Ontario’s HPV Immunisation Programme
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Transcript of Ontario’s HPV Immunisation Programme
Ontario’s HPV Immunisation ProgrammeOntario’s HPV Immunisation Programme
What Went Wrong?What Went Wrong?
CPHA Annual ConferenceCPHA Annual Conference2 June 2008 2 June 2008 Dr. Ian GemmillDr. Ian Gemmill
Medical Officer of HealthMedical Officer of HealthKingston, Frontenac and Lennox & Addington Public HealthKingston, Frontenac and Lennox & Addington Public Health
OUTLINEOUTLINE
HPV & its consequencesHPV & its consequences HPV vaccineHPV vaccine Description of Ontario’s programmeDescription of Ontario’s programme Negative publicity about HPV vaccineNegative publicity about HPV vaccine Lessons learnedLessons learned
HHuman papillomavirusuman papillomavirus HPV is one of several HPV is one of several
species of the genus species of the genus Papillomavirus in the Papillomavirus in the Papovaviridae familyPapovaviridae family
There are more than There are more than 200 types of HPV 200 types of HPV
HPV is a relatively small HPV is a relatively small virus containing two virus containing two strands of DNA within a strands of DNA within a spherical shell (capsid)spherical shell (capsid)
HPV capsids, approximately 55 nm in diameter
The virus
Image source: Dr Linda Stannard, UCT/Science Photo Library
Anogenital warts
Regression
6, 11, other low-risk types
Therapy
HPV infection
16, 18, other high-risk types
Transient infection
Cancer
CIN II/CIN III
Persistentinfection
CIN I/CIN II
Regression
Natural history of HPV infection
The virus
CIN = cervical intraepithelial neoplasia
A remarkably strong association in cancer epidemiology
RR
> 500 HPV 18 and cervical adenocarcinoma in the Philippines
HPV 16 and cervical cancer in Costa Rica
HPV and cervical cancer in Bangkok
100 Hepatitis B virus and liver cancer in Taiwan
50 Hepatitis B virus and liver cancer in Greece
20 Hepatitis C virus and liver cancer in Italy
10 Cigarette smoking and lung cancer
NEUTRAL REFERENCE LINE
0.1 Smoking cessation (< 50 years) and lung cancer
0.6 Adult HBV vaccination and liver cancer in Korea
0.1 Newborn HBV vaccination and liver cancer in Taiwan
1
Bosch FX et al. J Clin Pathol 2002; 55: 244–65.
HUMAN PAPILLOMA VIRUS & CERVICAL CANCER
Cervical Cancer: Incidence and Mortality per 100,000 Females, Canada, 1990-1995
Prepared by: Division of STD Prevention and Control, Bureau of HIV/AIDS and STD, LCDC, Health Canada, 1997
DR. I. M. GEMMILL, MD, CCFP, FRCPC
QUADRIVALENT HPV QUADRIVALENT HPV VACCINE:VACCINE:
GARDASILGARDASIL™™
HPV VACCINEHPV VACCINE
An excellent vaccine that promises to decrease HPV cancers An excellent vaccine that promises to decrease HPV cancers dramaticallydramatically
Immunogenicity:Immunogenicity: ~~100% seroconversion100% seroconversionEfficacy: Efficacy: nearly 100% type specific efficacynearly 100% type specific efficacy
protects against infection and CIN2protects against infection and CIN2Safety:Safety: side effects are mild and short-livedside effects are mild and short-lived
fewer reactions than with placebofewer reactions than with placeboDuration of protection:Duration of protection: unknown but at least 5 yearsunknown but at least 5 years
Antibody decay curve looks Antibody decay curve looks promisingpromising? 10 years to lifelong? 10 years to lifelong
Cross-reactivity:Cross-reactivity: HPV 45 & possibly HPV 31HPV 45 & possibly HPV 31
DR. I. M. GEMMILL, MD, CCFP, FRCPC
National Advisory Committee on Immunization Recommendations for HPV Vaccine
1. Females between 9 and 132. Females between the ages of 14 and 26,
even if they are already sexually active or have had HPV infection or its consequences
3. No recommendations can be made for females >26 years of age although its use can be considered in individual circumstances
CCDR. February 15, 2007; 33(ACS-2):1-32.
