ARTICLE

Long-term Study of a Quadrivalent Human

Papillomavirus Vaccine
AUTHORS: Daron Ferris, MD,a Rudiwilai Samakoses, MD,b WHATS KNOWN ON THIS SUBJECT: The short-term
Stan L. Block, MD,c Eduardo Lazcano-Ponce, MD,d Jaime immunogenicity and safety of a HPV4 vaccine have been
Alberto Restrepo, MD,e Keith S. Reisinger, MD, MPH,f previously evaluated in preadolescents and adolescents. To date,
Jesper Mehlsen, MD,g Archana Chatterjee, MD, PhD,h
no long-term studies of the safety, effectiveness, and
Ole-Erik Iversen, MD,i Heather L. Sings, PhD,j Qiong Shou,
immunogenicity of the HPV4 vaccine have been reported in this
PhD,j Timothy A. Sausser, BS,j and Alfred Saah, MD j
aDepartment of Obstetrics and Gynecology, Georgia Regents
age group.
University, Augusta, Georgia; bDepartment of Pediatrics,
Phramongkutklao Hospital, Bangkok, Thailand; cKentucky Pediatric WHAT THIS STUDY ADDS: The HPV4 vaccine administered to
and Adult Research, Inc, Bardstown, Kentucky; dCenter for adolescents demonstrated durability in clinically effective
Research in Population Health, National Institute of Public Health, protection and sustained antibody titers over 8 years. These data,
Cuernavaca Morelos, Mexico; eClinical Research Center, Medelln, along with extensive postapproval safety surveillance data, should
Colombia; fPrimary Physicians Research, Pittsburgh, Pennsylvania;
gCoordinating Research Centre, Frederiksberg Hospital,
help reinforce national recommendations for HPV vaccination of
Frederiksberg, Denmark; hDepartment of Pediatrics, University of preadolescents and adolescents.
South Dakota Sanford School of Medicine, Sanford Childrens
Specialty Clinics, Sioux Falls, South Dakota; iDepartment of
Obstetrics and Gynecology, Haukeland University Hospital, Bergen,
Norway; and jMerck & Co., Inc, Whitehouse Station, New Jersey
KEY WORDS
quadrivalent HPV vaccine, safety, effectiveness, immunogenicity,
abstract
adolescents, anogenital cancer, genital warts, immunogenicity BACKGROUND: We present a long-term safety, immunogenicity, and
ABBREVIATIONS effectiveness study of a quadrivalent human papillomavirus (HPV4)
AEadverse event
vaccine.
CDCCenters for Disease Control and Prevention
cLIAcompetitive Luminex immunoassay METHODS: Sexually naive boys and girls aged 9 to 15 years (N = 1781)
CVGCatch-Up Vaccination Group were assigned (2:1) to receive HPV4 vaccine or saline placebo at day 1
EVGEarly Vaccination Group
HPVhuman papillomavirus and months 2 and 6. At month 30, the placebo group (n = 482)
HPV4human papillomavirus (types 6, 11 16, 18) recombinant received HPV4 vaccine following the same regimen and both cohorts
vaccine were followed through month 96. Subjects $16 years were eligible
ITTintention to treat
for effectiveness evaluations. The primary objective was to evaluate
Dr Ferris enrolled patients and contributed to data collection for
the long-term anti-HPV6/11/16/18 serological levels. The secondary
the study and drafted the initial manuscript; Drs. Samakoses,
Block, Lazcano-Ponce, Restrepo, Reisinger, Mehlsen, Chatterjee, and objective was to estimate vaccine effectiveness against HPV6/11/16/
Iversen enrolled patients and contributed to data collection for the 18-related persistent infection or disease.
study and reviewed and revised the manuscript; Mr Sausser and
Dr Saah conceptualized and designed the study and reviewed and RESULTS: For each of the HPV4 vaccine types, vaccination-induced anti-
revised the manuscript; Dr Shou performed the statistical analyses HPV response persisted through month 96. Among 429 subjects who
and critically reviewed the manuscript; Dr Sings analyzed and received HPV4 vaccine at a mean age of 12, none developed HPV6/11/
interpreted the data and drafted the original manuscript; and all
authors approved the nal manuscript as submitted.
16/18-related disease or persistent infection of $12 months duration.
Acquisition of new sexual partners (among those $16 years) was 1
www.pediatrics.org/cgi/doi/10.1542/peds.2013-4144
per year. Subjects receiving HPV4 vaccine at month 30 (mean age 15
doi:10.1542/peds.2013-4144
years) had a similar baseline rate of seropositivity to $1 of the 4 HPV
Accepted for publication Jun 6, 2014
types to those vaccinated at day 1 (mean age 12 years; 1.9% [9 of 474]
Address correspondence to Daron Ferris, MD, 1423 Harper St, HH-
vs 1.7% [20 of 1157]); however, 4 of the 9 subjects vaccinated at the
1013, Georgia Regents University, Augusta, GA 30912. E-mail:
dferris@gru.edu later age were seropositive to 3 vaccine types, indicating previous HPV
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). exposure. No new signicant serious adverse events were observed
Copyright 2014 by the American Academy of Pediatrics
for 8 years postvaccination in both genders.
CONCLUSIONS: When administered to adolescents, the HPV4 vaccine
(Continued on last page) demonstrated durability in clinically effective protection and sustained
antibody titers over 8 years. Pediatrics 2014;134:e657e665

