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David C Fredenburg MD MPH MA AAP Liaison for the NHPS on Immunizations

" You (or We) are the key to HPV cancer prevention!“ Or Maybe Not So Much as We Wish We Were! NH Immunization Program Webinar June 25, 2014. David C Fredenburg MD MPH MA AAP Liaison for the NHPS on Immunizations. HPV Vaccine in NH Teens (13-17) Courtesy of Everett Lamm , MD.

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David C Fredenburg MD MPH MA AAP Liaison for the NHPS on Immunizations

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  1. "You (or We) are the key to HPV cancer prevention!“Or Maybe Not So Much as We Wish We Were!NH Immunization Program Webinar June 25, 2014 David C Fredenburg MD MPH MA AAP Liaison for the NHPS on Immunizations

  2. Fredenburg 2014 HPV Webinar

  3. HPV Vaccine in NH Teens (13-17)Courtesy of Everett Lamm, MD * Series complete: Percent of females and males who received 3 doses among those who had at least 1 HPV dose and at least 24 weeks between the first dose and the interview date. National Immunization Survey 2013, (Teen, 13-17 years) United States, NH results. Fredenburg 2014 HPV Webinar

  4. NHPS & NHMS HPV Grant Survey December 9-10, 2013“Please indicate which of the following best describes your practice:” Fredenburg 2014 HPV Webinar

  5. “Approximately how many prescribing clinicians see patients at your site?” “Which of the following best describes your practice location?” Fredenburg 2014 HPV Webinar

  6. “Do the clinicians or other staff at your site routinely recommend the HPV vaccine for female or male adolescents at 11-12 years of age?” Fredenburg 2014 HPV Webinar

  7. “Do the clinicians or other staff at your site routinely recommend the HPV vaccine for female adolescents at 11-12 years of age? If no, why not?” • do not see patient of that age group • The prison is for men, though we do have a few female inmates within the walls. • we do it at 14, 9th grade • Our adolescent population usually enters our program at age 14 and over. • parents sometimes decline • I did when still seeing out patients • not sure, time factor • I do not know about my partners • Not our age group patients. • Not seeing patients in this age group here • Not sure • Parents more receptive when girls are older around 14 or 15 when they may become sexually active and we are OK with this because our population is not active at such a young age.Also they are getting menactra/menveo around this age plus flu vaccine or hep A and the kids themselves want to space the imms out. • Most of the patients that we see have PCP office and receive that vaccine from them. • We don't see this age group • "They feel that it is a parents personal choice and that the parents should hae the option of having these kinds of discussions with their child first. • On the parents side they seem very reluctant at the earlier ages stating"" we don't need to deal with that yet"" presumingly meaning that they don't need to consider it as the child is not sexually active yet" • Active population is age 14 and older • physicians decided as a group what age group they wanted to start • The providers feel that the age is too young. We begin at age 13 • Sometimes at 11-12 but more commonly offered around 13 • I believe most offer at this time but recommendations are stronger in teen years ~ 14-16. • Not at 11 as we are giving 2-3 other vaccines then. We do start at 12 yrs usually. Fredenburg 2014 HPV Webinar

  8. “Do the clinicians and office staff at your site routinely recommend the HPV vaccine for male adolescents at 11-12 years of age? If no, why not?” • NA • I do, but my partner does not. • I do, but do not know if my partners do. • slow uptake of evidence • They are not seen here prior to age 18 • usually do it later age 14 • The adolescents enter our program at age 14 and older. • same • This may have changed by now • Not yet but we should • not all feel it is that easy to convince the parents. • Same as for females • starting to • difficult subject on STD prevention in this age group. for girls, its more about cancer prevention and easier • I believe this is simply because it has not entered people's consciousness in the same way as for females • usually, there may be some incosistency when it comes to boys • Females only. • slow to adopt new recommendations • same • We do recommend and show them the information when a child comes in for a PE at that age (Physical Exam) and let them decide. There are patients that do not want the vaccine and they are quite clear about the reasons. • just not consistenly • not sure, actually • It is increasing but not something that is as remembered as the females. • same answer as for girls • Do not see male patients. • Followed by outside PCP • We don't see this age group. • forget to • Do not see patients of this age • the physicians decided as a group what age group they wanted to start • again they feel the age is too young • Most do, but some to not promote it as much as I think they should • None of them want it that early... better accepted later at 14-15 • see last comment Fredenburg 2014 HPV Webinar

