Human papillomavirus and occupational exposure: The need for vaccine provision for healthcare providers

ABSTRACT

Introduction

The human papillomavirus (HPV) is the most prevalent sexually transmitted virus infection in the United States. HPV is a small deoxyribonucleic acid (DNA) virus that targets the squamous epithelium of the human body. It is the main culprit behind squamous cancers in different organs, including the cervix, vulva, vagina, penis, anus, and oropharynx.¹ Low-risk HPV genotypes, mainly HPV type-6 and type-11, are liable for anogenital warts and oropharyngeal papillomatosis.²

Cervical cancer is the fourth most common cancer in women globally. Global Cancer Observatory 2020 data estimated approximately 600,000 new cases of cervical cancer and 350,000 deaths from cervical cancer annually are expected.³ The incidence of HPV-related head and neck cancers primarily associated with HPV type-16 overtook HPV-related cervical cancers in 2018 in the United States.⁴ High-risk HPV, especially HPV type-16, is accountable for almost all anal cancers, and about 60% of vulvar-vaginal and penile cancers.^1,5

HPV-related cancers are preventable by prophylactic recombinant DNA vaccines targeting the major L1 capsid protein of high-risk HPVs, such as HPV type-16 and type-18.^6,7 The current FDA-approved HPV vaccine (Gardasil-9) supplies extended spectrum protection against high-risk HPV types 31, 33, 45, 52, and 58 and is approved for adults up to age 45 y since 2018.^1,6,8 HPV vaccination for healthcare providers who are occupationally exposed to the virus is recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP) and the American College of Obstetricians and Gynecologists (ACOG).^7,9

The treatment of HPV-related diseases consists of electrocautery, cryotherapy, loop electrical excision, and laser treatments, which providers widely use in daily practice to treat benign and preinvasive diseases. HPV-DNA has been proven to be distinctly isolatable from the surgical fumes produced during these treatments, indicating that healthcare professionals are passively exposed to HPVs during procedures to treat afflicted patients by particles found in the ambient air.^2,10 Moreover, it has been found that the viral particles containing HPV-DNAisolated from the surgical fumes are capable of infecting HPV-negative cervical cancer cell lines.¹⁰ It becomes then imperative that healthcare providers in positions vulnerable to exposure to such surgical fumes, and thus HPV-DNA molecules, mitigate their risk of susceptibility to becoming infected by a type of HPV.^2,11

This study aims to survey the awareness of healthcare providers in the context of occupational exposure to HPV and their knowledge of HPV vaccination in parallel with the ASCCP recommendations

Methods

After being determined to be exempt from the requirement for IRB approval by the local Institutional Review Board (23-002111), an electronic survey delivered to healthcare providers at Mayo Clinic (AZ, FL, MN) between April 2023 and July 2023 focused on four main themes: the awareness of occupational exposure to HPV, the knowledge of HPV vaccination, precautions for HPV exposure, and the understanding of the relationship of HPV with cancer. The generated data from the survey was captured and stored by Research Electronic Data Capture (REDCap) software.¹²

The demographic characteristics of healthcare providers were explored, including age, gender, HPV vaccination status, profession, and affiliated department. Additionally, healthcare providers replied to mainly four main themes within the query in which a dichotomous scale was used for each scale: (1) a 3-question scale questioning the awareness of occupational exposure to HPV (Graph 1), (2) a 3-question scale questioning healthcare providers’ knowledge about HPV vaccination recommendations (Graph 1), (3) and a 4-item scale questioning healthcare providers’ precautions for HPV exposure, (4) an 8-item scale questioning healthcare providers’ understanding about the relationship of HPV with cancer that included two reversal items to tackle with response bias (Graph 2). The complete survey questionnaire from the REDCap database in PDF format was provided as a supplementary file.

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Graph 1.

The responses to the HPV survey based on profession.

The bars of the graph were built based on yes responses. HPV: human papillomavirus, M.D.: Medical doctor, NP/PA/CRNA: Nurse Practitioner/Physician Assistant/Certified Registered Nurse Anesthetist.

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Graph 2.

Knowledge about HPV-related cancers by profession.

The bars of the graph were built based on yes responses.HPV: human papillomavirus, M.D.: Medical doctor, NP/PA/CRNA: Nurse Practitioner/Physician Assistant/Certified Registered Nurse Anesthetist.

Statistical analysis

The study’s statistical analysis was performed with open-source Jamovi statistical software (Version 2.3.21). The scale reliability of the survey was assessed with Cronbach’s alpha. The awareness of occupational HPV exposure, precautions for HPV exposure, HPV vaccine knowledge, and understanding of the relationship of HPV with cancer were compared based on age, gender, HPV vaccination status, profession, and department by non-parametric one-way analysis of variance, namely Kruskal-Wallis and pairwise comparisons were made with the Dwass-Steel-Critchlow-Fligner test. A p-value < .05 was considered statistically significant.

Results

The survey was completed by 349 healthcare providers, with one respondent excluded for inconsistent entry. Although 84% (n = 292) of respondents are well-informed about occupational human papillomavirus exposure and risk, most are unaware of the ASCCP recommendations for HPV vaccination among healthcare providers (n = 243, 70%). The majority of respondents (n = 313, 90%) were willing to get vaccinated if provided with the vaccine (Graph 1).