PEDIATRICS Volume 134, Number 3, September 2014 e657

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The quadrivalent HPV6/11/16/18 L1
viruslike particle vaccine (HPV4) was
launched in 2006 to substantially re-
duce the burden associated with HPV-
related neoplasias of the anogenital
tract. The results from a series of large
randomized controlled trials in .17
500 young women aged 16 to 26 years
conducted across 4 continents showed
that the vaccine was highly effective in
preventing cervical, vaginal, and vulvar
neoplasias and anogenital condylo-
mata in women who were naive to the
respective HPV type at enrollment.1,2 In
support of a gender-neutral vaccina-
tion program, excellent HPV4 vaccine
efcacy has been demonstrated for the
prevention of external genital and anal
lesions in hetero- and homosexual
men.3,4 Multiple studies of HPV4 vac-
cine immunogenicity across the 9- to
45-year-old age range have revealed
robust antibody responses for all 4 HPV
types.1,2,58 Evidence of a HPV4 vaccine
anamnestic response and immune
memory have also been observed.8,9
In 2 separate meta-analyses of 5 clinical
trials of the HPV4 vaccine, vaccination
was generally well tolerated with no
apparent adverse health impact after
completion of the vaccination regimen.10
National adverse event (AE) surveillance
systems have also monitored HPV4 vac-
cine safety postapproval. A review of the
Centers for Disease Control and Pre-
vention (CDC) Vaccine Adverse Event
Reporting System data for the HPV4
vaccine during the rst 2.5 years after
implementation showed most reported
AE rates were no greater than back-
ground rates associated with other vac-
cines.11 Several years later, in a study of
.600 000 HPV4 vaccine doses analyzed
using the CDC Vaccine Safety Datalink, no
statistically signicant increased risk for
any of the prespecied AEs were ob-
served. However, the authors concluded
that further study of a possible associa-
tion with venous thromboembolism after
vaccination was warranted.12 As of 2013,
e658 FERRIS et al
the Australian Therapeutic Goods Ad-
ministration Database of Adverse Events
Notications reported only mild AEs
previously recognized as routinely asso-
ciated with the HPV4 vaccine.13 Hence, in
the 7 years of independent postlicensure
vaccine safety monitoring and evalua-
tion, no serious safety concerns have
been identied.
Despite ample evidence of the safety,
immunogenicity, and efcacy of the HPV4
vaccine from numerous large ran-
domized controlled trials, national
AE surveillance systems, and recent
population-based documentation of the
positive impact of vaccination,1419 ques-
tions remain regarding the duration of
vaccine effectiveness. The vaccine needs
to show sustained immunity after vacci-
nation of the primary target population of
preadolescents. The possible need for an
additional booster dose depends on
whether loss of protection is observed
over the next 5 to 10 years after vacci-
nation. Additional long-term safety data
would also help to clarify lingering
unveried concerns about HPV vaccina-
tion. Although vaccine uptake in several
countries has been widespread, undoc-
umented concerns have unfortunately
fostered a negative impact on vaccination
rates in many other locations worldwide.
Suboptimal HPV4 vaccine uptake has
drawn the attention and concern from
organizations such as the CDC, which
acknowledged earlier this year that HPV
vaccines are safe, effective, and grossly
underutilized.20 Further dissemination of
data demonstrating long-term safety and
effectiveness could reduce reluctance to
vaccination and improve uptake.
The short-term immunogenicity and
safety of the HPV4 vaccine has been
previously established in preadolescent
and adolescent children.5,6 To date, no
long-term studies of the safety, dura-
bility, immunogenicity, and effectiveness
of the HPV4 vaccine in boys and girls
aged 9 to 15 years have been reported.5,6
To address these questions, we present
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a long-term follow-up study through
8 years postvaccination in boys and
girls who received HPV4 vaccine be-
tween the ages of 9 and 15 years.6
METHODS
Objectives
The lack of a placebo arm in the long-
term follow-up study made vaccine ef-
cacy hypothesis testing unavailable.
The primary objective was to evaluate
the anti-HPV6/11/16, and 18 serological
levels after administration of a 3-dose
regimen of HPV4 vaccine as measured at
months 72, 96, and 126. The secondary
objective was to estimate the long-term
effectiveness of the HPV4 vaccine with
respect to the combined incidence of
HPV6/11/16 and 18-related persistent
infection and disease. The safety objec-
tive was to describe the incidence of
serious AEs and deaths deemed to be
vaccine- or procedure-related.
Baseline Study
Protocol V501-018 was a randomized,
double-blind, placebo-controlled study to
assess the safety and immunogenicity of
the HPV4 vaccine among 9- to 15-year-old
boys and girls over a 1-year period after
the third dose, as previously described.6
An Institutional Review Board for each
clinical site approved the study protocol.
At enrollment, written consent was
obtained from each participant and his or
her legal guardian. Subjects were ran-
domized in a 2:1 ratio within study cen-
ters to receive 3 intramuscular injections
of either HPV4 vaccine or nonaluminum-
containing placebo at months 0, 2, and 6.
The data for the prespecied primary
endpoints for the base study were de-
scribed by Reisinger et al in 2007.6
Long-term Follow-up Study
The follow-up study was designed to
evaluate the long-term immunogenicity,
effectiveness, and safety of the HPV4
vaccine (Fig 1). The cohort who received
HPV4 vaccine at months 0, 2, and 6 in the

