1. CPHA Preventing Cervical Cancer- Making it Happen Cathy O’Keefe Gillian Butler May 29, 2014

2. Disclosures I have no financial interests to disclose

3. Acknowledgements Gillian Butler, CDC Nurse Specialist, GNL Peggy Allan, CDC Nurse, Western Health Hayley Cooze, CDC Nurse, Central Health The dedicated Public Health Nurses in NL who take ownership to make sure every child is immunized

4. Outline for May 29 Provide an overview of the first six years of the HPV female immunization program in NL Discuss the research available regarding herd immunity with HPV programs Describe current practice for informed consent and administration

5. Outline continued Compare coverage rates with other provinces and countries Discuss the need, or not, for evaluation and program expansion

6. Newfoundland and Labrador

7. What do you think ? Best age for HPV vaccine Consent no consent Females and males Catch-up for males Best way to optimize uptake

8. NACI recommendations NACI initial statement February 2007 Prevent cervical cancers caused by HPV infection NACI statement updated in 2012 HPV4 (Gardasil ® ) is recommended in males between 9 and 26 years of age for the prevention of anal intraepithelial neoplasia (AIN) grades 1, 2, and 3, anal cancer, and anogenital warts (NACI Recommendation Grade A). NACI has determined that there is good (Grade A) evidence to recommend the use of Gardasil ® in males between 9 to 26 years of age. To date PEI and Alberta have announced programs for males

9. Research The impact of vaccinating males, compared to that of improving vaccination uptake in existing female cohorts or vaccinating additional female cohorts. Inclusion of males in routine programs facilitates vaccination of males at a young age when the potential benefit of the vaccine is greatest. There are no studies that directly demonstrate that HPV vaccination of males will result in less sexual transmission of vaccine-related HPV types from males to females and in reduced incidence of cervical cancer. While current models predict that addition of males to a routine HPV vaccination program would prevent additional cases of genital warts and cervical cancer among females to varying degrees, Provinces and territories will need to compare the impact of vaccinating males with that of vaccinating additional female cohorts. While not directly comparable, lessons learned from gender-targeting e.g. rubella vaccine

10. Getting started 21 March 2007 Canadian Cancer Society Applauds Funding for HPV Vaccine Announced in Federal Budget TORONTO - The Canadian Cancer Society applauds the federal budget announcement of $300 million to help implement the HPV vaccine across Canada. The vaccine will help protect young women and girls from cervical cancer.

11. Choosing a cohort Jurisdictions have approached the age to provide immunization in different ways The NACI statement keeps the range broad NL decision made by looking at varied factors

12. Getting the best coverage NL factors for choosing a cohort Age of initiation of sexual activity Impact of school size and class attendance Duration of protection Ongoing surveillance and connection with cancer registry

13. Regional Participation The key component of making this work is collaboration with Regional Health Authorities in planning Some of the questions- What works best: –Grade- Age –Timing- Involving teachers –Materials for parents and teachers –PH Nurse training –Should we involve media

14. NL The process 2007 Fall 2006 Communicable Disease Nurses and Regional Medical Officers of Health were provided scientific information on HPV infection and vaccine Once NACI announced –managers had heard that implementation was most likely going to be fall 2008, but nevertheless did pass this info on to lower level managers who had been asked to work out the logistics... –so when the announcement was made, there was little difficulty mobilizing because much of the work was done

15. HPV NL Implementation August September 2007 Policy developed Materials: Education for health professionals Informed consent Fact sheet to facilitate consent Post immunization fact sheet Information package for teachers Flexibility in regions for operationalization

16. Consent

17. Implementation PH Nurses in-service on science and responding to parental concerns Materials printed Policies revised and distributed Work with Department of Education to develop an information package for school boards and teachers on HPV program Regions provided with vaccine, materials for education

18. Adding another Cohort As many of the PT came on board and costs reduced the key was to ensure equitable use of all the NIS trust funding Add cohort grade 9 for 2 years –Already completing a consent for Tdap –Not covered in 08-09 by the grade 6 program –2 years Result: 90% of females born 1994 and after have been immunized

19. Challenges at Regional level Hiring nurses on a casual basis Remote communities covering several cohorts Public vs. private access HPV not “reportable”

20. Uptake First 3 years

21. 2007-2010

22. Reaching the goal

23. Why this works All post natal referrals in this region are sent to PH nurses for follow-up. PH nurses use this opportunity to provide an appointment for child health clinics. The first vaccinations are at 8 weeks, two weeks later than the doctor’s the 6 week appointment. Also since the parent is called and an appointment is provided for immunization, the parent is made to feel it is important to have vaccines. All school based immunization programs are completed by PH nurses allowing physicians to work toward their scope of practice.

24. Why this works Single service provision of Childhood immunization Program Only one group responsible for provision of this service Public Health Nurses cover all communities Clear lines of communication for issues that arise They are directed and follow provincial policies and procedures. Have our immunization manuals to follow so there are clear consistent messages Strong support from provincial office: prompt response to concerns that arise

25. Why this works Issues and concerns were dealt with promptly. PHNs fell their work is valued and they take ownership of the immunization program. Vaccine products are changing continuously PHNs are immediately educated about any program changes or changes to vaccine product Written materials such as tear off sheets are provided promptly as well as product information Semi-monthly Public Health memo send from the CDCN keeps the PH nurses abreast of changes

26. What do you think? Revisit our questions and reflect on how this could work in your jurisdiction

27. Opportunities Linking immunization records to the cancer registry HPV monitoring and Surveillance Committee Reviewing policy related to immunizing males

28. Discussion & Questions

29. References CCDR NACI 2007 2012 Rosberger, Perez King, Franco Oncology exchange May 2013 Vol 12 No 2 Tabrizi, Brotherton, Kaldor, Cummins, Lui Journal of Infectious Diseases 2012:206 Brotherton, Fridman The Lancet 2011