What Will this Vaccination Prevent in Women?
Up to 70% of all cervical cancers About 90% of genital warts A large proportion of vulvar, anal and oral
cancers Precancerous lesions:
Cervical Vaginal Vulvar
Hon. Jim FlahertyHon. Jim FlahertyMinistre de FinanceMinistre de Finance
Honourable Dalton McGuintyHonourable Dalton McGuintyPremier of OntarioPremier of Ontario
MCGUINTY GOVERNMENT LAUNCHES LIFE-SAVING HPV IMMUNIZATION
PROGRAM
The programme:The programme:
announced on the 2 of August 2007 by announced on the 2 of August 2007 by premier McGuinty, one month before the premier McGuinty, one month before the beginning of the 2007 provincial election beginning of the 2007 provincial election campaigncampaign
targets Grade 8 girls (13 to 14 years)targets Grade 8 girls (13 to 14 years) administered in schoolsadministered in schools
administered by local public health administered by local public health agenciesagencies
scheduled to begin just weeks after the scheduled to begin just weeks after the announcement (1st September in Toronto, announcement (1st September in Toronto, because of the large population)because of the large population)
during the same period, public health runs during the same period, public health runs both universal influenza and HBV vaccine both universal influenza and HBV vaccine programmes programmes
Canadian Medical Association JournalCanadian Medical Association Journal28 August 200728 August 2007
‘‘Human papillomavirus, vaccines and Human papillomavirus, vaccines and women's health: questions and women's health: questions and cautions’cautions’
Abby Lippman PhD, Ryan Melnychuk Abby Lippman PhD, Ryan Melnychuk PhD, Carolyn Shimmin BJ, Madeline PhD, Carolyn Shimmin BJ, Madeline Boscoe inf. DUBoscoe inf. DU
Maclean’s MagazineMaclean’s MagazineCATHY GULLI, 27 August 2007CATHY GULLI, 27 August 2007
‘‘Our girls are not guinea pigs’Our girls are not guinea pigs’
‘‘Is an upcoming mass inoculation of a generation Is an upcoming mass inoculation of a generation unnecessary and potentially dangerous?’unnecessary and potentially dangerous?’
‘‘Maclean's cover story re-ignites Gardasil debate’Maclean's cover story re-ignites Gardasil debate’
‘‘Canada's top doctor expresses concern’Canada's top doctor expresses concern’
C
‘‘Showdown in Texas over HPV Showdown in Texas over HPV vaccine order’vaccine order’
AUSTIN, Texas (AP) — Texas lawmakers rejected Gov. AUSTIN, Texas (AP) — Texas lawmakers rejected Gov. Rick Perry's anti-cancer vaccine order Wednesday, Rick Perry's anti-cancer vaccine order Wednesday, sending him a bill that blocks state officials from sending him a bill that blocks state officials from requiring the shots for at least four years.requiring the shots for at least four years.
Perry has said he is disappointed but has not indicated Perry has said he is disappointed but has not indicated whether he will veto the bill. He has 10 days to sign or whether he will veto the bill. He has 10 days to sign or veto it, or the proposal will become law without his veto it, or the proposal will become law without his signature.signature.
Lawmakers can override a veto with a two-thirds vote of Lawmakers can override a veto with a two-thirds vote of both chambers. The legislation passed by well over that both chambers. The legislation passed by well over that margin in both chambers.margin in both chambers.