base study are referred to as the Early
Vaccination Group (EVG) and the cohort
who received placebo in the base study
and who later received a 3-dose regi-
men of HPV4 vaccine starting at month
30 are referred to as the Catch-up Vac-
cination Group (CVG). All subjects who
received 3 doses of HPV4 vaccine and
consented to participate in the exten-
sion were eligible. The protocol (see
Supplemental Information) stated an
interim analysis would be conducted at
months 72 and 96 relative to month 0 of
the base study. Here we present the
month 96 interim analysis.
Annual serum samples were collected
and a brief physical examination was
conducted at each scheduled visit until
the subject reached 16 years of age.
Starting at age 16 years, visits were
scheduled twice yearly and included the
collection of sexual history, serological
specimens, and genital clinical speci-
mens (if agreed to), consistent with
previous efcacy studies of the HPV4
vaccine in male and female subjects
FIGURE 1
Study design and number of subjects contributing to the efcacy analyses by time point. *Subjects who
had polymerase chain reaction (PCR) results from either a swab or biopsy at indicated visit.
PEDIATRICS Volume 134, Number 3, September 2014
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aged 16 to 26 and as described in the
study protocol.13,21
Effectiveness Endpoints and
Analysis Populations
Analyses for effectiveness began at
month 42, with follow-up visits occur-
ring every 6 months thereafter (Fig 1).
Disease was dened as a tissue sample
diagnosed by a 4-member pathology
panel as cervical intraepithelial neo-
plasia, adenocarcinoma in situ, vul-
var intraepithelial neoplasia, vaginal
intraepithelial neoplasia, genital con-
dyloma, cervical/vaginal/vulvar cancer,
penile intraepithelial neoplasia, or
penile/perineal/perianal cancer with
HPV6/11/16 or 18 DNA detected in tis-
sue from the same lesion, as previously
described in previous studies of the
HPV4 vaccine in female and male sub-
jects aged 16 to 26.14,7 Persistent in-
fection was dened as detection of the
same HPV type in genital swabs at $2
consecutive visits spaced $4 months
apart (prespecied endpoint) or $12
ARTICLE
months apart (post hoc analysis) or
the presence of disease associated
with the relevant type with DNA for that
same type found in the swab at the visit
directly before or after the biopsy.
The effectiveness analyses for the EVG
and CVG were assessed in an intention-
to-treat (ITT) population, which in-
cluded subjects who were $16 years of
age, received at least 1 dose of HPV4
vaccine, and had at least 1 follow-up
visit. In the effectiveness analyses
(presented in Table 3 later in the arti-
cle), a subject is counted only once for
each endpoint (ie, once in each row),
but a subject may have developed .1
endpoint during the trial (ie, a subject
may appear in .1 row). For example,
a female may have developed HPV16-
related persistent infection and HPV16-
related CIN1. Overall she would be
counted as a case once each for (1)
HPV6/11/16 or 18-related persistent
infection or disease, (2) HPV16-related
persistent infection, and (3) HPV6/11/
16 or 18-related cervical disease.
Immunogenicity Endpoints and
Analysis Populations
Previous studies of the HPV4 vaccine in
women aged 16 to 26 years have shown
important differences in the serologic
assays used to assess anti-HPV6/11/16
and 18 responses.21 Differences in se-
ropositivity status have been observed
between the standard competitive
Luminex immunoassay (cLIA) that was
used in the clinical trials of the HPV4
vaccine,22 and a new total immuno-
globulin (Ig)G assay that was devel-
oped as a research assay to evaluate
preclinical multivalent HPV vaccine
formulations.23 These differences are
attributed to the measurement param-
eters and sensitivity of the individual
immunoassays. 21 Whereas the cLIA
measures a single neutralizing epitope
that is a subset of the total immune
response to HPV vaccination, the total
IgG assay is a less restricted, sensitive
e659
assay that measures a broader subset
of the total immune response to vacci-
nation.21 Therefore, antibodies to HPV6/
11/16 and 18 were measured using both
the cLIA and the IgG assay. The immune
response to vaccination was assessed
in the per-protocol immunogenicity
population as previously described,6
with an additional criteria of not yet
having sexual debut until after receiving
