Transcript Slide 1

INCREASING ADOLESCENT HPV UPTAKE
Gale R Burstein, MD, MPH, FAAP
Erie County Department of Health
SUNY at Buffalo School of Medicine
QUESTIONS
Let’s get to know each other!
Raise your hand if you work in a….
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Community health center or physician office
Health department
Hospital
School based health center
College health
Other
Raise your hand if you are a……
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Physician
NP or PA
Nurse
Health educator
Other
Raise your hand if your clinical site offers
HPV vaccine
Raise your hand if the estimated % of HPV
vaccine refusers are
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0~%
~25%
~50%
>75%
Vaccines
• 2 FDA-licensed HPV vaccines
• Cervarix
o bivalent HPV vaccine
• prevents HPV types 16/18
o licensed for ♀
• Gardasil
o quadrivalent HPV vaccine
• prevents HPV types 16/18 & 6/11
o licensed for ♂ & ♀
ACIP HPV recommendations
• All 11 and 12 yo ♀ and ♂
o Can begin as young as age 9 yrs
• Catch – up vaccines for all 13-21 yo ♀ and ♂ who
not already vaccinated
• All 22-26 yo ♀
• All MSM and immunocompromised ♂
o i.e., routine vaccination for 22-26 yo ♂ with risk factors
• Permissive recommendation for 22-26 yo ♂
without risk factors
♂ HPV Cost Effectiveness
• Goal: estimate the cost-effectiveness of
adding HPV of 12 yo ♂ to ♀-only vaccination
program for ages 12–26 yo in US
• Methods:
o CEA
o The HPV-associated outcomes:
• FDA-indicated: CIN; genital warts; cervical, vaginal,
vulvar, & anal CA
• nonFDA-indicated: oropharyngeal & penile CA; RRP
Chesson HW, et al. Vaccine 2011;29:8443–50.
CEA Findings
• HPV immunization of 12 yo ♂ cost-effective,
particularly if
o ♀ HPV4 coverage is low
o all potential HPV vaccine health benefits included
in analysis
•  ♀ coverage more efficient strategy than ♂
vaccination to  overall HPV health burden
Chesson HW, et al. Vaccine 2011;29:8443–50.
Cost-effectiveness of male vaccination*
Cost per QALY gained by vaccinating 12 year-old boys
Indicated outcomes only
All outcomes
$160,000
Cost per QALY gained
$140,000
$120,000
$100,000
$80,000
$60,000
$40,000
$20,000
$0
Lower coverage scenario
Higher coverage scenario
*Includes transmission effects to females
“Indicated” outcomes include cervical outcomes, vaginal, vulvar, anal cancers, and genital warts. All outcomes
include indicated outcomes plus oropharyngeal cancer, penile cancer, and recurrent respiratory papillomatosis.
Lower coverage scenario: 30% 3-dose coverage at age 12 and 50% 3-dose coverage by age 26. Higher coverage
scenario: 50% 3-dose coverage at age 12 and 70% 3-dose coverage by age 26.
*Chesson HW, et al Vaccine 2011
Number of lifetime cancer cases averted by vaccinating
1 million males in a birth cohort
Excludes indirect effects (herd immunity). Outcomes are not discounted. Results obtained from Chesson et al model, Vaccine
2011. Vaccine efficacy was assumed to be 90% against HPV 6/11 genital warts and 75% against HPV 16/18 cancers in males.
HPV Disease Burden
It’s bad!!
Genital Warts—Initial Visits to Physicians’
Offices, United States, 1966–2011
NOTE: The relative standard errors for genital warts estimates of more than 100,000 range from 18% to 30%.
SOURCE: IMS Health, Integrated Promotional Services ™. IMS Health Report, 1966–2011.
2011-Fig 53. SR
Human Papillomavirus—Prevalence of High-risk and Low-risk
Types Among Females Aged 14–59 Years, National Health and
Nutrition Examination Survey, 2003–2006
*HPV=human papillomavirus.
NOTE: Error bars indicate 95% confidence intervals. Both high-risk and low-risk HPV types were detected in some females.
SOURCE: Hariri S, Unger ER, Sternberg M, Dunne EF, Swan D, Patel S, et al. Prevalence of genital HPV among females in
the United States, the National Health and Nutrition Examination Survey, 2003-2006. J Infect Dis. 2011;204(4):566-73
2011-Fig 52. SR
Genital HPV Prevalence Rates in Males
(%)
years
Males aged 18–44 years in Tucson, Arizona (N = 290).
High-risk/oncogenic HPV types included 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66. Low-risk/non-oncogenic HPV types included 6, 11, 26, 40, 42, 53, 54,
55,62, 64, 67–73, 81–84, IS39, CP6108.
Giuliano AR et al. J Infect Dis. 2008;198:827–835.
