You are the Key to HPV Cancer Prevention Understanding the Burden of HPV Disease, the Importance of the HPV Vaccine Recommendation, and Communicating about.

You are the Keyto HPV Cancer Prevention

Understanding the Burden of HPV Disease, the Importance of the HPV Vaccine Recommendation,

and Communicating about HPV Vaccination

Dana H. GreenwoodChief Nurse ConsultantImmunization DivisionIN State Dept Health

November 7, 2014

Disclosure

I have not financial disclosures or conflicts of interest

Objectives1. Describe the burden of HPV infection in the

United States2. Share best practices for talking with parents

about the HPV vaccine

HPV Rate Girls: 54.1% (series initiation) 34.6% (series completion)

HPV Rate Boys: 18.2% (series initiation) 8.1% (series completion)

HPV INFECTION & DISEASEUnderstanding the Burden

HPV Types Differ in their Disease Associations

Mucosal sites of

infection

Cutaneoussites of

infection

~ 80 Types

“Common” Hand and Foot

Warts

~40 Types

Genital WartsLaryngeal PapillomasLow Grade Cervical

Disease

Low risk (non-oncogenic)HPV 6, 11

High risk (oncogenic)HPV 16, 18

Cervical Cancer Anogenital Cancers

Oropharyngeal Cancer Cancer Precursors Low Grade Cervical

Disease

HPV Infection

Most females and males will be infected with at least one type of HPV at some point in their lives Estimated 79 million Americans currently infected 14 million new infections/year in the US HPV infection is most common in people in their teens and

early 20s

Most people will never know that they have been infected

Jemal A et al. J Natl Cancer Inst 2013;105:175-201

Cancers Attributed to HPV, U.S.

CDC, United States Cancer Statistics (USCS), 2006-2010

Cancer site

Average number of cancers per year in sites where HPV

is often found

Percentage of cancers per year probably caused

by HPV

Average number of cancers per year probably caused

by HPV†

Male Female Both Sexes Male Female

Both Sexes

Anus 1,549 2,821 4,370 91% 1,400 2,600 4,000

Cervix 0 11,422 11,422 91% 0 10,400 10,400

Oropharynx 9,974 2,443 12,417 72% 7,200 1,800 9,000

Penis 1,048 0 1,048 63% 700 0 700

Vagina 0 735 735 75% 0 600 600

Vulva 0 3,168 3,168 69% 0 2,200 2,200

TOTAL 12,571 20,589 33,160 9,300 17,600 26,900

Average Number of New Cancers Probably Caused by HPV, by Sex, United States 2006-2010

CDC, United States Cancer Statistics (USCS), 2006-2010

Women (n = 17,600)

Oropharynxn=1,80010%

Anusn=2,60015%

Cervixn=10,40059%

Vaginan=6003%

Vulva n=2,200 13%

Men (n = 9,300)

Anusn=1,40015%

Oropharynxn=7,20077%

Penisn=7008%

HPV VACCINEEvidence-Based HPV Prevention

HPV Prophylactic Vaccines

HPV Virus-Like Particle

Recombinant L1 capsid proteins that form “virus-like” particles (VLP)

Non-infectious and non-oncogenic

Produce higher levels of neutralizing antibody than natural infection

HPV VaccineQuadrivalent/HPV4

(Gardasil) Name Bivalent/HPV2(Cervarix)

Merck Manufacturer GlaxoSmithKline

6, 11, 16, 18 Types 16, 18

Females: Anal, cervical, vaginal and vulvar precancer

and cancer; Genital warts Males: Anal precancer and

cancer; Genital warts

IndicationsFemales: Cervical precancer and

cancerMales: Not approved for use in

males

Hypersensitivity to yeast ContraindicationsHypersensitivity to latex (latex

only contained in pre-filled syringes, not single-dose vials)

3 dose series: 0, 2, 6 months Schedule (IM) 3 dose series: 0, 1, 6 months

ACIP Recommendation and AAP Guidelines for HPV Vaccine

Routine HPV vaccination recommended for both males and females ages 11-12 years

Also ages 13-21 years for males; 13-26 for females

Vaccine can be given starting at age 9 years of age for both males and females; vaccine can be given ages 22-26 years for males

CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2007;56(RR02):1-24.