the third dose of HPV4 vaccine. Subjects
must have also had at least 1 follow-up
visit after dose 3. Reasons for exclusion
from the per-protocol immunogenicity
population are shown in Supplemental
Table 5.
Safety endpoints and analysis
populations
The safety objective was to describe the
incidence of deaths and serious AEs
deemed by the study investigators to be
vaccine- or procedure-related for all
subjects in the long-term follow-up study
who received at least 1 dose of the HPV4
vaccine.
RESULTS
Among the 1781 subjects who received
HPV4 vaccine (N = 1184) or placebo (N =
597) during the baseline study, 1661
(1179 vaccine [EVG] and 482 placebo
recipients [CVG]) participated in the
long-term follow-up study. Table 1 dis-
plays the baseline characteristics of
these subjects at the time of the rst
dose of HPV4 vaccine. As expected, the
mean age of the CVG group was 3 years
older than the EVG (15 vs 12 years). In
both groups, approximately half were
female. Although subjects were sup-
posed to be sexually naive at the time of
enrollment in the base study, prevacci-
nation anti-HPV titers above the sero-
positivity cutoff for a given HPV type
indicated likely previous exposure to that
type in 20 (1.7%) subjects in the EVG. The
seropositivity rate in the CVG as mea-
sured at month 30 immediately before
receiving the rst dose of HPV4 vaccine
e660 FERRIS et al
TABLE 1 Baseline Characteristics of Subjects at the Time They Received the First Dose of HPV4
Vaccine
EVG (n = 1179) CVG (n = 482)
Gender, n (%)
Female 614 (52.1) 262 (54.4)
Male 565 (47.9) 220 (45.6)
Age (y)
Mean (SD) 11.9 (1.9) 14.5 (1.9)
Median (range) 12 (9 to 16) 15 (11 to 18)
Region, n (%)
Asia-Pacic 143 (12.1) 60 (12.4)
Europe 317 (26.9) 128 (26.6)
Latin America 210 (17.8) 104 (21.6)
Nordic 23 (2.0) 11 (2.3)
North America 486 (41.2) 179 (37.1)
HPV serostatus, m/n (%)
Positive to HPV6/11/16 or 18 20/1157 (1.7) 9/474 (1.9)
Positive to HPV6 8/1155 (0.7) 7/474 (1.5)
Positive to HPV11 1/1155 (0.1) 3/474 (0.6)
Positive to HPV16 8/1154 (0.7) 5/474 (1.1)
Positive to HPV18 3/1156 (0.3) 2/474 (0.4)
Positive to exactly 1 type 20/1157 (1.7) 5/474 (1.1)
Positive to exactly 2 types 0 0
Positive to exactly 3 types 0 4/474 (0.8)
Positive to exactly 4 types 0 0
m/n, number of subjects with serology data for the indicated type/number of subjects with the indicated characteristic.
was similar at 1.9% (9 of 474); however, 4 immune response, the reported sero-
of the 9 subjects were seropositive to 3 positivity results were different at month
vaccine types. This was attributable to 96, particularly for HPV18. In the cLIA as-
the older age of CVG group and the say, the proportion of subjects with de-
higher likelihood of having been exposed tectable anti-HPV6/11/16 and 18 antibody
to HPV before receiving the rst dose of levels (both genders combined) at month
HPV4 vaccine at a mean age of 15 years 96 were 88.4%, 89.1%, 96.8%, and 64.1%,
rather than at 12 years of age. respectively; whereas the corresponding
seropositivity rates for the total IgG assay
Immunogenicity were 94.3%, 89.4%, 99.5%, and 88.8%,
A total of 1116 subjects (95%) in the EVG respectively.
had follow-up for immunogenicity with
amedian(mean)follow-uptimeof6.8(5.2) Indicators of Sexual Activity
years postdose 3. The median (mean) During the long-term follow-up study,
follow-up time postdose 3 for the CVG was among subjects $16 years of age, the
4.7 (3.5) years, thus the following analyses rate of acquisition of new partners
focus on the EVG. For each of the HPV4 among male subjects tended to be
vaccine types for both genders, the higher than that for their female
vaccination-induced anti-HPV response counterparts (Table 3). In the EVG and
persisted through month 96; however, for CVG groups, male subjects acquired
bothboysandgirls,geometricmeantiters 1.2 new partners per year, and fe-
(GMTs) at month 96 were 11- to 34-fold male subjects acquired 0.7 and 0.9 new
lower than the GMTs observed at month 7 partners per year, respectively. The 3%
(Table 2). to 4% incidence of Chlamydia and
As shown in Fig 2, the seroconversion gonorrhea was similar between the
status differed between the total IgG and EVG and CVG groups and between male
cLIA assays. Because the cLIA measures and female subjects within the EVG and
a much more restricted subset of the CVG groups (Table 3).
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 ARTICLE

