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Immunisation Against Human
Papilloma Virus
David Green – Immunisation Coordinator and Infection Control
Nurse
Contents
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Epidemiology and pathology of infection
Conditions caused by HPV
HPV Vaccine
Consent
The DH immunisation campaign
Results
Future challenges
Brain Teaser
• What is the connection between this moth
and the HPV vaccine?
Cabbage looper or Trichoplusia ni
HPV infection
• Human papilloma virus (HPV) is a small DNA
virus.
• It infects the deeper layers of the skin and
internal lining of organs such as the vagina and
mouth.
• HPV is often asymptomatic.
• There are more than 100 types, of which 40
infect the genital area.
• HPV infections normally resolve spontaneously 90% do so within two years.
• Persistent HPV infection causes the cell
changes that eventually lead to cancer.
HPV Transmission
• HPV is spread by direct physical
contact
• Any genital contact is important,
not just sexual intercourse.
• Hand to genital contact may
cause some infections.
• Anyone who is sexually active is
at risk.
• The risk of acquiring HPV
increases with the number of
sexual partners.
Epidemiology of genital HPV
infection
• HPV infection is common – at least half of
all sexually active women will be infected
by a strain of genital HPV strain in their
lifetimes.
• The rate of genital HPV infection increases
from age 14.
• Women are most likely to be infected in
their late teens and early twenties.
• 15% of 20 to 24-year-old women were
recently infected with HPV 16 or 18.
Effects of HPV infection
• The HPV virus infects cells and then integrates
its DNA in to the DNA of the host cell.
• Persistent infection leads to cells becoming
damaged and abnormal.
• Eventually cancer - abnormal uncontrolled
growth of tissues – occurs after many years.
• HPV infections can’t be treated but abnormal
changes can be detected by screening and
removed.
Categories of genital HPV infection
• Genital HPV types are categorised as either:
– high-risk (oncogenic) types - that cause cervical
intraepithelial neoplasia and invasive cancer, and
– low-risk types - that cause genital warts.
• 99% of all cervical cancer cases are caused by
HPV infection.
• Two high-risk types, HPV 16 and 18, cause over
70% of cervical cancers.
• Other HPV types can also cause cervical
cancer.
HPV types that cause cervical cancer
HPV type
Percentage of cervical
cancer
cases caused by HPV type
Cumulative
percentage
16
58.1%
58.1%
18
15.7%
73.8%
33
4.4%
78.2%
31
4.0%
82.2%
45
2.9%
85.1%
35
1.6%
86.7%
58
1.2%
87.9%
56
1.0%
88.9%
52
0.6%
89.5%
39
0.2%
89.7%
51
0.2%
89.9%
68
0.3%
90.2%
59
0.1%
90.3%
Other
1.4%
91.7%
No type identified
8.3%
100%
Adapted from Smith JS et al.,
2007; Int J Cancer.
121(3):621-32.
Percentage of different cancer types caused
by high-risk HPV types
Cancer site
Cervix
Percentage of
cases caused by
HPV
> 99%
Penis
40%
Vulva, vagina
40%
Anus
90%
Mouth
3%
Oropharynx
12%
Source: Prof Margaret Stanley, University of Cambridge
Epidemiology of cervical cancer
• 2253 cases of invasive cervical cancer were
diagnosed in England in 2005.
• It is the second most common cancer of women
worldwide.
• Most cases occur in women in their late 30s or in
their 70s/80s (latter group were not screened when
younger).
• In developed countries, most cases are prevented
by cervical screening.
• In the UK, death rates are about 60% lower than
30 years ago, mainly due to screening.
Number of cases and age specific rates of newly diagnosed
cervical cancer, England 2005
Age group
85+
80-84
75-79
70-74
65-69
60-64
0
55-59
0
50-54
5
45-49
100
40-44
10
35-39
200
30-34
15
25-29
300
20-24
20
Cases per 100,000
population
Cases per 100,000 population
400
15-19
Number of cases
Number of cases
HPV Immunisation
Cervarix
• Cervarix® is a bivalent vaccine
manufactured by GlaxoSmithKline.
• Cervarix® protects against HPV
types 16 and 18.
• Cervarix® was chosen after
assessment of the two available
vaccines against a wide range of
criteria, such as the scientific data on
vaccine effectiveness and costeffectiveness
• Costs approx £80 per dose
Cervarix Controversy
• The competitor brand (Gardasil) protects
against strains 6, 11, 16 and 18.