  9. “Are parents and adolescents knowledgeable about diseases associated with HPV and vaccination before the 11-12 year physical exam?” • “How have they learned this information?” • Sources cited media, internet, commercials, older siblings, general knowledge • Only 18 out of 41 (43.9%) of responses mentioned medical office as source of HPV info Fredenburg 2014 HPV Webinar

  10. What issues are the most difficult in parental or adolescent acceptance of vaccination (at any age)? Fredenburg 2014 HPV Webinar

  11. Lack of Knowledge of HPV-Associated Diseases Fredenburg 2014 HPV Webinar

  12. “With which of the following HPV-related diseases are they (parents/patients) familiar?” Fredenburg 2014 HPV Webinar

  13. Human PapillomavirusAs Common as the Wart on the Nose on Your Face Fredenburg 2014 HPV Webinar

  14. Fredenburg 2014 HPV Webinar

  15. Human Papillomavirus • HPV produces epithelial tumors of the skin & mucous membranes • >100 HPV types are known • 3 clinical categories: • Anogenital or mucosal • Nongenital cutaneous • Epidermodysplasiaverruciformis (EV) Fredenburg 2014 HPV Webinar

  16. Fredenburg 2014 HPV Webinar

  17. HPV Genital Wart Burden • Anogenital HPV is the most common sexually transmitted infection in the US • ~ 20 million currently infected • 6.2 million new infections/year • Common in adolescents & young adults • HPV types 6 and 11 (and others) • Estimated 80% of sexually active women will have been infected by age 50 • Infection also common in men Fredenburg 2014 HPV Webinar

  18. Fredenburg 2014 HPV Webinar

  19. Numbers of US Cancers & Genital Warts Attributed to HPV Infections Data from President’s Cancer Panel Annual Report 2012-2013 Fredenburg 2014 HPV Webinar

  20. Average Number of New HPV-Associated Cancers by Sex, in the United States, 2005-2009 n=1003 n=2317 n=3039 n=694 n=1687 n=3084 Oropharynx n=9312 n=11279 • Jemal A et al. J Natl Cancer Inst 2013;105:175-201 Fredenburg 2014 HPV Webinar

  21. Numbers of US Cancers Warts Attributed to HPV Infections • Jemal A et al. J Natl Cancer Inst 2013;105:175-201 Fredenburg 2014 HPV Webinar

  22. HPV-Associated Cervical Cancer Rates by Race and Ethnicity, United States, 2004–2008 Jemal A et al. J Natl Cancer Inst2013;105:175-201 Fredenburg 2014 HPV Webinar

  23. HPV – Cervical Dysplasias & Cancer • HPV types 16 and 18 - high-risk types of HPV • Intraepithelial lesions may progress to carcinomas • HPV infection & implicated cofactors • Tobacco use • Ultraviolet radiation • Pregnancy • Folate deficiency • Immune suppression • Cervical metaplasia is prevalent among sexually active adolescents with increased risk for HPV infection • Immune system clearance within 1-2 years is common Fredenburg 2014 HPV Webinar

  24. Cervical Cancer • Cervical cancer is the most common HPV-associated cancer among women • 500,000+ new cases and 275,000 attributable deaths world-wide in 2008 • 11,000+ new cases and 4,000 attributable deaths in 2011 in the U.S. • 37% cervical cancers occur in women who are between the ages of 20 and 44 • 13% (or nearly 1 in 8) between 20 and 34 • 24% ( or nearly 1 in 4) between 35 and 44 Fredenburg 2014 HPV Webinar CDC. HPV–associated cancers—US, 2004–2008. MMWR 2012;61(15):258–261. Cervical Cancer Counts by Age. US Cancer Statistics data from 2010, CDC.gov.

  25. HPV-Associated Cervical Cancer Incidence Rates by State, United States, 2004–2008 Fredenburg 2014 HPV Webinar

  26. Without vaccination, annual burden of genital HPV in U.S. females: 4,000 cervical cancer deaths 10,846 new cases of cervical cancer 330,000 new cases of HSIL: CIN2/3 (high grade cervical dysplasia) 1 million new cases of genital warts 1.4 million new cases ofLSIL: CIN1 (low grade cervical dysplasia) 3 million cases and $7 billion American Cancer Society. 2008 Sex Transm Dis. 2004 ; SchiffmanArch Pathol Lab Med. 2003; Insinga, Pharmacoeconomics, 2005 Fredenburg 2014 HPV Webinar