TABLE 2 Summary of Anti-HPV cLIA Geometric Mean Titers (mMU/mL) Among Male and Female infection attributable to HPV16 was
Subjects in the Long-term Follow-up Study (Per-Protocol Immunogenicity Populations)
comparable to that observed among
Time Female Subjects Male Subjects vaccine recipients in previous efcacy
n GMT 95% CI n GMT 95% CI trials of the HPV4 vaccine in women
A. HPV6 aged 16 to 26 (Fig 3).1,2 There were no
Base study observed cases of HPV6/11/16- or 18-
,8 ,8,8 ,8 ,8,8
Day 1 535 498
related persistent infection of $12
Month 7 501 893.9 818.7976.0 456 962.7 874.21060.1
Month 18 491 213.9 195.7233.8 450 224.5 202.4249.0 months duration (data not shown).
LTFU study Among male subjects (n = 173), no cases
Month 42 302 122.6 108.9137.9 252 106.7 92.4123.1
Month 60 227 112.7 98.3129.1 201 104.3 89.6121.4 of HPV6/11/16- or 18-related disease and
Month 72 258 123.9 110.4139.0 220 114.1 99.1131.5 2 cases of persistent infection of $4
Month 84 268 88.6 78.3100.2 229 74.1 63.486.5 months duration (1 HPV6-related and 1
Month 96 242 77.7 67.989.0 197 63.2 53.974.0
B. HPV11
HPV16-related) were seen (Table 4). As
Base study with female subjects, the incidence of
Day 1 535 ,8 ,8,8 498 ,8 ,8,8 persistent infection was comparable to
Month 7 501 1356.8 1245.11478.6 457 1370.8 1249.61503.8
that observed among vaccine recipients
Month 18 491 304.1 276.8334.2 451 290.2 261.8321.7
LTFU study in a previous efcacy trial in male sub-
Month 42 302 140.3 123.3159.6 252 127.5 110.4147.2 jects aged 16 to 26 years (Fig 3),3 and the
Month 60 227 125.8 108.0146.5 201 118.1 100.4138.8 2 cases of persistent infection were of
Month 72 258 140.8 122.9161.2 220 132.8 114.2154.4
Month 84 268 89.0 77.0102.9 229 80.1 67.695.0 ,12 months duration.
Month 96 242 72.7 61.885.5 197 61.7 51.673.8
C. HPV16 CVG
Base study
Day 1 534 ,12 ,12,12 498 ,12 ,12,12 In the ITT analyses for the CVG among
Month 7 497 4992.2 4501.95535.9 456 6091.0 5447.06811.0 female subjects, 2 cases of HPV16-related
Month 18 487 1258.8 1142.11387.4 450 1388.3 1238.81555.8
LTFU study persistent infection and 4 cases of HPV
Month 42 299 597.1 521.8683.4 253 577.2 484.5687.7 18-related persistent infection were
Month 60 225 464.7 398.6541.7 199 459.0 380.8553.3 detected (Table 4). The 4 cases of HPV18-
Month 72 257 523.0 455.4600.7 219 528.2 443.3629.4
Month 84 267 401.4 350.6459.7 228 365.3 302.4441.3
related persistent infection were per-
Month 96 240 353.0 303.1411.0 196 293.6 240.5358.4 sistent infections of $12 months du-
D. HPV18 ration. In the CVG, there was also 1 case
Base study
CIN1 related to HPV18. Four of these 6
Day 1 537 ,8 ,8,8 502 ,8 ,8,8
Month 7 503 1130.8 1018.31255.7 458 1470.7 1311.21649.5 subjects who developed a case of per-
Month 18 492 181.4 159.5206.3 452 231.5 199.8268.2 sistent infection or disease were also
LTFU study diagnosed with Chlamydia or gonorrhea
Month 42 303 73.9 62.587.3 255 90.5 73.6111.1
Month 60 227 56.3 46.468.4 203 72.3 57.890.4 during the study. Among male subjects,
Month 72 258 64.4 53.377.8 222 82.2 66.0102.4 no cases of disease and 1 case of HPV6-
Month 84 269 45.4 38.553.6 231 53.6 43.565.9 related persistent infection of ,12
Month 96 241 41.8 35.049.9 199 42.8 34.553.2
months duration was observed. This
CI, condence interval; GMT, geometric mean titer; LTFU, long-term follow-up; mMU, milli Merck units.
subject was also diagnosed with Chla-
mydia during the follow-up period. All of
Effectiveness the subject reached 16 years of age in these subjects (both male and female)
Figure 2 shows the number of subjects both groups. were seronegative to all 4 vaccine types
with a follow-up visit to assess vaccine at day 1 (ie, before vaccination), except
effectiveness between months 42 and EVG for 1 female who developed a case of
96. The median (mean) follow-up time Among female subjects (n = 256), no HPV16-related persistent infection, who
to assess vaccine effectiveness for cases of HPV6/11/16- or 18-related was seropositive to HPV6 at day 1.
persistent infection and disease was disease were observed (Table 4). Two
similar for both groups: 4.1 (3.8) years cases of HPV16-related persistent in- Safety
in the EVG and 3.9 (3.6) years in the CVG fection of $4 months duration were Three serious AEs occurred during the
because this evaluation began when detected. The incidence of persistent long-term follow-up study: a fatal road

