Transcript You are the Keyto HPV Cancer PreventionUnderstanding the

You are the Key
to HPV Cancer Prevention
Understanding the Burden of HPV Disease,
the Importance of the HPV Vaccine Recommendation,
and Communicating about HPV Vaccination
Dana H. Greenwood
Chief Nurse Consultant
Immunization Division
IN State Dept Health
November 7, 2014
Disclosure
I have not financial disclosures or
conflicts of interest
Objectives
1. Describe the burden of HPV infection in the
United States
2. 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)
Understanding the Burden
HPV INFECTION & DISEASE
HPV Types Differ in their
Disease Associations
~40 Types
Mucosal
sites of infection
High risk (oncogenic)
HPV 16, 18
Cervical Cancer
Anogenital Cancers
Oropharyngeal Cancer
Cancer Precursors
Low Grade Cervical Disease
Cutaneous
sites of infection
~ 80 Types
Low risk (non-oncogenic)
HPV 6, 11
Genital Warts
Laryngeal Papillomas
Low Grade Cervical Disease
“Common”
Hand and Foot
Warts
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.
Average number of cancers
per year in sites where HPV
is often found
Cancer site Male
Anus
Female
Both
Sexes
Average number of cancers
per year probably caused
by HPV†
Percentage of
cancers per year
probably caused
by HPV
Male
Female
Both
Sexes
1,549
2,821
4,370
91%
1,400
2,600
4,000
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
Cervix
CDC, United States Cancer Statistics (USCS), 2006-2010
Average Number of New Cancers Probably Caused by HPV,
by Sex, United States 2006-2010
Vagina
n=600
3%
Penis
n=700
8%
Vulva
Anus
n=2,200 n=2,600
13%
15%
Oropharynx
n=1,800
10%
Anus
n=1,400
15%
Cervix
n=10,400
59%
Oropharynx
n=7,200
77%
Women (n = 17,600)
Men (n = 9,300)
CDC, United States Cancer Statistics (USCS), 2006-2010
Evidence-Based HPV Prevention
HPV VACCINE
HPV Prophylactic Vaccines
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 Virus-Like Particle
HPV Vaccine
Quadrivalent/HPV4
(Gardasil)
Merck
6, 11, 16, 18
Females: Anal, cervical,
vaginal and vulvar precancer
and cancer; Genital warts
Males: Anal precancer and
cancer; Genital warts
Name
Manufacturer
Types
Bivalent/HPV2
(Cervarix)
GlaxoSmithKline
16, 18
Indications
Females: Cervical precancer and
cancer
Males: Not approved for use in
males
Hypersensitivity to yeast
Contraindications
Hypersensitivity 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 3
24 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 immunity
Garland et al, Prev Med 2011; Ali et al, BMJ 2013; Markowitz JID 2013; Nsouli-Maktabi MSMR 2013
HPV VACCINE COVERAGE
Adolescent Vaccination Coverage
United States, 2006-2013
100
90
86
80
77.8
70
60
57.3
Percent
50
Vaccinated
40
37.6
30
34.6
MCV4
1 HPV girls
3 HPV girls
1HPV boys
3 HPV boys
20
13.9
10
0
2006
MMWR 2014; 63(29);625-633.
Tdap
2007
2008
2009
2010
Survey Year
2011
2012
2013
Missed Opportunities: Indiana
Females Only
Kansas
Arkansas
Utah
Montana
New Jersey
Missouri
Kentucky
Tennessee
Florida
West Virginia
Maryland
Virginia
Alaska
Hawaii
Mississippi
Illinois
Georgia
Nevada
Indiana
Wyoming
Alabama
Ohio
Oklahoma
Idaho
DC
Connecticut
South Dakota
Texas
Iowa
North Dakota
Colorado
Minnesota
North Carolina
Wisconsin
Pennsylvania
Louisiana
Maine
Vermont
South Carolina
Washington
New York
Massachusetts
Arizona
Nebraska
Michigan
Oregon
New Mexico
California
New Hampshire
Delaware
Rhode Island
Percent
HPV Vaccine Series Initiation
Girls 13-17 Years, by State, 2013
90
80
70
60
50
40
30
20
10
0
State
Top 5 reasons for not vaccinating daughter,
among parents with no intention to vaccinate
in the next 12 months, NIS-Teen 2013
Not sexually active
Not recommended
13%
Safety concern/Side effects
Not needed or necessary
Lack of knowledge
0
5
10
Percent
CDC. National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012
MMWR 2014; 63(29);625-633.
15
20
Talking about HPV vaccine
FRAMING THE CONVERSATION
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 partners
Jemal A et al. J Natl Cancer Inst 2013;105:175-201
Kahn. MMWR. 2014; 63(4)
Rationale for vaccinating early:
Protection prior to exposure to HPV
HPV Vaccine
Duration 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.
Resources for HPV vaccine conversations
COMMUNICATION TOOLS
“You Are the Key” HPV portal for Providers
cdc.gov/vaccines/YouAreTheKey
cdc.gov/vaccines/who/teens/products/print-materials.html
Resources for Patients
Factsheets
cdc.gov/vaccines/schedules/easy-to-read/preteen-teen.html
Resources for Patients
Adolescent Immunization Schedule
Vaccines for Preteens and Teens Website
Resources for Patients
cdc.gov/vaccines/teens
Acknowledgments
A BIG thank you to the CDC’s adolescent
vaccination team for contributing the slides
for today’s presentation!
HPV VACCINE IS
CANCER PREVENTION
And YOU are the key!
#WeCanStopHPV