  27. Oropharyngeal Squamous Cell Carcinoma • SCC - 95% of laryngeal cancers • ~11,000 new cases diagnosed in US annually • Risk Factors • Chronic HPV RR~230 • Tobacco & alcohol RR>100 • Tobacco abuse RR~14-35 • Excess ETOH use RR~16 • Infrequent F/V RR~2.7 http://accessmedicine.mhmedical.com.ezproxy.mcphs.edu/content.aspx?bookid=685&sectionid=45361075 Fredenburg 2014 HPV Webinar

  28. Recurrent Respiratory Papillomatosis • Most common benign neoplasm of the larynx among children • HPV 6, 11 & 16 implicated • Incidence • 4.3 per 100,000 children • 1.8 per 100,000 adults • Triad of risk factors for juvenile onset • Firstborn child • Teenage mother • Vaginal delivery – risk of contracting RRP after delivery from infected mother is 0.25 – 3%, C-section does not uniformly prevent RRP Fredenburg 2014 HPV Webinar

  29. Evolution of recommendations for HPV vaccination in the United States Quadrivalent Routine, females 11 or 12 yrs* and 13-26 yrs not previously vaccinated Quadrivalent or Bivalent Routine, females 11 or 12 yrs* and 13-26 yrs not previously vaccinated Quadrivalent Routine, males 11 or 12 yrs* and 13-21 yrs not previously vaccinated May be given, 22-26 yrs** Quadrivalent May be given, males 9-26 yrs* June October Quadrivalent (HPV 6,11,16,18) vaccine; Bivalent (HPV 16,18) vaccine * Can be given starting at 9 years of age; ** For MSM and immunocompromised males, quadrivalent HPV vaccine through 26 years of age Fredenburg 2014 HPV Webinar

  30. HPV Vaccine Impact:HPV Prevalence Studies • Prospective case controlled study of adolescent women, ages 14–17, pre and post HPV vaccine • Most of the women studied (89.3%) had received 1 or more doses of the HPV vaccinecompared to non-vaccinated group • HPV 6, 11, 16 and 18 types were detected significantly less often in the studied group (5.3%) as compared to the controls (24%): OR = 5.6, CI = 1.9, 16.5 • OR = 9.5 when comparing 2 or more vaccine doses to their matched controls • Only behavioral difference found was that the vaccinated women used condoms more frequently Cummings T, Zimet GD, Brown D, et al. Reduction of HPV infections through vaccination among at-risk urban adolescents. Vaccine. 2012; 30:5496-5499.

  31. HPV Vaccine Impact:HPV Prevalence Studies • 13-26 yo adolescent females with h/o sexual contact : compared 2006–07 prevaccination versus 2009–10 (where 59% were vaccinated) • Prevalence rate for HPV 6. 11, 16, 18 decreased from 31.7% to13.4% • Prevalence decrease not only occurred among vaccinated (31.8%–9.9%), but also unvaccinated (30.2%–15.4%) adolescents in the 2009-10 cohort • Nonvaccine-type HPV increased (60.7%–75.9%) for vaccinated postsurveillance study participants Kahn JA, Brown DR, Ding L, et al. Vaccine-Type Human Papillomavirus and Evidence of Herd Protection After Vaccine Introduction. Pediatrics. 2012; 130:249-56.

  32. Fredenburg 2014 HPV Webinar

  33. Fear of Side Effects with HPV Vaccine Fredenburg 2014 HPV Webinar

  34. Fredenburg 2014 HPV Webinar

  35. Trends in Total and Serious Female HPV4 Vaccine Reports to VAERS by Year, June 2006 – March 2013 (N=21,194) 35 MMWR 2013;62:591-595

  36. Institute of Medicine ReportAdverse Effects of Vaccines: Evidence and Causality • IOM reviewed possible associations between adverse health events & 8 vaccines • Evidence “favors acceptance” of a causal relationship between HPV vaccine and anaphylaxis (yeast and latex components) • Evidence “convincingly supports” a causal relationship between the injection of a vaccine and syncope • Inadequate evidence was found for causal relationships between HPV vaccination and 12 other specific health events studied Institute of Medicine. Adverse Effects of Vaccines: Evidence and Causality. Washington DC. The National Academies Press, 2012.