Age-Specific Anal Canal HPV Prevalence
Among Men Having Sex with Women
Nyitray AR, et al. et al J Infect Dis. 2012;206(2):202-11
The Burden of Anal Cancer is Increasing
Age standardized incidence rates of anal cancer in Denmark
 US anal cancer rates (~2.7%/year);
Nielsen et al, Int J Cancer In Press
Rates ♀ >> ♂
Anal Cancer Affects Women and Men
• Estimated 5,820 ♀ and ♂ in US diagnosed with
anal cancer in 2011
o 3,680 in ♀ and 2,140 in ♂
• > 60% of anal CA cases and deaths occur in ♀
• Anal CA can occur in heterosexual ♂
o 53% of male anal cancers occur in heterosexual ♂
ACS. www.cancer.org/Cancer/AnalCancer/DetailedGude/anal-cancer-what-is-key-statistics
Last update: 10/25/2011
Nielsen IPV 2010
Daling et al Cancer 2004
Prevalence of Oral HPV Infection
in the United States, 2009-2010
Gillison ML, et al. JAMA 2012;307(7):693-703.
Prevalence of Oral HPV Infection
Methods
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2009-2010 NHANES survey
♀ & ♂ aged 14 to 69 yrs
Participants (N=5579) provided 30-sec oral rinse
PCR and type-specific hybridization
Demographic and behavioral data by
standardized interview
Gillison ML, et al. JAMA. 2012;307(7):693-703
Prevalence of Oral HPV Infection
Results
• Prevalence all HPV types = 6.9%
o HPV type 16 prevalence = 1.0%
• 85% of HPV-related OP cancers are positive for HPV-16
• Bimodal pattern for age
o 30-34 yo = 7.3%
o 60-64 yo =11.4%
• ♂ (10.1%) >>♀ (3.6%); PR=2.8
Gillison ML, et al. JAMA. 2012;307(7):doi:10.1001/jama.2012.101
Gillison ML, et al. JAMA. 2012;307(7):doi:10.1001/jama.2012.101
What sexual behavior was most associated
with oral HPV?
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Oral sex
Vaginal sex
Any sex
No sex
Oral HPV and Sex
• > 8 x higher in persons report ever having had
sex (7.5%) vs not (0.9%)
•  with  # partners for any kind of sex (vaginal
sex, or oral sex)
• More common among sexually experienced
individuals who did NOT perform oral sex vs.
sexually inexperienced individuals
o consistent with transmission by other sexually
associated contact (eg, deep kissing)
Gillison ML, et al. JAMA. 2012;307(7):693-703
Gillison ML, et al. JAMA. 2012;307(7):doi:10.1001/jama.2012.101
Incidence rates for overall oropharyngeal cancer, HPV–positive oropharyngeal
cancers, and HPV-negative oropharyngeal cancers during 1988 -2004 in
Hawaii, Iowa, and Los Angeles.
Chaturvedi AK, et al.
J Clin Oncol
Oral HPV transmission??!!
Unclear what types of oral
contact are risk
Estimated average annual % and # of cancers attributable
to HPV, by anatomic site and sex — United States, 2004–8
ANATOMIC AVG ANNUAL # % attributable # attributable
AREA
of CASES
to HPV
to HPV
FEMALE
Cervix
11,967
96
11,500
Vagina
729
64
500
Vulva
3,136
51
1,600
Anus
3,089
93
2,900
Oropharynx
2370
63
1,500
TOTAL:FEMALE
21,227
1,754
17,880
MALE
Penis
1,046
36
400
Anus
1678
93
1,600
Oropharynx
9356
63
5,900
TOTAL:MALE
11,553
7490
7080
HPV IMMUNIZATION COVERAGE AND
PREVALENCE AMONG 14-19 YR OLD ♀
PRE- VS POST-HPV VACCINE ERA
Markowitz L E et al. J Infect Dis. 2013;208:385-393
↓ ♀ HPV Among Following U.S. HPV4 Introduction,
NHANES, 2003–2010
• National Health and Nutrition Examination
Surveys (NHANES)
• HPV prevalence data
o vaccine era (2007–2010) vs prevaccine era
(2003–2006)
• Analyzed vaccine types (HPV-6, -11, -16, or 18) for 14–19 yr old ♀
Markowitz L E et al. J Infect Dis. 2013;208:385-393
HPV4 Coverage and Sexual Behavior among
14-19 yr old ♀
• 34% reported >1 HPV4
o 63% of vaccinated had 3 doses
• % 14–19 yr old ♀ reported had sex similar in
pre- vs post-vaccine eras
o 2003–2006: 53.9% (95% CI, 50.8–56.9)
o 2007–2010: 50.3% (95% CI, 45.0–55.5), (P = .24)
o small, nonsignificant differences in lifetime #
partners and race/ethnicity
Markowitz L E et al. J Infect Dis. 2013;208:385-393
HPV4 Prevalence among 14-19 yr old ♀
pre- vs post-HPV vaccine era
????????