PEDIATRICS Volume 134, Number 3, September 2014 e661

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FIGURE 2
Percent of subjects who were seropositive to HPV6, 11, 16, and 18 at month 96 using both the cLIA and IgG
assays for the EVG, stratied by gender.
trafc accident (EVG; 4.7 years postdose
3), 1 case of tonic-clonic movements of 3
minutes duration postphlebotomy (EVG;
7 years postdose 3), and 1 case of cra-
nial nerve VII paralysis of 2.7 weeks
duration (CVG, 131 days postdose 3). The
latter case was determined by the in-
vestigator to be vaccine-related. The
subject with cranial nerve paralysis was
treated with prednisolone; vitamins B1,
B6, and B12; and omeprazole and fully
recovered. No signicant pregnancy-
related adverse outcome trends were
observed. Of the 67 and 37 pregnancies
with a known outcome reported in the
EVG and CVG groups, 48 (72%) and 26
(70%) were live births. Of the live births
in the EVG and CVE, 45 (94%) and 24
(92%) had a normal infant outcome.
Only 3 births reported a congenital
anomaly (2 cases of trisomy 21 [EVG]
and 1 case of unilateral choanal atresia
CVG]). The duration of time from the
subjects last vaccination with HPV4 to
conception was 15 months, 61 months,
and 28 months, respectively.
Discussion
This is the rst study to present detailed
long-term immunogenicity, effective-
ness, and safety data for the HPV4
vaccine from a closely monitored group
of preadolescents (the intended pri-
mary targeted population). Three doses
of HPV4 vaccine provided high pro-
tection against disease and persistent
infection. The only cases of persistent
HPV infection and the sole case of CIN1
were seen in the CVG (ITT analysis) who
were fully vaccinated 3 years later than
the EVG. With 5 years of follow-up
postdose 3, no cases of HPV6/11/16/
18-related anogenital disease were
detected among female or male sub-
jects in the per-protocol effectiveness
population. On the basis of previous
placebo-controlled trials, some dis-
ease cases would have been expected
during this interval in unvaccinated
subjects (Fig 3).14 The observed ac-
quisition of 1 new sexual partner per
year and an incidence of Chlamydia
and gonorrhea being on the order of
3% to 4% in both genders indicate the
emerging risks encountered by these
young individuals. High uptake of HPV
vaccination, preferably before sexual
debut and HPV acquisition, is para-
mount to reduce the risk of HPV-related
cancers in large populations.
According to the CDC, for each year the
3-dose HPV vaccine series coverage
remains near the current level of 33%
instead of achieving the Healthy People
2020 goal of 80% coverage, an addi-
tional 4400 women will be diagnosed
annually with cervical cancer along
with 1400 cervical cancerattributable
deaths.20 In addition, many more indi-
viduals will experience the morbidity
and signicant anxiety associated with
the diagnosis and treatment of HPV-
induced premalignant diseases. Long-
term HPV vaccine effectiveness and
safety data, such as that provided by
our study, should help to reassure
health providers, patients, and fami-
lies, and ultimately improve vaccine
acceptance and compliance. These
data also reinforce existing national
vaccine recommendations.