Progress of the ProgrammeProgress of the Programme
the programme is mostly complete for 2007-the programme is mostly complete for 2007-20082008
only 50% of eligible girls have accepted the only 50% of eligible girls have accepted the vaccinevaccine
in some schools, none has been immunisedin some schools, none has been immunised some teachers have discouraged girls not to some teachers have discouraged girls not to
take the vaccinetake the vaccine in some schools, girls who received the vaccine in some schools, girls who received the vaccine
were ridiculed by their peers. were ridiculed by their peers.
What went wrong?What went wrong?
negative publicity almost undoubtedly has negative publicity almost undoubtedly has contributed to the low uptakecontributed to the low uptake
a significant proportion of girls, their a significant proportion of girls, their parents or both appear to have lost parents or both appear to have lost confidence in the vaccineconfidence in the vaccine
This reaction is completely different than This reaction is completely different than the experience with HBV vaccine in the the experience with HBV vaccine in the 1990’s, when complaints were from 1990’s, when complaints were from parents whose children were not eligible parents whose children were not eligible for the vaccine for the vaccine
What went wrong?What went wrong?
The large impact of the negative publicity The large impact of the negative publicity was not anticipated by public health was not anticipated by public health officialsofficials
There were some who advised not taking There were some who advised not taking action to avoid giving credibility to the action to avoid giving credibility to the negative publicitynegative publicity
Others underestimated the impact or did Others underestimated the impact or did not have time to get enough information not have time to get enough information outout
Some Measures that Were TakenSome Measures that Were Taken
The Government of Ontario:The Government of Ontario: The Ministry monitored the co-operation of The Ministry monitored the co-operation of
school boardsschool boards It provided web information and fact sheets It provided web information and fact sheets a new media campaign has since been launcheda new media campaign has since been launched
The Council of Ontario Medical Officers of HealthThe Council of Ontario Medical Officers of Health Letters to both Maclean’s and to the CMAJLetters to both Maclean’s and to the CMAJ
Some Measures that Were TakenSome Measures that Were Taken
Local action:Local action: press conferencepress conference letter from the MOH to girls & their parentsletter from the MOH to girls & their parents increased information on HPV & the vaccineincreased information on HPV & the vaccine questions answered by telephone and at questions answered by telephone and at
clinicsclinics support for the programme was solicited from support for the programme was solicited from
other health professionalsother health professionals
Lessons LearnedLessons Learned
Pay attention to negative and untruthful Pay attention to negative and untruthful stories in the mediastories in the media
Do not underestimate the potential power Do not underestimate the potential power and effect of the media to influence the and effect of the media to influence the publicpublic
Respond quickly and forcefully to counter Respond quickly and forcefully to counter mistruths or misinformation that is mistruths or misinformation that is promulgated about vaccinespromulgated about vaccines
Lessons LearnedLessons Learned
The public can quickly become mistrustful The public can quickly become mistrustful of a vaccineof a vaccine
People are prepared to believe mistruths People are prepared to believe mistruths about vaccine about vaccine
Ensure that populations that are targeted Ensure that populations that are targeted for vaccine receive lots of information that for vaccine receive lots of information that is:is: simple & clearsimple & clear timely, accessible & plentifultimely, accessible & plentiful
Next StepsNext Steps
Ontario needs to reconsider its HPV Ontario needs to reconsider its HPV programme:programme: extend eligibility of Grade 8 girls who have extend eligibility of Grade 8 girls who have
turned down the vaccine this yearturned down the vaccine this year extend the programme to all female high extend the programme to all female high
schoolschool consider providing the vaccine to boysconsider providing the vaccine to boys consider providing the vaccine to women out consider providing the vaccine to women out
of high schoolof high school
Next StepsNext Steps
Need to assess what factors were more Need to assess what factors were more important in parents’ decisionsimportant in parents’ decisions
Ontario needs to promote its HPV Ontario needs to promote its HPV programme better:programme better: more prominence of media adsmore prominence of media ads better communication to students & parentsbetter communication to students & parents timely provision of materials to local public timely provision of materials to local public
health agencieshealth agencies
THANK YOU.THANK YOU.
QUESTIONS?QUESTIONS?