9vHPV vaccine: Prevention of oropharyngeal cancer

In 2020, the US Food and Drug Administration (FDA) approved the 9-valent human papillomavirus (9vHPV) vaccine for the prevention of oropharyngeal cancer. The 9vHPV vaccine contains inactive L1 capsid proteins for 9 HPV types, including types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The vaccine stimulates the production of neutralizing antibodies to the capsid protein.

9vHPV is approved for females aged 9 to 45 years to prevent cancers and precancers of the cervix, vulva, vagina, and anus caused by HPV types 16, 18, 31, 33, 45, 52, and 58.¹ It is also approved for males aged 9 to 45 years to prevent cancer and precancers of the anus caused by those viral types. In 2020 the 9vHPV vaccine was approved by the FDA to prevent oropharyngeal cancer in males and females. Of note, the FDA reported that, “the oropharyngeal and head and neck cancer indication is approved under accelerated approval based on effectiveness in preventing HPV-related anogenital disease. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.”²

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of girls and boys, 11 to 12 years of age.¹ Children with a history of sexual abuse or assault can start the vaccine at 9 years of age. Catch-up vaccination is recommended for all females and males through age 26 years. The ACIP recommends shared clinical decision-making regarding vaccination for some adults 27 to 45 years of age. Gynecologists with routine exposure to HPV may have occupational risk that warrants HPV vaccination³ (see “As a gynecologist, should you receive the 9vHPV vaccine?”).

For most individuals who start the vaccine series before age 15, two doses of 9vHPV vaccine are recommended, with the second dose 6 to 12 months following the first dose. For teens and adults aged 15 to 26 years, 3 doses of 9vHPV vaccine are recommended, with the second dose 1 to 2 months later and the third dose 6 months following the first dose. Immunocompromised individuals 9 to 26 years of age, including those with HIV infection, should receive 3 doses of the vaccine.

References

1. Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:698-702.

2. Gardasil 9 [package insert]. Whitehouse Station, NJ: Merck & Co. Inc; 2020.

3. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

Surgical treatment of tissues infected with human papillomavirus (HPV) often involves the use of laser or electrosurgical devices that generate smoke, which is known to contain HPV nucleic acid sequences and may contain infective virions.¹ It is known that HPV nucleic acid sequences are present in surgical smoke. In one study plantar warts were treated with a carbon dioxide laser or electrocoagulation. The vapor produced from the surgery was collected with a dry filter apparatus. Five of 8 laser-derived vapors and 4 of 7 electrocoagulation-derived vapors were positive for HPV DNA. The concentration of HPV DNA was greater with laser than with electrocoagulation treatment.²

It is not known if surgical smoke derived from treatment of HPV-infected tissues contains infective HPV virions. In an experimental bovine model, smoke generated by laser ablation of fibropapillomas was collected. Injection of the contents of the smoke caused cutaneous papillomavirus lesions when inoculated into calves, suggesting that the smoke contained infective HPV virions.³ Although this animal experiment is a proof of principle that surgical smoke generated from treatment of HPVinfected tissue contain virions, it is unclear if surgical smoke generated in gynecologic practice contains HPV virions.

To investigate the prevalence of nasal HPV DNA among gynecologists, 700 physicians in Zhejiang Province, China, completed a questionnaire and provided a nasal swab for HPV DNA analysis.⁴ Among gynecologists who performed or did not perform LEEP, the prevalence of HPV DNA in the nose was 10% and 3%, respectively. The most common HPV types detected were HPV16 (76%), HPV31 (10%), HPV58 (5%), HPV55 (5%), HPV56 (2%), and HPV59 (2%).⁴ Among gynecologists who performed LEEP procedures, the prevalence of HPV DNA was 19% for those who did not use a surgical mask, 8% for clinicians who used a standard surgical mask, and 0% for those who used an N95 filtering facepiece respirator, suggesting that an N95 respirator provides the greatest protection from surgical smoke.⁴ Over 24 months of follow-up, all the gynecologists who had initially tested positive for HPV DNA no longer had detectable nasal HPV DNA. In this study, no gynecologist was diagnosed with an HPV-associated oropharyngeal disease. The investigators concluded that surgical masks, especially an N95 respirator, should be used by gynecologists performing LEEP procedures.

Investigators also have evaluated for the presence of HPV DNA in matched samples from the cervix of 134 patients undergoing loop electrosurgical excision procedure (LEEP) for cervical dysplasia, as well as the smoke generated during the procedure and nasal swabs from the surgeon performing the LEEP.⁵ HPV DNA was detected in 95% of the cervical samples, 30% of the surgical smoke samples, and 1.5% of the surgeons’ nasal swabs.⁵ At 6 months of follow-up, the two surgeons who initially had HPV-positive nasal swabs no longer had detected HPV DNA.