TABLE 3 Incidence of New Sexual Partners and Chlamydia or Gonorrhea Among Male and Female Subjects, ITT Populations
Endpoint EVG CVG
a
n No. of Cases Rate 95% CI n No. of Cases Ratea 95% CI
New partners since sexual debut
Male subjects 226 976 120.0 112.6127.8 111 426 121.4 110.1133.5
Females 263 645 69.2 64.074.8 143 399 89.4 80.998.6
Chlamydia or gonorrheamale subjects 273 26 2.5 1.73.7 140 12 2.3 1.23.9
Chlamydia 273 20 1.9 1.23.0 139 12 2.3 1.23.9
Gonorrhea 264 7 0.7 0.31.4 134 1 0.2 0.01.0
Chlamydia or gonorrheafemale subjects 356 44 3.1 2.24.2 194 29 3.9 2.65.5
Chlamydia 356 42 2.9 2.14.0 194 28 3.7 2.55.4
Gonorrhea 350 8 0.8 0.21.1 190 8 1.0 0.42.0
CI, condence interval; n, number of subjects with at least one follow-up visit for effectiveness.
a Incidence rate per 100 person-year-at-risk.

e662 FERRIS et al
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 ARTICLE

TABLE 4 Vaccine Effectiveness in Preventing HPV6/11/16/18-Related Persistent Infection or Disease, ITT Populations
Endpoint EVG CVG

n No. of cases Ratea 95% CI n No. of cases Ratea 95% CI

Females
HPV6/11/16 or 18-related persistent infection or disease 256 2 0.3 01.1 126 6 1.8 0.74.0
HPV6-related 256 0 0 00.5 126 0 0 01.1
HPV11-related 256 0 0 00.5 126 0 0 01.1
HPV16-related 256 2 0.3 01.1 126 2 0.6 0.12.1
HPV18-related 256 0 0 00.5 126 4 1.2 0.33.1
HPV6/11/16 or 18-related persistent infection 240 2 0.3 01.2 121 6 2.0 0.74.4
HPV6-related 240 0 0 00.6 121 0 0 01.2
HPV11-related 240 0 0 00.6 121 0 0 01.2
HPV16-related 240 2 0.3 01.2 121 2 0.6 0.12.3
HPV18-related 240 0 0 00.7 121 4 1.3 0.43.5
HPV6/11/16 or 18-related cervical disease 206 0 0 00.7 107 1b 0.3 01.9
HPV6/11/16 or 18-related genital warts or vulvar/vaginal 256 0 0 00.6 126 0 0 01.1
disease
Males
HPV6/11/16 or 18-related persistent infection or disease 173 2 0.4 0.11.5 90 1 0.4 02.4
HPV6-related 173 1 0.2 01.2 90 1 0.4 02.4
HPV11-related 173 0 0 00.8 90 0 0 01.6
HPV16-related 173 1 0.2 01.2 90 0 0 01.6
HPV18-related 173 0 0 00.8 90 0 0 01.6
HPV6/11/16 or 18-related persistent infection 171 2 0.4 0.11.6 89 1 0.4 02.4
HPV6-related 171 1 0.2 01.2 89 1 0.4 02.4
HPV11-related 171 0 0 00.8 89 0 0 01.6
HPV16-related 171 1 0.2 01.2 89 0 0 01.6
HPV18-related 171 0 0 00.8 89 0 0 01.6
HPV6/11/16 or 18-related disease 173 0 0 00.8 89 0 0 01.6
CI, condence interval; n, number of subjects with at least 1 follow-up visit for effectiveness. A subject is counted only once within each applicable row but may appear in more than 1 row.
a Number of subjects with an endpoint per 100 person-years-at-risk.
b The single case of cervical disease was HPV18-related CIN1.

only 64.1% of subjects were seropositive

FIGURE 3
Incidence of HPV 6/11/16/18-related persistent infection in Protocol 018 and previous studies of young
adult women and men.13 qHPV, quadrivalent HPV vaccine.
Long-term antibody persistence was
observed for HPV6, 11, and 16 for each
gender and each age group, and the vast
majority (86%100%) of subjects re-
mained seropositive through 8 years.
Reduced anti-HPV18 titers have been
reported for women aged 16 to 26
compared with the other 3 antibody
titers as measured by the cLIA.21 In our
study, a 27- to 34-fold decline in GMTs
occurred by month 96, relative to month
7 (ie, 1 month postdose 3). In addition,
to HPV18 at month 96. However, when
a total IgG assay was compared with
the cLIA, antibodies to other HPV18
neutralizing epitopes were detected,
resulting in a higher seropositivity rate.
The particular neutralizing epitope and
relevant mAb selected for the HPV18
cLIA (18.J4) was selected for its analyt-
ical specicity. Although it can distin-
guish between HPV18 antibody response
and other HPV types that are phylo-
genetically related to HPV18 (such as
HPV45), it is not detecting all of the
HPV18 neutralizing antibodies.24 The
IgG assay data corroborate the already
documented sustained HPV4 vaccine
effectiveness against HPV18-related
anogenital disease.24 Yet no immune
correlate of protection nor antibody
threshold that correlates with protec-
tion against HPV infection or disease
has been established.