The mean age of respondents was 42.7 ± 10.9 and of those, 68% (n = 229) female, and 32% (n = 109) male. Of the unvaccinated respondents, 43.3% (n = 87) were ≤45 y of age (eligible for vaccination approved by FDA in 2018), while those vaccinated formed 41% (n = 140) of the respondents. The demographic features of the respondents are summarized in Table 1. The value for Cronbach’s alpha for the survey was α = 0.72.

Discussion

This survey highlights that the awareness of occupational HPV exposure is 84% among healthcare providers, and unvaccinated respondents comprise 59% of the survey, of whom 43.3% were ≤45 y, and could be protected against occupational HPV exposure if vaccinated. However, only 30% of respondents knew of the ASCCP recommendation for vaccinating healthcare providers treating HPV-related diseases. In such cases, most respondents welcomed vaccination, which was believed to be 100% safe by medical doctors and allied health professionals.

Emerging evidence from recent studies indicates that exposure to surgical smoke during procedures on HPV-related lesions may result in nasal and oropharyngeal HPV infection. For healthcare workers specializing in gynecology, dermatology, otolaryngology, urology, and proctology, understanding the role of surgical smoke in relation to HPV-associated lesions is critical for their practice. A growing body of research suggests a possible association between performing such procedures that involve HPV-associated lesions and generating surgical smoke and a handful of cases of HPV-related upper respiratory tract disease in medical workers with suspected occupational origins.^10–15 This information could inspire healthcare providers to protect themselves from surgical smoke. In parallel with this, the awareness of occupational exposure to HPV among healthcare providers in this survey is remarkable. The National Institute for Occupational Safety and Health (NIOSH) recommends using high-efficiency local smoke evacuators in addition to general room ventilation, which must contain a high-efficiency particulate air (HEPA) filter or equivalent.¹³ Smoke evacuation has been considered an effective and beneficial method for reducing surgical smoke. It has been proven to be the most effective way to lower the potentially hazardous effects of electrosurgical and laser plumes.^11,16 Despite the lack of guidelines regarding respirator usage during surgical procedures, it is clear that NIOSH-approved respirators or N95 masks offer the most significant protection against surgical plumes generated by electrocautery, lasers, or ultrasonic scalpels.¹⁷ Survey data showed that healthcare providers underestimated N95 face masks (n = 141, 41%) as a protective measure against surgical plumes, considered carriers for HPV-DNA. To develop behavior-changing interventions, it’s imperative to perform a root cause analysis that uncovers the underlying attitudes and beliefs influencing their actions.

It has been estimated that nearly half a million of healthcare providers are exposed to surgical smoke annually by the American Occupational Safety and Health Administration. This estimation signifies that occupational exposure to HPV is a growing concern for governing bodies and providers in healthcare.^17,18 In reaction to this warning, the ASCCP recommended HPV vaccinations for healthcare providers treating HPV-related lesions; however, only 30% of healthcare providers in this survey were aware of that recommendation.^7,9 The consumption of health-related videos on social media in the United States has been on the rise.¹⁹ Developing effective social media strategies is crucial in spreading awareness of national oncology recommendations on HPV exposure and vaccination among healthcare providers.

Surprisingly, even if it was believed that the human papillomavirus vaccine was safe, it was unveiled in this survey that 59% of the healthcare providers were unvaccinated, of whom 43.3% were ≤45 y. Although ACOG announced HPV vaccine is safe and effective, vaccine hesitancy varies across countries and healthcare providers.^20,21 The worldwide acceptance and uptake of HPV vaccines have been impacted by a multitude of factors.²² This might stem from the lack of knowledge about the vaccine and its safety, which could be overcome through vocational education.²³ The Health Belief Model (HBM) theory has been used to explore the dynamics of human behavior in regards to vaccination.²⁴ Recent studies have revealed that the perception of susceptibility, severity, benefit, self-efficacy, and behavioral intention plays a crucial role in determining the uptake of HPV vaccination. Prioritizing the elements of the HBM might effectively increase HPV vaccination rates among healthcare workers.^22,25 All in the healthcare system should be vaccinated, especially those ≤45 y. Employers are responsible for advocating for their staff and making the vaccine readily available. It was revealed in this survey analysis that most employees would welcome this if vaccination was provided. One of the main barriers to HPV vaccination is the high cost of the three-dose vaccine series, which has negatively impacted the elements of the HBM.²² The three dose vaccine series should be covered without financial burden to the employee at risk.

Strengths and limitations

The greatest strength of our survey was pinpointing a neglected subject with well-crafted questions. To the best of our knowledge, our survey is the first to reveal awareness among healthcare providers regarding occupational exposure to HPV, as well as their understanding and attitudes toward vaccination.

The response rate in our survey was 26%, which could have affected the results due to an increased sampling bias. Furthermore, the survey analysis is also prone to both recall and selection bias due to its nature (respondents were contacted by e-mail). The acquiescence bias for our survey was 10% and 21%. The cross-sectional design of the survey provides a fourth-level grade of scientific evidence.

Supplementary Material

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

References