Of concern is that otolaryngologists have reported sporadic cases of oropharyngeal squamous cell cancer⁶ and laryngeal papillomatosis⁷ in health care workers with frequent and repetitive exposure to HPVs. For example, in one case report, a 53-year-old male gynecologist, nonsmoker, presented to his physician with a lump on the neck.⁶ The gynecologist had performed more than 3,000 laser ablation or LEEP procedures of dysplastic cervical, vaginal, and vulvar lesions over a span of 20 years.⁶ Most of the procedures were performed without wearing a mask and in a poorly ventilated procedure room. A computed tomography scan demonstrated a 2.2-cm soft tissue lesion in the right tonsil extending to the right soft palate and a level-2 lymph node. A biopsy of the tonsil confirmed invasive squamous cell carcinoma containing HPV16. He was treated with 35 fractions of radiotherapy and adjuvant cisplatin. Treatment adverse effects included dysphagia and xerostomia, and the patient lost 40 pounds.

Available interventions to reduce exposure of clinicians to HPV virions that may be present in surgical smoke include:

• wearing a fit-tested N95 respirator  
• routinely using a smoke evacuation device, and
• ensuring sufficient ventilation in the procedure room.

A new recommendation is to consider 9vHPV vaccination for clinicians who are routinely exposed to HPV virions.^8,9 In February 2020, the American Society for Colposcopy and Cervical Pathology recommended that clinicians who are routinely exposed to HPVs consider 9vHPV vaccination.⁸ This recommendation pertains to all members of the clinical team in the procedure room, including physicians, nurses, and staff. Based on the available data, gynecologists who have not been vaccinated will need to weigh the benefits and costs of receiving a 9vHPV vaccine to protect themselves against an occupational exposure that may adversely impact their health.

References

1. Liu Y, Song Y, Hu X, et al. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among gynecologists. J Cancer. 2019;10:2788-2799.
2. Sawchuk WS, Weber PJ, Lowy DR, et al. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 1989;21:41-49.
3. Garden JM, O’Banion MK, Bakus AD, et al. Viral transmitted by laser-generated plume (aerosol). Arch Dermatol. 2002;138:1303-1307.
4. Hu X, Zhou Q, Yu J, et al. Prevalence of HPV infections in surgical smoke exposed gynecologists. Int Arch Occup Environ Health. 2020; Epub September 1. doi: 10.1007 /s00420-020-01568-9.
5. Zhou Q, Hu X, Zhou J, et al. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Manag Res. 2019;11:3643-3654.
6. Rioux M, Garland A, Webster D, et al. HPV-positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg. 2013;42:54-57.
7. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol. 1991;248:425-427.

8. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. www.asccp.org/Assets/d3abdb05-25c5-4e58-%209cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

9. Harrison R, Huh W. Occupational exposure to human papillomavirus and vaccination for health care workers. Obstet Gynecol. 2020;136:663-665

In 2020, the US Food and Drug Administration (FDA) approved the 9-valent human papillomavirus (9vHPV) vaccine for the prevention of oropharyngeal cancer. The 9vHPV vaccine contains inactive L1 capsid proteins for 9 HPV types, including types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The vaccine stimulates the production of neutralizing antibodies to the capsid protein.

9vHPV is approved for females aged 9 to 45 years to prevent cancers and precancers of the cervix, vulva, vagina, and anus caused by HPV types 16, 18, 31, 33, 45, 52, and 58.¹ It is also approved for males aged 9 to 45 years to prevent cancer and precancers of the anus caused by those viral types. In 2020 the 9vHPV vaccine was approved by the FDA to prevent oropharyngeal cancer in males and females. Of note, the FDA reported that, “the oropharyngeal and head and neck cancer indication is approved under accelerated approval based on effectiveness in preventing HPV-related anogenital disease. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.”²

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of girls and boys, 11 to 12 years of age.¹ Children with a history of sexual abuse or assault can start the vaccine at 9 years of age. Catch-up vaccination is recommended for all females and males through age 26 years. The ACIP recommends shared clinical decision-making regarding vaccination for some adults 27 to 45 years of age. Gynecologists with routine exposure to HPV may have occupational risk that warrants HPV vaccination³ (see “As a gynecologist, should you receive the 9vHPV vaccine?”).

