1. HPV Vaccine is Cancer Prevention
NCSR update May 2017
Dr Jane Morgan, Waikato DHB

2. Key Messages
HPV vaccine + screening offer the most effective protection against cervical cancer
Recent changes to immunisation schedule
Funded 9-valent HPV vaccine
Boys too – universal eligibility up to 27th birthday
2 doses vs 3 doses by age
BPAC Nov

3. Why do we vaccinate vs HPV?
To prevent HPV-associated cancer
To improve equity of health outcomes
Current screening is good but NOT enough to prevent all HPV-associated cancers

4. Infection With Mucosal HPV Is Common
Lifetime risk > 80%
Close (skin-to-skin) contact; being intimate vs ‘sexually active’
Persistent HPV infection linked to cancer
Early vaccination prevents initial infection
Vaccine immune protection lasts at least 10 years (studies ongoing)

5. HPV Types and Disease Associations
Mucosal
Sites of infection
Cutaneous
~ 80 Types
“Common” Hand and Foot
Warts
~40 Types
Genital Warts
Laryngeal Papillomas
Low Grade cervical changes
Low risk (non-oncogenic) HPV 6, 11
High risk (oncogenic) HPV 16, 18, 31, 33, 45, 52, 58
Cervical Cancer Anogenital Cancers Oropharyngeal Cancer
Cancer Precursors

6. HPV vaccines Bivalent Cervarix® Quadrivalent Qardasil® 9-valent16 18 16 18 6 11 16 18 6 11 31 33 45 52 58
Numerous studies show a large reduction on genital warts and vaccine-related HPVs in females1-4
1 Chow EP et al. Lancet Inf Dis. 2015; 15:
2 Chow EP et al. Sex Trans Inf. 2015; 91:
3Ali H et al. BMJ. 2013: 346: f2032.
4Tabrizi SN et al. Lancet Inf Dis. 2014; 14:

7. Extra benefit of 9-Valent HPV vaccine
Adds at least an extra 15% of cervical cancers
Overall, these 5 => 14% HPV-related cancers in women, 4% men
CIN 2+ lesions: 50% => HPV 16/18, 25% => 31,33,45,52,58

8. Efficacy of 9vHPV Vaccine Against HPV Types 31/33/45/52/58
Per-protocol Population
End Point
9vHPV
Cases/Total
4vHPV
Risk Reduction
(95% CI)
High grade cervical, vulvar or vaginal disease
1/6016
30/6017
96.7 ( )
High grade CIN, AIS* and cervical cancer
1/5948
27/5943
96.3 ( )
Persistent infection (> 6 months)
35/5939
810/5953
96.0 ( )
*AIS = adenocarcinoma in situ
Joura EA, et al. New Engl J Med. 2015;372:

9. Why Do We Want to Protect Boys From HPV?
HPV-related cancers in all men
Anal, genital & oral
Penile cancer rare
Oropharyngeal cancer rates rising & more common in men
Anal cancer risk for men who have sex with men
Squamous cell carcinoma of the posterior oropharyngeal wall.

10. Genital HPV more common in men
Higher genital HPV prevalence in men vs women
Duration/clearance of initial HPV infection is similar
Men: lower immune response to natural infection
More new HPV infections?
More re-activation of persistent HPV infection?

11. HPV-Related Oropharyngeal Cancers
HPV-related oral cancers have more than doubled in the past 20 years.
Most due to HPV-16
Expected to exceed Cervical Ca by 2020
Chatuverdi AK, et al. J Clin Oncol. 2011;29:

12. Monitoring Impact of HPV Vaccine
HPV-associated Outcomes
Early Outcomes
(years)
HPV Prevalence
Genital warts
Mid Outcomes
(years - decades)
CIN/Precancers
Late Outcomes
(decades)
HPV-associated Cancers

13. HPV Vaccine: Early Evidence of Impact in Australia
Genital warts in women < 21 years old decreased from 18.4% in 2004/2005 to 1.1% in 2013/20014 (P < .001)
Chow EP, et al. Sex Transm Infect. 2015;91:

14. Early impact in NZ
AKL study: decrease in new cases of genital warts among young women attending SHC from
Larger drop among young Māori & Pacific women (93.4% less in vaccine-era) cf to NZ European women (80.2%)
HPV vaccine rates for Māori & Pacific girls in Auckland DHBs were notably higher than for others
Much less impact for Auckland men
Need 75-80% coverage for wider benefit, herd immunity
HPV-related cancers in men who have sex with men

15. Goal: 75% HPV vaccine coverage
National 3-dose coverage HPV4 at Dec 2016,

16. Vaccine Recommendations
Aim is effective delivery of HPV vaccine to all
Higher antibody levels in 9-14 yr olds vs yr olds
2 dose schedule for under 15s: 0 & 6-12 months
3 dose schedule if older: 0, 2 months, 6 months
Note 3 dose schedule if transplant/HIV aged 9-26 yr olds
Catch-up programme up to 26 years (not 27)
Start asap, rather than defer / miss opportunity
Can use any HPV vaccine to complete the 3-dose series
No need to restart if dosing was interrupted
HPV9 not funded if already completed funded 3 doses x HPV4

17. HPV vaccine in primary care
Non-immunised school-aged males in Year 9 and above
Non-immunised people aged between 9 and 26 years who declined their school vaccination programme
Those aged 14 years who are still eligible for a two-dose vaccine regimen before turning 15 years (when they then require the three-dose regimen)
Those aged 26 years have limited opportunity to receive free vaccination; if 1st dose is given prior to turning 27 years, the funded 3-dose course can be completed

18. HPV Vaccine Recommendations
For now … transplant patients, those receiving stem cell treatments & people who have received chemotherapy require 3 doses at zero, two and six months, regardless of age, unless an alternative schedule is advised
If person aged under 14 years has already had two doses of HPV4 vaccine, a third dose of either HPV4 or HPV9 is required if the two doses were less than six months apart

19. Fake news and fear-mongering vs facts & science for centuries

20. Not yet vaccinated ..
Refusers – focused on vaccine risk, biased towards information that supports their views, more likely to believe cover-up about serious events
Skeptics – vaccine not necessary, disease not serious
Delayers – not needed now, can we do it later? Eg child not sexually active
Focus on ‘fence-sitters’: make it easy for them

21. HPV Vaccine Safety Millions of doses of HPV vaccine given worldwide
Post-licensure monitoring
Vaccine Adverse Event Reporting System
Vaccine Safety Datalink Studies
Pregnancy registries
Only serious AES are syncope and anaphylaxis (3 per million doses)
HPV9 slightly higher injection site reaction than HPV4

22. Ease Main Concern
Elicit: “What’s your main concern about HPV vaccine?” “Do they really need it? Maybe we can wait until they’re a little older?” Acknowledge: “I get it, they’re young. I can see why you might think that they don’t yet need HPV vaccine.” Share your commitment: “But HPV vaccine protects against cancer. I think it’s really important.” Educate on what the research shows: “Children should get HPV vaccine at this age because younger children develop better protection. We want them to complete the 2- dose vaccine course way before there is any chance of being exposed to an infection that could lead to cancer.”

23. QUESTIONS?