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HPV vaccine for teenagersHPV vaccine for teenagers

Dr Sally Ferguson with thanks to MSD.. for most of the slides

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What is HPV?HPV is a common virus (the

human papillomavirus) Some HPV types can cause

genital warts Other types can infect a

woman’s cervix and lead to cervical cancer over many years

The Problem:

• Lifetime risk of genital /cervical HPV 1 in 2

• Lifetime risk of HGSIL is 1 in 25

• Lifetime risk of Cervical cancer is 1 in 31 (no pap smears done)

• Lifetime risk of Cervical cancer 1 in 125 (having pap smears)

• Lifetime risk of genital warts 1 in 8

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Natural history of HPV infection to Cervical cancer

0–1yrs 0–5yrs

Cervical Cervical CancerCancer

Persistent infection

Low GradePrecancers

(CIN 1)

1–20yrs

HPV infection

High Grade

Precancers (CIN 2/3)

Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.

Recovery: HPV clearance…90%

5Parkin DM Lacey CJN Vaccine 2006 S3/17 35

HPV Attributable %

HPV related diseases in Male and Female

Female cancers:• Cervix 100%• Vulva 40%• Vagina 40%• Anus 90%• Oro-pharynx 12%• Other illnesses• RRP (larynx wart in

children)100%

• Genital Wart 100%

Male Cancers Anus 90% Penis 40% Oro-pharynx 12% Other illnesses RRP 100% Genital Wart 100%

6Report of Hong Kong Cancer Registry HA 2010http://www3.ha.org.hk/cancereg/

New Case

400(2010)

Death

146(2010)

Crude rate: 10.7 per 100,000

HK Cervical Cancer(1996-2010)

10th among female cancers10th among female cancers

Lifetime risk: 1 in 145Lifetime risk: 1 in 145

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New cases per year：

Genital Warts = 11, 524

204 cases per 100,000 adults

Lin C BMC Infect Dis. 2010 Sep 17 10 272

Genital warts are common in Hong Kong

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子宮頸癌的預防方法

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99.7% Cervical cancers are associated with HPV

10GARDASIL is a trademark of Merck & Co., Inc., Whitehouse Station, NJ, USA.*VLP = Virus-like particle. 1. Villa LL, Costa RL, Petta CA, et al. Lancet Oncol. 2005;6:271–278.

HPV Vaccine technology

Image courtesy of Dr. Ian Frazer

Real Real ViruViru

ssVaccineVaccine

• Empty Shell formed by recombinant biotechnology to mimic the viral 3D shape.

• Does not contain infectious DNA。

• Does not contain mercury (thimerosal)

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Dosing schedule

GARDASIL Intramuscular injection (IM)

Recommended schedule

3 doses at month 0,2,6

Completed within 1 year will be considered as per-protocol

CERVARIX Vaccine:

3 doses at month 0,1,6

month

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4 in 1 vaccine: 9 years Long Term follow-up

9 years Antibody report8 years Efficacy report

Nygård M IPC 2012 Nov 30 – Dec 6, Puerto Rico, EP-741

Gardasil: No breakthrough case up to 8 years

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How long is the duration of protection ？Is booster dose needed?

US CDC 2012 Feb:Gardasil vaccine information statement

• Protection from HPV vaccine is expected to be long-lasting

• Additional (booster) doses are not recommended.

http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hpv-gardasil.pdf

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All women are at risk of HPV infection

Chan et al. Determinants of cervical human papillomavirus infection: differences between high and low oncogenic risk types.J Infect Dis 2002; 185: 28-35.

All HPV

High risk HPV

Low risk HPV*

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North America:

USACanada Mexico

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South America:Brazil BoliviaArgentina UruguayPeru EcuadorColombia ChileParaguay

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Middle East & Africa:

Gabon NamibiaIsrael C.A.R.Morocco MauritiusKenya KuwaitMauritania UAE Guinea Eq. EthiopiaUganda TogoMalawi Congo BrazzavilleJordan EgyptCote d’Ivoire Burkina FasoChad Bahrain Botswana Lebanon Tanzania ZambiaSouth Africa Cameroon NigeriaPakistan Tunisia MaliGuinea Conakry Saudi Arabia Rwanda

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Asia Pacific & Japan:KyrgyzstanUzbekistanKazakhstanAustraliaIndonesia KoreaTaiwanHong KongSingaporeNew ZealandMacauMalaysiaPhilippinesThailandIndiaVietnamFijiBhutanGeorgiaJAPANSri LankaBrunei

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Europe:

Germany Cyprus Ireland France Czech Republic LatviaUK Denmark LithuaniaSpain Estonia

LuxembourgItaly Finland MaltaAustria Greece NetherlandsBelgium Hungary NorwayBulgaria Iceland PolandPortugal Romania SlovakiaSlovenia Sweden SerbiaMontenegro Switzerland

LiechtensteinBosnia Russia BelarusCroatia Turkey UkraineHerzogovina Macedonia Albania

Caribbean & Central America:

Costa Rica Trinidad/TobagoPuerto Rico El SalvadorGuatemala HondurasCuraçao NicaraguaBermuda PanamaBahamas Cayman IslandsBarbados ArubaJamaica Dominican

Republic

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Gardasil / Silgard ApprovalsGARDASIL approved in 127 countries (includes 24 GAVI-eligible)

GAVI – Eligible Registration Approvals (24): Burkina Faso, Cameroon, Central African Republic, Chad, Congo (DR), Cote d’Ivoire, Ethiopia, Guinea (Conakry), India, Kenya, Kyrgyzstan, Malawi, Mali, Mauritania, Nicaragua, Nigeria, Pakistan, Rwanda, Tanzania, Togo, Uganda, Uzbekistan, Vietnam, Zambia

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Routine immunization of Male with Gardasil in US and Australia ( and Canada)

Accessed 26 Oct 2011http://www.cdc.gov/media/releases/2011/a1025_ACIP_HPV_Vote.htmlhttp://www.merck.com/newsroom/news-release-archive/vaccine-news/2011_1025.htmlhttp://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2011-11/nov-2011-pbac-outcomes-positive-recommendations.pdf

US: 11 - 21 Male

Australia: 12 - 13 Male

18Read TR Sex Transm Infect. 2011 Oct 4

The near disappearance of genital warts in young women 4 years after Gardasil program in Australia

Female <21: ↓ 90% Male <21: ↓ 87%

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2 in 1 HPV vaccine

UK Health Protection Agency Report 2010

UKUK AustraliaAustraliaRead TR Sex Transm Infect. 2011 Oct 4

Data are NOT generated from head-to-head study and results are NOT directly comparable because of differences in the methodologies and analysis populations.

4 in 1 HPV vaccine

Trend of genital warts after universal HPV vaccination

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To prevent vaccine type relatedFemale: Cervical 、 vaginal 、 vulvar Cancers and genital warts

Male: genital warts

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4-in-1 HPV vaccination Regular Pap screening

HPV vaccine is for men and women