For most individuals who start the vaccine series before age 15, two doses of 9vHPV vaccine are recommended, with the second dose 6 to 12 months following the first dose. For teens and adults aged 15 to 26 years, 3 doses of 9vHPV vaccine are recommended, with the second dose 1 to 2 months later and the third dose 6 months following the first dose. Immunocompromised individuals 9 to 26 years of age, including those with HIV infection, should receive 3 doses of the vaccine.

References

1. Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:698-702.

2. Gardasil 9 [package insert]. Whitehouse Station, NJ: Merck & Co. Inc; 2020.

3. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

Surgical treatment of tissues infected with human papillomavirus (HPV) often involves the use of laser or electrosurgical devices that generate smoke, which is known to contain HPV nucleic acid sequences and may contain infective virions.¹ It is known that HPV nucleic acid sequences are present in surgical smoke. In one study plantar warts were treated with a carbon dioxide laser or electrocoagulation. The vapor produced from the surgery was collected with a dry filter apparatus. Five of 8 laser-derived vapors and 4 of 7 electrocoagulation-derived vapors were positive for HPV DNA. The concentration of HPV DNA was greater with laser than with electrocoagulation treatment.²

It is not known if surgical smoke derived from treatment of HPV-infected tissues contains infective HPV virions. In an experimental bovine model, smoke generated by laser ablation of fibropapillomas was collected. Injection of the contents of the smoke caused cutaneous papillomavirus lesions when inoculated into calves, suggesting that the smoke contained infective HPV virions.³ Although this animal experiment is a proof of principle that surgical smoke generated from treatment of HPVinfected tissue contain virions, it is unclear if surgical smoke generated in gynecologic practice contains HPV virions.

To investigate the prevalence of nasal HPV DNA among gynecologists, 700 physicians in Zhejiang Province, China, completed a questionnaire and provided a nasal swab for HPV DNA analysis.⁴ Among gynecologists who performed or did not perform LEEP, the prevalence of HPV DNA in the nose was 10% and 3%, respectively. The most common HPV types detected were HPV16 (76%), HPV31 (10%), HPV58 (5%), HPV55 (5%), HPV56 (2%), and HPV59 (2%).⁴ Among gynecologists who performed LEEP procedures, the prevalence of HPV DNA was 19% for those who did not use a surgical mask, 8% for clinicians who used a standard surgical mask, and 0% for those who used an N95 filtering facepiece respirator, suggesting that an N95 respirator provides the greatest protection from surgical smoke.⁴ Over 24 months of follow-up, all the gynecologists who had initially tested positive for HPV DNA no longer had detectable nasal HPV DNA. In this study, no gynecologist was diagnosed with an HPV-associated oropharyngeal disease. The investigators concluded that surgical masks, especially an N95 respirator, should be used by gynecologists performing LEEP procedures.

Investigators also have evaluated for the presence of HPV DNA in matched samples from the cervix of 134 patients undergoing loop electrosurgical excision procedure (LEEP) for cervical dysplasia, as well as the smoke generated during the procedure and nasal swabs from the surgeon performing the LEEP.⁵ HPV DNA was detected in 95% of the cervical samples, 30% of the surgical smoke samples, and 1.5% of the surgeons’ nasal swabs.⁵ At 6 months of follow-up, the two surgeons who initially had HPV-positive nasal swabs no longer had detected HPV DNA.

Of concern is that otolaryngologists have reported sporadic cases of oropharyngeal squamous cell cancer⁶ and laryngeal papillomatosis⁷ in health care workers with frequent and repetitive exposure to HPVs. For example, in one case report, a 53-year-old male gynecologist, nonsmoker, presented to his physician with a lump on the neck.⁶ The gynecologist had performed more than 3,000 laser ablation or LEEP procedures of dysplastic cervical, vaginal, and vulvar lesions over a span of 20 years.⁶ Most of the procedures were performed without wearing a mask and in a poorly ventilated procedure room. A computed tomography scan demonstrated a 2.2-cm soft tissue lesion in the right tonsil extending to the right soft palate and a level-2 lymph node. A biopsy of the tonsil confirmed invasive squamous cell carcinoma containing HPV16. He was treated with 35 fractions of radiotherapy and adjuvant cisplatin. Treatment adverse effects included dysphagia and xerostomia, and the patient lost 40 pounds.

Available interventions to reduce exposure of clinicians to HPV virions that may be present in surgical smoke include:

• wearing a fit-tested N95 respirator  
• routinely using a smoke evacuation device, and
• ensuring sufficient ventilation in the procedure room.

A new recommendation is to consider 9vHPV vaccination for clinicians who are routinely exposed to HPV virions.^8,9 In February 2020, the American Society for Colposcopy and Cervical Pathology recommended that clinicians who are routinely exposed to HPVs consider 9vHPV vaccination.⁸ This recommendation pertains to all members of the clinical team in the procedure room, including physicians, nurses, and staff. Based on the available data, gynecologists who have not been vaccinated will need to weigh the benefits and costs of receiving a 9vHPV vaccine to protect themselves against an occupational exposure that may adversely impact their health.

