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?