• Use of Cervarix rather than Gardasil has
been called “short sighted” (Terrence
Higgins Trust) and a “missed opportunity”
(FPA).
• Prevention of cervical cancer is the
primary purpose of the HPV vaccination
programme.
The nature of Cervarix vaccine
• Proteins that coat the HPV virus are made using
DNA recombinant technology in cells that have
been infected by baculoviruses (insect viruses)
which uses cells derived from Trichoplusia ni.
• These purified proteins assemble themselves
into small spheres called virus-like particles
(VLPs).
• VLPs cannot cause HPV infection or cancer.
• The VLPs produce immunity to HPV.
• Immunised individuals mount a rapid immune
response when subsequently exposed to HPV.
Duration of immunity
• The immune response to HPV vaccination lasts
at least six years (the current maximum length of
post-vaccination follow-up).
• For at least five years post-vaccination, antibody
levels have been shown to be higher from
vaccination than from natural infection.
• At present there is no evidence for waning
immunity, but important long-term follow-up
studies are taking place to establish whether
boosting will be necessary.
• Routine HPV vaccination will save the lives
of around 400 women each year.
Consent
• Consent is being asked for a course of
treatment (all three doses)
• For year 8 girls (aged 12 and 13) the
person with parental responsibility gives
consent
• Year 13 (aged 17 and 18) girls give their
own consent
Vaccine schedule and
administration
• Schedule for Cervarix®:
– first dose of 0.5ml HPV vaccine;
– second dose of 0.5ml, at least one to two
months after the first; and
– a third dose of 0.5ml, at least six months after
the first.
• HPV vaccination is normally given by the
usual route, in the upper arm by IM
injection
HPV Immunisation Program
Vaccination of boys and young
women 18 and over
• The benefits of HPV vaccination are less for
boys and JCVI has advised that vaccination of
boys is not cost-effective.
• The vaccination of girls will reduce HPV
infections in boys by a herd immunity effect.
• The DH are not currently planning to offer
vaccine to those aged 18 and over as part of a
national programme
• All young women will still be covered by the
cervical screening programme and should still
be actively promoted by HCWs.
The HPV routine and catch-up vaccination schedule for
girls and young women in England, as of September
2008
School
year 7
School
year 8
2008/09
2009/10
2010/11
2011/12
Routine programme for Year 8 girls
Catch-up programme for older girls
School
year 9
School
year 10
School
year 11
School
year 12
Girls
aged 1718
(school
year 13)
Implementation in Calderdale PCT
• A schools-based programme was used for those
in school as it was likely that:
– vaccine coverage will be higher in schools
– costs would be lower than a GP-delivered
model, and
– using schools would be more acceptable to
parents/pupils.
– Opt out of school program available if
necessary
• Offering vaccination in the summer term is
problematic, so an early start in the school year
was thought necessary.
Implementation in Calderdale
Schools
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Dose one - Sept 08 (plus mop ups)
Dose two – Nov 08 (plus mop ups)
Dose three – March 09 (plus mop up)
Those who miss mop up could attend their
GP practice to receive outstanding dose(s)
Regional and National Comparison
(Jan 09)
Dose
Calderdale
Y&H
Region
(Average)
90%
England
(Average)
One (Yr 8)
92%
One (Yr 13) 46%
32%
32%
Two (Yr 8)
89%
78%
73%
Two (Yr 13) 37%
15%
21%
82%
Uptake in Calderdale (as of
31.3.09)
Year 8 (12 and 13 years old) =
• Dose 1 = 94.4%
• Dose 2 = 91.6%
• Dose 3 = 81.5%
Year 13 (17 and 18 year olds) =
• Dose 1 = 56.9%
• Dose 2 = 43.6%
• Dose 3 = 27.7%
Future challenges
• Year 8 - To bring uptake of doses 2 and 3
up to dose 1 level
• Year 13 – To achieve 90% uptake!
• To implement the new “accelerated” HPV
immunisation campaign from Sept 09.
The Accelerated HPV Campaign
School
year 7
2008/09
2009/10
2010/11
2011/12
School
year 8
School
year 9
School
year 10
School
year 11
School
year 12
Girls
aged 1718
(school
year 13)
Questions?