix ®
      vaccine as a three dose schedule (0, 1, and 6 months) to be given to all girls at the last
      year of primary school as part of the national immunisation program. This is a unique
      opportunity to determine if fewer than three doses of Gardasil® vaccine are immunologically
      similar to the standard three-dose schedule 6 years after receiving the vaccine (ie
      indicating long-term protection).

      This is an open label Phase II/III clinical trial in girls (now aged 14-17 years) who
      previously received zero, one, two or three doses of Gardasil® in 2008/9. A dose of Cervarix
      ® will be administered to all the girls in this study so that immunological evidence of
      long-term protection in terms of antibody levels (including neutralisation titres), number of
      memory B and T cells (including cytokine responses) and gene expression profiles can be
      measured.

      A non-random sample of 200 girls will be recruited; girls previously received one, two or
      three doses of Gardasil® will be identified through school vaccination lists obtained from
      the MoH and Ministry of Education; girls that did not receive any vaccines previously will be
      recruited via recommendations of friends of the girls and by informal networks. The
      investigators aim to have approximately 50% indigenous Fijian (i-Taukei)/others and 50%
      Fijians of Indian descent in the study.

      Informed consents will be obtained from both the parent/guardian of the participant and the
      participant, as well as checking the participant's eligibility by the study nurses.
      Twenty-five milliliters (mL) of blood in total will be drawn from each participant before and
      28 days after a dose of Cervarix® vaccine. To ensure all participants receive three doses of
      HPV vaccine by the end of study, follow up appointments will be made for study participants
      to receive off-study vaccine for those that did not receive any HPV vaccine previously or
      received only one dose of Gardasil® in 2008/9 campaign; no samples will be collected in the
      follow-up appointments.

      Peripheral blood mononuclear cells (PBMC) and plasma will be separated from the blood, and
      freeze down down in liquid nitrogen and -80 degree freezer until laboratory analysis,
      respectively.

      Sample size:

      The primary outcome is the comparison of the geometric mean concentrations (GMCs) of HPV-
      specific antibody responses (including neutralisation titres) against HPV 6, -11, -16 and
      -18, between the groups that previously received zero, one, two or three doses of Gardasil®.
      Based on published data from a 5 year follow-up study (Olsson et al. 2007), the standard
      deviations for anti-HPV antibodies are 570 (HPV16) and 84 (HPV18). The sample size required
      to provide 80% power to detect a 30% difference in HPV antibodies ranges from 48/group
      (HPV16) to 49/group (HPV18). A sample size of 50/group will be used in this study.

      Statistical Analysis Plan:

      Comparison of GMCs of anti-HPV antibody levels and neutralising antibody levels will be
      compared using log-transformed data using the Student's t-test. The proportion with
      seropositivity will be compared using the Fisher's exact test. These analyses will also be
      used to compare anti-HPV antibody levels and neutralising antibody levels one month post
      Cervarix®. Comparison of B- and T- cell frequencies will be done using the Mann-Whitney U
      test. For cytokine secretion in PBMC supernatants, comparison of GMCs ± 95% confidence
      intervals (CI) will be done on log-transformed data using the Student's t-test. The gene
      expression profiles (tumour necrosis factor-α, interleukin (IL)- 6, IL-8, interferon-γ, IL-18
      and IL-1β) in different groups will be compared using a paired student t test. The fold
      increase or decrease in the gene expression will be assessed using the sign test. A p-value
      <0.05 will be considered statistically significant for all analyses.

      Data Collection:

      Each child will have a unique study number and folder collating the field site study case
      report forms (CRFs). All laboratory processing will be undertaken in a blinded fashion using
      de-identified samples. Field and clinical data will be entered in the study office by trained
      study staff using the EpiData software and sent to Drs Russell and Licciardi for analysis.
      The design of the computer databases and data cleaning will be done by the study staff under
      supervision of the principal investigators. Only designated study staff and the investigators
      associated with this project will have access to this data. Data will be analysed with help
      of staff from Clinical Epidemiology and Biostatistics Unit (CEBU), Murdoch Childrens Research
      Institute (MCRI).

      Data Storage:

      All laboratory data collected in this study will be stored electronically and in hard copy
      format and secured in lockable filing cabinets for 15 years after the completion of the
      study.

      Study Record Retention:

      The biological samples will be stored at the Immunology Laboratory at MCRI for 15 years
      following completion of the study, in accordance to ethics requirements for a clinical trial.
      The samples will be destroyed if the participants do not consent for their blood sample to be
      used for further ethics approved HPV related studies. If the participant consent for their
      blood sample to be used for future ethically approved research, related to this study only,
      the samples will be kept indefinitely at MCRI, Melbourne, Australia. Additional ethics
      approval is required if the investigators wish to use these future use samples later on for
      HPV related studies.

      All the consent forms will be filed in proper folders and secured in lockable filing cabinets
      on-site in Fiji for 15 years following completion of the study. The consent forms will be
      shredded and disposed in locked security bins.

      All participating investigators and research staff will maintain subject confidentiality.
      Except for the consent form, participants will be identified only by their unique study
      number throughout the study. This extends to the clinical information, testing of the
      biological samples, documentation, and laboratory database.

      Parents/guardians will be reimbursed for their time and travel for the sample collection.

      MCRI and Fiji MoH have signed a Memorandum of Understanding (MoU). A Research Specific
      Agreement is being developed by the Fiji MoH and MCRI which will include intellectual
      property and publication clauses. The agreement to be developed will not unreasonably delay
      the publication of results from the study, or harm or prejudice an outcome of the research
      program or an interest a party has in intellectual property, either developed pursuant to the
      research program or that owned by the party.
    

Intervention name(s): Cervarix®
Intervention type(s): Biological
Intervention description(s): All groups will received one dose of Cervarix® vaccine
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        In 2008/9, the MoH in Fiji accepted a one-off donation of 110,000 doses of Gardasil®
        vaccine, which was enough to vaccinate four birth cohorts of girls (30,338 girls aged 9-12
        years) with a three-dose schedule via a school-based program. However, not all the girls
        received the full-recommended three-dose schedule, mainly due to absence from school on the
        day the school health team were visiting. The coverage following the initial and the
        subsequent mop-up campaign was: 62%, 56%, and 55% for doses one, two, and three
        respectively. The girls that received different doses of Gardasil® vaccine in Suva area who
        are potentially contactable in this study are 676 (three doses), 204 (two doses) and 116
        (one dose), demonstrating feasibility of recruitment.
      
Biospecimen description: 
      We will be collecting blood from the participants, which include the plasma and peripheral
      blood mononuclear cells.