Human Papillomavirus Kenneth McCall, BSPharm, PharmD, BCGP Associate Professor | UNE Immunization Update: Maine Pharmacy Association April 2017

October 13-15, 2017 Portland, Maine

Both males and females may become infected and transmit HPV1,2 Certain HPV-related cancers occur more frequently in females than males; however, both sexes can have potentially serious consequences of HPV infection.1,3 1. Centers for Disease Control and Prevention (CDC). Epidemiology and Prevention of Vaccine-Preventable Disease. 11th revised edition. Public Health Foundation; 2009. 2. Hernandez BY et al. Emerg Infect Dis. 2008;14:888–894.. 3. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World Summary Report 2010. hpv2010.org/main/images/stories/docs/HPVInformationCentre_SummaryReportWorld_Feb2010.pdf. Accessed March 10, 2011.

What percentage of people in the US will be infected with HPV in their lifetime? 80% 60% 40% 20%

Human Papillomavirus Vaccines Gardasil® (HPV4) – Types 6,11,16,18 Gardasil9 (HPV9) – Types 6,11,16,18,31,33,45,52,58 Cervarix® (HPV2) – Types 16,18

Healthy People 2020 goal is 80%

What is the Healthy People 2020 HPV vaccination goal for female adolescents? 40% 60% 80% 100%

Recent HPV Vaccine News FDA approved Gardasil 9 in December, 2014. Cervarix withdrawn from US Market in October, 2016, due to low sales. CDC recommends HPV vaccine 2-dose schedule for certain patients, December, 2016.  Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405–1408.

HPV Vaccine Recommendations POPULATION # OF HPV DOSES INTERVAL Persons initiating HPV vaccine at ages 9 through 14 years, except immune-compromised persons 2 0, 6-12 months* Persons initiating HPV vaccine at ages 15 through 26 years and immuno-compromised persons initiating HPV vaccine at ages 9 through 26 years 3 0, 1-2, 6 months** *In a 2-dose schedule of HPV vaccine, the minimum interval between the first and second doses is 5 months. ** In a 3-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second doses, 12 weeks between the second and third doses, and 5 months between the first and third doses.

Human Papillomavirus (HPV) vaccination HPV vaccines are not live vaccines and can be administered to persons who are immuno-compromised as a result of infection (including HIV infection), disease, or medications. HPV vaccine can be administered to persons with a history of genital warts, abnormal Papanicolaou test, or positive HPV DNA test.

What is the routine schedule for the HPV vaccine for an 18-year old? 0, 1-2, 6 months 0, 2-4, 12 months 0 and 6 months 0 and 2 months

A patient misses the 3nd dose of the HPV vaccine series by a month A patient misses the 3nd dose of the HPV vaccine series by a month. What is the best option? The HPV vaccine is no longer indicated. Give 3rd dose now to complete series. Repeat the second dose. Restart the series with the first dose.

A patient who has begun the HPV vaccine series becomes pregnant A patient who has begun the HPV vaccine series becomes pregnant. What should be done? The HPV vaccine is no longer indicated. The next dose should be delayed until the 3rd trimester. The next dose should be delayed until after pregnancy. The patient should complete the series on an accelerated schedule.

Administration Gardasil® IM - deltoid 1 inch, 25 gauge needle

Storage Refrigeration at 36 to 46 F Do not Freeze Administer as soon as possible – total time out of fridge should not exceed 72 hours

Gardasil®: 3 dose series Cervarix®: 3 dose series The mother of a 12-year-old boy requests the HPV vaccination. Select the correct vaccine and series. Gardasil®: 3 dose series Cervarix®: 3 dose series Gardasil®: 2 dose series Cervarix®: 2 dose series

Gardasil®: 3 dose series Cervarix®: 3 dose series The mother of a 12-year-old boy who has a history of cancer and B lymphocyte antibody deficiency requests the HPV vaccination. Select the correct vaccine and series. Gardasil®: 3 dose series Cervarix®: 3 dose series Gardasil®: 2 dose series Cervarix®: 2 dose series

Gardasil®: 3 dose series Cervarix®: 3 dose series An 18-year-old man requests the HPV vaccine. He has no contraindications. Select the correct vaccine and series. Gardasil®: 3 dose series Cervarix®: 3 dose series Gardasil®: 2 dose series Cervarix®: 2 dose series

Same day, opposite arm, separate syringe A 12-year-old girl needs to start the HPV vaccine series and she also needs a Tdap booster. Which of the following statements about the administration of HPV and Tdap vaccines is true? Same day, opposite arm, separate syringe Same day, same arm, mixed in 1 syringe Must be separated by at least 7 days Must be separated by at least 4 weeks

Questions and Discussion