PEDIATRICS Volume 134, Number 3, September 2014 e663

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Our study is accompanied by some limi-
tations. The lack of a control group did not
allow fora direct measurement of vaccine
efcacy. However, given the known attri-
butes of the HPV4 vaccine, failure to
subsequently administer the vaccine to
the later control group would have been
considered unethical. Some attrition was
also observed, which is not uncommon in
long-term follow-up trials. This is partic-
ularly true for adolescents faced with
a required rst-time genital examination.
Only 25% of original enrollees contin-
ued into the effectiveness portion of the
study. The relatively small number of
participants also precludes the ability to
detect rare and serious adverse events.
These data complement the large
population-based evaluations of the HPV4
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CONCLUSIONS
The HPV4 vaccine administered to pre-
adolescents and adolescents demon-
strated durability in clinically effective
protection and sustained antibody titers
over 8 years. No new signicant serious
AEs were observed for 8 years after
vaccination in both genders. These long-
term follow-up data, along with other
extensive postapproval safety surveil-
lance data, should help to encourage
practitioners and reinforce national rec-
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ACKNOWLEDGMENTS
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(Merck) for editorial support.
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(Continued from rst page)

FINANCIAL DISCLOSURE: Dr Ferris reports having received grant support from Merck though his institution and having received personal fees for consultancy and
advisory boards for Merck; Dr Block reports having received grant support and speaker fees from Merck; Dr Mehlsen reports having received grant support from
Merck; Dr Chatterjee reports having received speaker and advisory board member fees from Merck and Glaxo Smith Kline; Dr Iversen reports having received
lecture fees and/or compensation through institution as investigator for HPV vaccine studies on behalf of Merck and GSK and serves on the advisory board for
Mercks second generation HPV vaccine. Drs Sings, Shou, Mr Sausser, and Dr Saah are Merck employees and hold stock/stock options. The remaining authors have
indicated they have no potential conicts of interest to disclose.
FUNDING: The study was funded by Merck & Co., Inc
POTENTIAL CONFLICT OF INTEREST: Daron Ferris reports having received grant support from Merck though his institution and having received personal fees for
consultancy and advisory boards for Merck; Stan L. Block reports having received grant support and speaker fees from Merck; Jesper Mehlsen reports having
received grant support from Merck; Archana Chatterjee reports having received speaker and advisory board member fees from Merck and Glaxo Smith Kline; Ole-
Erik Iversen reports having received lecture fees and/or compensation through institution as investigator for HPV vaccine studies on behalf of Merck and GSK and
serves on the advisory board for Mercks second generation HPV vaccine. Heather L. Sings, Qiong Shou, Timothy A. Sausser, and Alfred Saah are Merck employees
and hold stock/stock options. The remaining authors have indicated they have no potential conicts of interest to disclose.

PEDIATRICS Volume 134, Number 3, September 2014 e665

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 Long-term Study of a Quadrivalent Human Papillomavirus Vaccine
Daron Ferris, Rudiwilai Samakoses, Stan L. Block, Eduardo Lazcano-Ponce, Jaime
Alberto Restrepo, Keith S. Reisinger, Jesper Mehlsen, Archana Chatterjee, Ole-Erik
Iversen, Heather L. Sings, Qiong Shou, Timothy A. Sausser and Alfred Saah
Pediatrics 2014;134;e657; originally published online August 18, 2014;
DOI: 10.1542/peds.2013-4144
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
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 Long-term Study of a Quadrivalent Human Papillomavirus Vaccine
Daron Ferris, Rudiwilai Samakoses, Stan L. Block, Eduardo Lazcano-Ponce, Jaime
Alberto Restrepo, Keith S. Reisinger, Jesper Mehlsen, Archana Chatterjee, Ole-Erik
Iversen, Heather L. Sings, Qiong Shou, Timothy A. Sausser and Alfred Saah
Pediatrics 2014;134;e657; originally published online August 18, 2014;
DOI: 10.1542/peds.2013-4144

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/134/3/e657.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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