  37. Sexual Activity & Changes with HPV Vaccination Fredenburg 2014 HPV Webinar

  38. HPV Vaccine & that Sexual Activity Thing? • “HPV vaccination in the recommended ages was not associated with increased sexual activity–related outcome rates.” Bednarczyk RA et al. Sexual activity–related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics, 130 (2012): 798–805 • “These data…suggest that sexual behaviors were not altered because of the vaccine.” Cummings T et al. Reduction of HPV infections through vaccination among at-risk urban adolescents. Vaccine, 30 (2012): 5496–5499 • “No association was found between HPV vaccination and risky sexual behavior.” Liddon NC et al. Human papillomavirus vaccine and sexual behavior among adolescent and young women.Am. J. Prev. Med., 42 (2012): 44–52 Fredenburg 2014 HPV Webinar

  39. Lack of Parental Acceptance, But Not So Much Patient Fredenburg 2014 HPV Webinar

  40. Parents’ Opinions of Mandatory Human Papillomavirus Vaccination: Does Ethnicity Matter? • Vaccinated daughters against HPV • 100% of Caucasian parents, • 90% of African- American parents • 73% of Afro-Caribbean/African parents • 90% of Latino parents • Supported HPV vaccine mandates • 11% of Caucasian parents (believed vaccine should be individual decision in that virus can only be spread sexually) • 78% of African-American* • 60% of Afro- Caribbean/African* • 90% of Latino parents* (special importance to protecting daughters from STDs) *viewed mandates as the most effective way to protect their daughters from cervical cancer http://www.sciencedirect.com.ezproxy.mcphs.edu/science/article/pii/S1049386710000897# Fredenburg 2014 HPV Webinar

  41. HPV vaccine decision-making and acceptance: does religion play a role? • Catholic parents were more likely than nonaffiliated parents to have already vaccinated their daughters (compared with being undecided) • (OR = 3.26, 95% CI = 1.06-10.06) • Parents with frequent attendance at religious services were more likely than parents who do not attend services to have decided against vaccination (compared with being undecided) • (OR = 2.92, 95% CI = 1.25-6.84) http://www.ncbi.nlm.nih.gov/pubmed/22076049 Fredenburg 2014 HPV Webinar

  42. Racial and Ethnic Differences in HPV Knowledge, Attitudes, and Vaccination Rates among Low-income African-American, Haitian, Latina, and Caucasian Young Adult Women • 90% were somewhat or very likely to accept HPV vaccination if offered by their physician • But only 51% initiated the vaccination over the next 5 years • 75% of those who initiated vaccination eventually completed the 3 doses of the HPV vaccine series • 45% who started the series completed 3 doses within 5 years • 42% of African-American • 33% of Haitian • 63% of Latina • 65% of White • Study showed low knowledge regarding HPV infections & vaccine, but reported high levels of trust in physicians; willing to vaccinate if recommended by their physicians http://www.sciencedirect.com/science/article/pii/S1083318813002829# Fredenburg 2014 HPV Webinar

  43. http://www.sciencedirect.com.ezproxy.mcphs.edu/science/article/pii/S0264410X13016654#http://www.sciencedirect.com.ezproxy.mcphs.edu/science/article/pii/S0264410X13016654# Fredenburg 2014 HPV Webinar

  44. http://www.sciencedirect.com.ezproxy.mcphs.edu/science/article/pii/S0264410X13016654#http://www.sciencedirect.com.ezproxy.mcphs.edu/science/article/pii/S0264410X13016654# Fredenburg 2014 HPV Webinar

  45. Prefer to Defer Until Older Fredenburg 2014 HPV Webinar

  46. The Kinsley Institute The Kinsley Institute http://www.kinseyinstitute.org/resources/FAQ.html#Age Fredenburg 2014 HPV Webinar

  47. Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2006–2010 National Survey of Family Growth - CDC • For both male and female teenagers, a significantly smaller percentage were sexually experienced if: • they lived with both parents when they were aged 14 • their mothers had their first birth at age 20 or over • the teenager’s mother was a college graduate • the teenager lived with both of her/his parents http://www.cdc.gov/nchs/data/series/sr_23/sr23_031.pdf Fredenburg 2014 HPV Webinar

  48. Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2006–2010 National Survey of Family Growth CDC http://www.cdc.gov/nchs/data/series/sr_23/sr23_031.pdf Fredenburg 2014 HPV Webinar

  49. Fredenburg 2014 HPV Webinar

  50. Cost Concerns Regarding HPV Vaccination Fredenburg 2014 HPV Webinar

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