HPV Vaccination Schedule

ACIP Recommended schedule is 0, 1-2*, 6 months Following the recommended schedule is

preferred Minimum intervals

4 weeks between doses 1 and 2 12 weeks between doses 2 and 324 weeks between doses 1 and 3

Administer IM

CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2014;63(RR05):1-30.

HPV Vaccine Is Safe, Effective, and Provides Lasting Protection

HPV Vaccine is SAFE Safety studies findings for HPV vaccine similar to safety

reviews of MCV4 and Tdap vaccines HPV Vaccine WORKS

Vast reductions in high grade cervical lesions decline in Australia

80% of school aged girls vaccinated Prevalence of vaccine types declines by more than half in US

With only 33% of teens fully vaccinated

HPV Vaccine LASTS Studies suggest that vaccine protection is long-lasting; no

evidence of waning immunityGarland et al, Prev Med 2011; Ali et al, BMJ 2013; Markowitz JID 2013; Nsouli-Maktabi MSMR 2013

HPV VACCINE COVERAGE

Adolescent Vaccination CoverageUnited States, 2006-2013

MMWR 2014; 63(29);625-633.

2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

90

100

86

77.8

57.3

37.6

34.6

13.9

TdapMCV41 HPV girls3 HPV girls1HPV boys3 HPV boys

Survey Year

PercentVaccinated

Missed Opportunities: IndianaFemales Only

HPV Vaccine Series InitiationGirls 13-17 Years, by State, 2013

0

10

20

30

40

50

60

70

80

90

State

Perc

ent

Top 5 reasons for not vaccinating daughter, among parents with no intention to vaccinate

in the next 12 months, NIS-Teen 2013

Lack of knowledge

Not needed or necessary

Safety concern/Side effects

Not recommended

Not sexually active

0 5 10 15 20

Percent

CDC. National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012MMWR 2014; 63(29);625-633.

13%

FRAMING THE CONVERSATIONTalking about HPV vaccine

The Conversations with Parents

1. Give a STRONG recommendation

2. Start conversation early and focus on cancer prevention

3. Offer a personal story

4. Welcome questions from parents, especially about safety

Framing the HPV Vaccine Conversation

Bundle Them Up!

Successful recommendations group all of the adolescent vaccines Recommend HPV vaccine the same way and on the

same day you recommend Tdap and meningococcal vaccines.

A strong recommendation from you is the main reason parents decide to vaccinate Many parents responded that they trusted their child’s

doctor and would get the vaccine for their child as long as they received a recommendation from the doctor

Unpublished CDC data, 2013.

Surely, this kid isn’t going to be having sex anytime soon, right? Guess again.

47% of high school students have already engaged in sexual intercourse (vaginal-penile) 6% of these students had sexual intercourse

before age 13 years 1/3 of 9th graders and 2/3 of 12th graders have

engaged in sexual intercourse 1 in 7 high school students (all grades) have had

sexual intercourse with 4 or more partnersJemal A et al. J Natl Cancer Inst 2013;105:175-201Kahn. MMWR. 2014; 63(4)

Rationale for vaccinating early: Protection prior to exposure to HPV

HPV VaccineDuration of Immunity

Studies suggest that vaccine protection is long-lasting; no evidence of waning immunity Available evidence indicates protection for at least

8-10 years Multiple cohort studies are in progress to monitor

the duration of immunity

Romanowski B. Long term protection against cervical infection with the human papillomavirus: review of currently available vaccines. Hum Vaccin. 2011 Feb;7(2):161-9.

COMMUNICATION TOOLSResources for HPV vaccine conversations

“You Are the Key” HPV portal for Providers

cdc.gov/vaccines/YouAreTheKey

Factsheets Resources for Patients

cdc.gov/vaccines/who/teens/products/print-materials.html

Adolescent Immunization Schedule

cdc.gov/vaccines/schedules/easy-to-read/preteen-teen.html

Resources for Patients

Vaccines for Preteens and Teens Website

cdc.gov/vaccines/teens

Resources for Patients

Acknowledgments

A BIG thank you to the CDC’s adolescent vaccination team for contributing the slides for today’s presentation!

HPV VACCINE IS CANCER

PREVENTIONAnd YOU are the key!

#WeCanStopHPV