1. A program of the International Association of Immunization Managers Peer-to-Peer Exchange HPV Vaccination in Ireland Dr. Brenda Corcoran for Molly Howell, MPH Immunization Program Manager Assistant Director of Disease Control North Dakota Department of Health IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 1

2. Human Papillomavirus (HPV) in the United States Every 20 minutes, someone in the U.S. is diagnosed with an HPV-related cancer. About 79 million Americans are currently infected with HPV. About 14 million people become newly infected each year (mostly in teens and early 20s). For each year the U.S. stays at 30% coverage for HPV vaccine instead of achieving 80% 4,400 future cervical cancer cases and 1,400 cervical cancer deaths will occur annually. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 2

3. HPV Vaccine Recommendations in the U.S. HPV vaccine is administered as a 3-dose series. 0, 1-2, and 6 months HPV vaccines are routinely recommended by ACIP for 11 and 12 year-old girls and boys. The vaccine series can be started beginning at age 9. Female recommendation: 2007 Male recommendation: 2010 Catch-up vaccination is routinely recommended for 13 – 26 year-olds. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 3

4. North Dakota North Dakota is located in the north-central portion of the U.S. Population:723,393 Conservative, rural, agricultural state that is currently experiencing an “oil boom” and significant population increase Historically, high rates of immunization All recommended vaccines required for childcare or school entry, with the exception of HPV and influenza. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 4

5. North Dakota Adolescent (13-17) Immunization Rates (NIS) IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 5

6. North Dakota vs. U.S. HPV Vaccination Rates (2013 NIS) IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 6

7. Peer-to-Peer Exchange: HPV Vaccination Objectives Be able to describe strategies used to implement and achieve high rates of HPV vaccination amongst adolescents, including, school located clinics, communication initiatives, educational materials, insurance coverage, healthcare provider education, etc. Understand mandatory (or lack there of) school immunization requirements Determine the process used by another country to assess immunization coverage, including the use of immunization information systems Understand barriers to immunization and strategies used to combat barriers in another country Be able to summarize the healthcare structure of the country and possible differences that may impact immunization coverage rates Determine opportunities for implementation of learned strategies in North Dakota IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 7

8. Peer-to-Peer Exchange: Ireland Population: 4.595 million Mixture of cities and very rural areas 84.2% Catholic Universal childhood immunization programs General Practitioners vaccinate infants Local vaccination teams visit primary and second level schools. No school immunization requirements (mandates) IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 8

9. Peer-to-Peer Exchange: Ireland Dublin, Ireland September 8 – September 11, 2014 Peer Supporter: Dr. Brenda Corcoran, Ireland National Immunization Office (NIO), Health Service Executive (HSE) Agenda: Met with NIO staff Attended three school immunization clinics Met with surveillance and communications staff within the HSE IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 9

10. Peer-to-Peer Exchange: Ireland In April 2008, the National Immunization Advisory Committee (NIAC) (similar to ACIP in the U.S.) recommended HPV vaccine for all girls at age 12. Three-dose schedule Ireland supplies 100% recommended vaccines (very limited private purchase). Government agreed funding Sept 2008 Deferred due to economic situation Funding not agreed until January 2010 IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 10

11. HPV Vaccine Program – Ireland 2010/2011 Vaccine procured – HPV4 Training program developed Information materials tested Vaccinated all girls entering second level school (“7 th grade” age 12-13) 2010/2011 and 2009/2010 (double cohort) No national IT system so manual recording of uptake (target 80%) IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 11

12. HPV Vaccine Program- Ireland 2010/2011 IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 12

13. HPV Vaccine Program – Ireland 2011/2012 Routine program continued Catch-up program for all girls in last year of second level school (“seniors” age 17-18) minors can consent for themselves (no parental consent needed) at age 16 target 60% IT system developed tracks consent, demographics, vaccine etc. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 13

14. HPV Vaccine Program – Ireland Age 12-13 IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 14 2011/20122012/2013 Over 80% uptake achieved for 3 dose schedule >96% girls who started dose 1 completed dose 3

15. HPV Vaccine Program – Ireland Age 17-18 2011/2012 2012/2013 Over 60% uptake achieved for 3 dose schedule Over 93% girls who started dose 1 completed dose 3 Some girls may have already received HPV vaccine

16. HPV Vaccine Program -Ireland 2014 – 2015 Changed to a two-dose HPV vaccine schedule 0 and 6 months First dose administered with Tdap Second dose administered with new booster of Meningococcal C (MenC) vaccine Tdap and MenC vaccines administered to boys IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 16

17. Lessons Learned from Ireland Delay in funding for HPV vaccine caused increased demand for the vaccine. Parents and general public demanded that the Irish Government provide HPV vaccine after funding stopped. Created positive media attention for HPV vaccine United Kingdom TV reality star, Jade Goody, died of cervical cancer at age 27 in March 2009. Created positive media attention for HPV vaccine Catholic Church mostly silent on HPV vaccine IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 17

18. Lessons Learned from Ireland School-located clinics are an effective way to vaccinate. Convenience Parents in Ireland are familiar with school based vaccinations because primary school entry vaccines are given there. Persistent and passionate school teams contact parents of children who missed school clinics. NIO has a close relationship with the Department of Education. One-time consent in Ireland makes school vaccinations easier. The government funds 100% of the vaccine cost and administration; no billing of insurance. If girls do not get the vaccine at school or “mop-up clinic,” then the family may have to pay out-of-pocket later. The public trusts information from Irish health authorities. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 18

19. Lessons Learned from Ireland People know HPV vaccine as the “cancer vaccine.” IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 19

20. Possible Applications for North Dakota Pilot school clinics with local public health units or mass vaccinators in North Dakota Conduct a media/educational campaign with focus on preventing cancer Focus on the need for vaccination prior to exposure. Educate physicians/nurses about how to communicate with parents about the vaccine. Use trusted sources for HPV promotion/information Local physicians North Dakota residents impacted by HPV IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 20

21. Thank You! International Association of Immunization Managers Dr. Brenda Corcoran, National Immunization Office in Ireland Ireland HSE staff North Dakota Department of Health IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 21