HPV4 Prevalence among 14-19 yr old ♀
pre- vs post-HPV vaccine
• Pre-vaccine era 2003–2006 : 11.5%
• Post-vaccine era 2007–2010 : 5.1%
o 56% decline!!!!!!
• No significant decrease in non-vaccine type
HPV prevalence
Prevalence of individual HPV types among ♀ aged 14–19 yrs,
2003–2006 and 2007–2010
Markowitz L E et al. J Infect Dis. 2013;208:385-393
HPV PREVALENCE AMONG SEXUALLY
ACTIVE 14–19 YR OLD ♀ BY
VACCINATION HISTORY
HPV prevalence in pre- vs post-vaccine era
among sexually active 14-19 yr old ♀
• Overall demographic and sexual risk behavior
did not differ between 2 periods
• Overall HPV vaccine type prevalence 53% lower
in post- vs pre-vaccine era
• 88% vaccine type prevalence ↓ among
vaccinated ♀
• Estimated >1 dose vaccine effectiveness = 82%
HOW ARE WE DOING WITH HPV
IMMUNIZATION RATES?
Estimated Vaccination Coverage among 13-17 yr old,
NIS-Teen, US, 2006-20012
2011-12:
No change
2007-2011:
↑rates 6%/yr
www.cdc.gov/mmwr/preview/mmwrhtml/mm6234a1.htm?s_cid=mm6234a1_w
HPV Vaccine Coverage
• ≥1 dose of any HPV vaccine ↑ from 25% in
2007 to 53% in 2011,
o No change in 2012 (54%)
• If HPV vaccine given at visits when another
vaccine given, vaccine coverage for ≥1 dose
would be 93%
• Safety monitoring data continue to indicate
that HPV4 is safe
Human papillomavirus (HPV) vaccination among
females 19–26 yrs (≥1 dose), ever — National Health
Interview Survey, U.S., 2010
25
20
15
%♀ ≥1 dose
% change from 2009
10
5
0
Total
White
Black
Hispanic
Asian
Other
www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm#tab1
HPV vaccination among ♂ (≥1 dose),
ever— National Health Interview Survey,
U.S., 2010
Age
19–26 yrs
19–21 yrs
%
0.6
0.3
www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm#tab1
WHAT WE CAN DO!!!
#1: Education of parents
• 3 of 5 of parents’ main reasons for not
vaccinating daughters indicate gaps in
understanding
o including why vaccination is recommended by
age 13 years
• Parents reported vaccine safety concerns
• Updated CDC educational materials
addressing these issues at
www.cdc.gov/vaccines/who/teens/index.html
www.cdc.gov/vaccines/who/teens/products/print-materials.html
#2: Providers must ↑ consistency &
strength of HPV vaccine recommendations
• Studies show that providers give weaker
recommendations for HPV vaccine vs other
adolescent vaccines
o Especially young adolescents
• Provider counseling and recommendations
greatly influence parental vaccine acceptance
• CDC developed a tip sheet available at
www.cdc.gov/vaccines/who/teens/for-hcptipsheet-hpv.html
#3: missed vaccination opportunities must ↓
• Health-care access is NOT main impediment
• ↑ missed opportunities during 2007–2012 due
to ↑ coverage for other adolescents vaccines
• 2012 NIS-Teen shows 84% of unvaccinated ♀
had health-care visit where another vaccine
given
• If the 3-dose HPV series was started at these
visits, coverage for ≥1 dose would be 93%
Lessons Learned
• High HPV vaccination coverage with
existing infrastructure and health-care
utilization is possible!
• Using every health-care visit, including
acute-care visits, to assess every
adolescent's vaccine status can ↓ missed
opportunities
Office systems changes strategies
• Use vaccination prompts in EMRs
• Check NYSIIS
• Nurse counsels for HPV4 before pt seen
by provider
• Schedule appointments for 2nd & 3rd
doses at 1st HPV dose visit
• Use automated reminder-recall systems
• Assessment of practice-level vaccination
rates with feedback to staff members
LHD Vaccination PROGRAM strategies
• Provider education
o HEDIS measure
• Education of potential vaccine recipients
• Publicity to promote vaccination
• ↑ access to vaccination services in
medical and complementary settings
o Workplaces and pharmacies
HPV Resources
• www.cdc.gov/vaccines/who/teens/for-hcp/hpvresources.html
• www.cdc.gov/vaccines/who/teens/downloads/hcpfactsheet.pdf
• www.health.ny.gov/prevention/immunization/providers
/hpv_q_and_a.htm
• www.health.ny.gov/publications/2110.pdf
• www.cdc.gov/vaccines/who/teens/for-hcp-tipsheethpv.pdf
• www.cdc.gov/vaccines/vpd-vac/hpv/downloads/disHPV-color-office.pdf
• www.cdc.gov/vaccines/vpd-vac/hpv/downloads/PL-dispreteens-hpv.pdf
QUESTIONS?
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