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Policy Update on the HPV Vaccine in South Carolina

Policy Update on the HPV Vaccine in South Carolina. Heather M. Brandt, PhD, CHES University of South Carolina Cancer Prevention and Control Program Arnold School of Public Health Department of Health Promotion, Education, and Behavior. Sarah R. Bryant, MPH University of South Carolina

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Policy Update on the HPV Vaccine in South Carolina

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  1. Policy Update on the HPV Vaccine in South Carolina Heather M. Brandt, PhD, CHES University of South Carolina Cancer Prevention and Control Program Arnold School of Public Health Department of Health Promotion, Education, and Behavior Sarah R. Bryant, MPH University of South Carolina Arnold School of Public Health Department of Health Promotion, Education, and Behavior Annual Meeting of the South Carolina Cancer Alliance • May 11, 2007

  2. Session Overview • This session will provide general information about human papillomavirus (HPV) and cervical cancer as well as the impact in SC. Public health policies related to prevention and control of cervical cancer will be discussed, including a look at the proposed HPV vaccine requirement - pros and cons. • Objectives: By the end of the session, participants will: • Understand what HPV is and its impact on South Carolina. • Understand what can be done to prevent cervical cancer. • Understand how a policy study can be used to determine South Carolina's readiness for mandatory HPV vaccination. • Understand that South Carolina may not ready for mandatory HPV vaccination.

  3. Epidemiologic Overview of Cervical Cancer and HPV

  4. Cervical Cancer Worldwide • 7th most frequently occurring cancer overall (2002) • 2nd most common cancer among women worldwide (2002) • 493,000 new cases • 3rd most common cause of cancer-related deaths among women worldwide (2002) • 274,000 deaths • Much more common in developing world • 83% of new cases Source: Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005 Mar-Apr;55(2):74-108.

  5. Cervical Cancer Worldwide Estimated Number of New Cancer Cases and Cancer Deaths in 2002 Clear difference between developed and developing world Source: Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005 Mar-Apr;55(2):74-108.

  6. Cervical Cancer Worldwide Age-standardized Incidence and Mortality Rates for Cervical Cancer Eastern Africa Northern America Source: Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005 Mar-Apr;55(2):74-108.

  7. Public Health Problem: Excess Cervical Cancer Mortality Source: Freeman HP, Wingrove BK. Excess cervical cancer mortality: A marker for low access to health care in poor communities. Rockville, MD: National Cancer Institute, Center to Reduce Cancer Health Disparities; 2005. Report: NIH Pub. No. 05-5282.

  8. Cervical Cancer Disparities in SC • African American women are 1.5 times more likely to be diagnosed with cervical cancer than European American women in SC. • African American women are almost 2.5 times more likely to die from cervical cancer than European American women in SC. • African American women are more likely to report having a Pap test in past three years compared to European American women yet are less likely to obtain timely follow-up care in SC. Source: Brandt HM, Modayil MV, Hurley D, Pirisi-Creek LA, Johnson MG, Davis J, Mathur SP, Hebert JR. Cervical cancer disparities in South Carolina: An update of early detection, special programs, descriptive epidemiology, and emerging directions. J S C Med Assoc. 2006 Aug;102(7):223-30.

  9. HPV: The Basics • Very common and usually harmless sexually transmitted infection • Transmission is skin-to-skin (not through bodily fluids) • ~75% of sexually active people will acquire in lifetime • Most common among 15-24 year olds • Over 100 types of HPV • 40 types can infect anogenital region of males and females

  10. HPV: The Basics • Two categories of genital HPV infection • High-risk or oncogenic (cancer causing) • Cervical dysplasia (“abnormal cells”) and cervical cancer • Other types of cancer: penile, anal, vaginal, vulvar, oral, head and neck… • Low-risk or non-oncogenic (not cancer causing) • Genital warts

  11. HPV: The Basics • Prevention: How to STOP getting and/or passing on HPV • Use condoms • Avoid sexual contact • Limit number of sexual partners • Wait until older to have sexual contact • Vaccines (for females)

  12. HPV: The Basics • Detection: How to find out if you have or had HPV • High-risk HPV types • Females: having a Pap test and then an HPV DNA test • Males: No approved ways to know for sure • Low-risk HPV types • Looking at the genital area of males and females for genital warts that can be seen

  13. Gardasil®: First HPV Vaccine • New vaccine, called Gardasil® (Merck & Co.), for some types of genital HPV infection is available • Females age 9-26 • Four types of genital HPV infection • High-risk (oncogenic) types 16, 18 • Present in ~70% of cervical cancer cases • Low-risk (non-oncogenic) types 6, 11 • Cause ~90% of genital warts cases

  14. Gardasil®: First HPV Vaccine • Preventive vaccine • Ideally given before sexually active • No evidence of harm if given to female who already has HPV • Vaccines will not replace cervical cancer screening (but will likely change it in the future)