References

1. Liu Y, Song Y, Hu X, et al. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among gynecologists. J Cancer. 2019;10:2788-2799.
2. Sawchuk WS, Weber PJ, Lowy DR, et al. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 1989;21:41-49.
3. Garden JM, O’Banion MK, Bakus AD, et al. Viral transmitted by laser-generated plume (aerosol). Arch Dermatol. 2002;138:1303-1307.
4. Hu X, Zhou Q, Yu J, et al. Prevalence of HPV infections in surgical smoke exposed gynecologists. Int Arch Occup Environ Health. 2020; Epub September 1. doi: 10.1007 /s00420-020-01568-9.
5. Zhou Q, Hu X, Zhou J, et al. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Manag Res. 2019;11:3643-3654.
6. Rioux M, Garland A, Webster D, et al. HPV-positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg. 2013;42:54-57.
7. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol. 1991;248:425-427.

8. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. www.asccp.org/Assets/d3abdb05-25c5-4e58-%209cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

9. Harrison R, Huh W. Occupational exposure to human papillomavirus and vaccination for health care workers. Obstet Gynecol. 2020;136:663-665

In 2020, the US Food and Drug Administration (FDA) approved the 9-valent human papillomavirus (9vHPV) vaccine for the prevention of oropharyngeal cancer. The 9vHPV vaccine contains inactive L1 capsid proteins for 9 HPV types, including types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The vaccine stimulates the production of neutralizing antibodies to the capsid protein.

9vHPV is approved for females aged 9 to 45 years to prevent cancers and precancers of the cervix, vulva, vagina, and anus caused by HPV types 16, 18, 31, 33, 45, 52, and 58.¹ It is also approved for males aged 9 to 45 years to prevent cancer and precancers of the anus caused by those viral types. In 2020 the 9vHPV vaccine was approved by the FDA to prevent oropharyngeal cancer in males and females. Of note, the FDA reported that, “the oropharyngeal and head and neck cancer indication is approved under accelerated approval based on effectiveness in preventing HPV-related anogenital disease. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.”²

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of girls and boys, 11 to 12 years of age.¹ Children with a history of sexual abuse or assault can start the vaccine at 9 years of age. Catch-up vaccination is recommended for all females and males through age 26 years. The ACIP recommends shared clinical decision-making regarding vaccination for some adults 27 to 45 years of age. Gynecologists with routine exposure to HPV may have occupational risk that warrants HPV vaccination³ (see “As a gynecologist, should you receive the 9vHPV vaccine?”).

For most individuals who start the vaccine series before age 15, two doses of 9vHPV vaccine are recommended, with the second dose 6 to 12 months following the first dose. For teens and adults aged 15 to 26 years, 3 doses of 9vHPV vaccine are recommended, with the second dose 1 to 2 months later and the third dose 6 months following the first dose. Immunocompromised individuals 9 to 26 years of age, including those with HIV infection, should receive 3 doses of the vaccine.

References

1. Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:698-702.

2. Gardasil 9 [package insert]. Whitehouse Station, NJ: Merck & Co. Inc; 2020.

3. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

Surgical treatment of tissues infected with human papillomavirus (HPV) often involves the use of laser or electrosurgical devices that generate smoke, which is known to contain HPV nucleic acid sequences and may contain infective virions.¹ It is known that HPV nucleic acid sequences are present in surgical smoke. In one study plantar warts were treated with a carbon dioxide laser or electrocoagulation. The vapor produced from the surgery was collected with a dry filter apparatus. Five of 8 laser-derived vapors and 4 of 7 electrocoagulation-derived vapors were positive for HPV DNA. The concentration of HPV DNA was greater with laser than with electrocoagulation treatment.²

It is not known if surgical smoke derived from treatment of HPV-infected tissues contains infective HPV virions. In an experimental bovine model, smoke generated by laser ablation of fibropapillomas was collected. Injection of the contents of the smoke caused cutaneous papillomavirus lesions when inoculated into calves, suggesting that the smoke contained infective HPV virions.³ Although this animal experiment is a proof of principle that surgical smoke generated from treatment of HPVinfected tissue contain virions, it is unclear if surgical smoke generated in gynecologic practice contains HPV virions.

To investigate the prevalence of nasal HPV DNA among gynecologists, 700 physicians in Zhejiang Province, China, completed a questionnaire and provided a nasal swab for HPV DNA analysis.⁴ Among gynecologists who performed or did not perform LEEP, the prevalence of HPV DNA in the nose was 10% and 3%, respectively. The most common HPV types detected were HPV16 (76%), HPV31 (10%), HPV58 (5%), HPV55 (5%), HPV56 (2%), and HPV59 (2%).⁴ Among gynecologists who performed LEEP procedures, the prevalence of HPV DNA was 19% for those who did not use a surgical mask, 8% for clinicians who used a standard surgical mask, and 0% for those who used an N95 filtering facepiece respirator, suggesting that an N95 respirator provides the greatest protection from surgical smoke.⁴ Over 24 months of follow-up, all the gynecologists who had initially tested positive for HPV DNA no longer had detectable nasal HPV DNA. In this study, no gynecologist was diagnosed with an HPV-associated oropharyngeal disease. The investigators concluded that surgical masks, especially an N95 respirator, should be used by gynecologists performing LEEP procedures.

Investigators also have evaluated for the presence of HPV DNA in matched samples from the cervix of 134 patients undergoing loop electrosurgical excision procedure (LEEP) for cervical dysplasia, as well as the smoke generated during the procedure and nasal swabs from the surgeon performing the LEEP.⁵ HPV DNA was detected in 95% of the cervical samples, 30% of the surgical smoke samples, and 1.5% of the surgeons’ nasal swabs.⁵ At 6 months of follow-up, the two surgeons who initially had HPV-positive nasal swabs no longer had detected HPV DNA.

Of concern is that otolaryngologists have reported sporadic cases of oropharyngeal squamous cell cancer⁶ and laryngeal papillomatosis⁷ in health care workers with frequent and repetitive exposure to HPVs. For example, in one case report, a 53-year-old male gynecologist, nonsmoker, presented to his physician with a lump on the neck.⁶ The gynecologist had performed more than 3,000 laser ablation or LEEP procedures of dysplastic cervical, vaginal, and vulvar lesions over a span of 20 years.⁶ Most of the procedures were performed without wearing a mask and in a poorly ventilated procedure room. A computed tomography scan demonstrated a 2.2-cm soft tissue lesion in the right tonsil extending to the right soft palate and a level-2 lymph node. A biopsy of the tonsil confirmed invasive squamous cell carcinoma containing HPV16. He was treated with 35 fractions of radiotherapy and adjuvant cisplatin. Treatment adverse effects included dysphagia and xerostomia, and the patient lost 40 pounds.

Available interventions to reduce exposure of clinicians to HPV virions that may be present in surgical smoke include:

• wearing a fit-tested N95 respirator  
• routinely using a smoke evacuation device, and
• ensuring sufficient ventilation in the procedure room.

A new recommendation is to consider 9vHPV vaccination for clinicians who are routinely exposed to HPV virions.^8,9 In February 2020, the American Society for Colposcopy and Cervical Pathology recommended that clinicians who are routinely exposed to HPVs consider 9vHPV vaccination.⁸ This recommendation pertains to all members of the clinical team in the procedure room, including physicians, nurses, and staff. Based on the available data, gynecologists who have not been vaccinated will need to weigh the benefits and costs of receiving a 9vHPV vaccine to protect themselves against an occupational exposure that may adversely impact their health.

References

1. Liu Y, Song Y, Hu X, et al. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among gynecologists. J Cancer. 2019;10:2788-2799.
2. Sawchuk WS, Weber PJ, Lowy DR, et al. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 1989;21:41-49.
3. Garden JM, O’Banion MK, Bakus AD, et al. Viral transmitted by laser-generated plume (aerosol). Arch Dermatol. 2002;138:1303-1307.
4. Hu X, Zhou Q, Yu J, et al. Prevalence of HPV infections in surgical smoke exposed gynecologists. Int Arch Occup Environ Health. 2020; Epub September 1. doi: 10.1007 /s00420-020-01568-9.
5. Zhou Q, Hu X, Zhou J, et al. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Manag Res. 2019;11:3643-3654.
6. Rioux M, Garland A, Webster D, et al. HPV-positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg. 2013;42:54-57.
7. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol. 1991;248:425-427.

8. Stockdale CK, Einstein MH, Huh WK. ASCCP recommends HPV vaccination for providers. February 19, 2020. www.asccp.org/Assets/d3abdb05-25c5-4e58-%209cec-05c11fb2b920/637177876310030000/hpv-vaccinemember-announcment-02-19-20-pdf. Accessed October 23, 2020.

9. Harrison R, Huh W. Occupational exposure to human papillomavirus and vaccination for health care workers. Obstet Gynecol. 2020;136:663-665