  15. Gardasil®: First HPV Vaccine • Virus-like particles – “copycat” or “look like” HPV types • Three doses (0, 2, 6 months) • How long the vaccine lasts is unknown • Studies will continue • Cost is about $120 per dose (~$360 total for three doses) • Public assistance programs • Private insurance

  16. Gardasil®: First HPV Vaccine • 100% effective in short term, cervical cancer and genital warts outcomes caused by four HPV types (6, 11, 16, 18) included in the vaccine • Very safe as demonstrated in studies thus far • Most common side effect is pain and soreness at injection site and mild fever in some women • Protects against: • Cervical cancer • Precancerous cervical lesions • Precancerous vaginal lesions • Precancerous vulvar lesions • Genital warts

  17. Analyzing Policy Opportunities for Mandatory HPV Vaccination inSouth Carolina Sarah R. Bryant, MPH USC Arnold School of Public Health Practicum for degree in Health Promotion, Education, and Behavior

  18. Background • Availability of an innovation, i.e. HPV vaccine • Mandatory HPV Vaccination Policy • South Carolina’s House Bill 3136 • 7th grade girls; 2009-2010 school year • Stay tuned for update! • Michigan’s Senate Bill 132 • 6th grade girls; 2008-2009 school year • not passed • Texas’s Governor’s Executive Order • 6th grade girls; 2008-2009 school year • still stands

  19. Purpose • This study was conducted to determine South Carolina’s readiness for a mandatory HPV vaccination policy.

  20. Research Questions • How much do policymakers and stakeholders know about HPV, cervical cancer, and HPV vaccines? • What do policymakers and stakeholders think about mandating the HPV vaccine? • What are the perceptions of South Carolinians’ opinions about the possible mandate according to policymakers and stakeholders?

  21. Methods • Study population • South Carolina • Legislators (Representatives) • Physicians • Researchers • DHEC Officials • Lobbyist

  22. Methods • Data Collection • semi-structured interview guide • knowledge of HPV, cervical cancer, and an HPV vaccine • opinions about mandatory HPV vaccination • perceived barriers to getting an HPV vaccine • the public’s perception of an HPV vaccine

  23. Methods • Data Collection • in-person, telephone, email, or fax interviews at about 20 minutes each • recorded field notes and paraphrased responses • Data Analysis and Interpretation • Constant Comparison Method • responses grouped by theme • Also analyzed by another person

  24. Format 4 in-person 10 telephone 2 email 1 fax Sample Description 7 Legislators 3 Physicians 4 Researchers 2 DHEC Officials 1 Lobbyist Results • 17 Interviews Conducted

  25. Results • Major Themes • Limited knowledge • mixed knowledge about HPV, cervical cancer, and an HPV vaccine among participants • Variable attitudes • mixed attitudes about an HPV vaccination mandate

  26. Results • Barriers to HPV vaccination • the vaccine’s cost • lack of information about the vaccine • parental acceptance of the vaccine • Perception of the onus of cost • both private insurance and the government should pay for an HPV vaccine, regardless of mandatory status

  27. Results • Public perceptions • public has mixed views about HPV, cervical cancer, and an HPV vaccine, if they know about it • if mandated, most of the public will get vaccinated, regardless of how much they know about the vaccine

  28. Results • Facilitating factors of mandatory HPV vaccination policy • high level of vaccination if required • 95% vaccination rate • increased availability of funding • could reduce gaps in who has access to the vaccine • could result in greater public health impact by reducing numbers of cases and deaths from cervical cancer

  29. Public Views of HB 3136 • Ancillary examination of public opinion throughout project period exuded some study results • WLTX.com Posts • In general, demonstrated a lack of education about HPV, cervical cancer, and HPV vaccine • “I've been doing my own research and there are 21 different strains of HPV, this shot only protects against 5.” • “This is just another way to make money for the drug manufacturing companies.”

  30. Public Views of HB 3136 • Published public comments • “If it is sexually transmitted, then what about the boys?” • “Why would we want our children to be the drug companies guinna [sic] pigs?” • “Boys are getting this HPV from girls who do not know that they are affected and passing it on to another girl. (Engaging in SEX)”

  31. Public Views of HB 3136 • Published public comments • “The lawmakers, politicians, and lobbyists who support this bill should have a vasectomy and/or their tubes tied.” • “Parents should have to apply for a license to have kids.”

  32. Public Views of HB 3136 • Published public comments • “The state and gov't needs to look into the families that just keep having babies and living off the welfare system, why not mandate that they get their tubes tied or a vasecotomy [sic] after the 4th or 5th kid?” • “Sign my child up and let me not worry about talking to her about sex and STD’s.”

  33. Public Views of HB 3136 • Published public comments • “Nanny state politics.” • “Stop the madness!!! Stay out of my life.” • “Do we live in a communist country?” • “So by 2009 it will be mandatory, I guess I will be home schooling my children.”

  34. Mandatory HPVVaccination now? • March 21, 2007 • Passed Subcommittee • Health and Environmental Affairs (3) • April 12, 2007 • Passed full Committee • 3M: Medical, Military, Public and Municipal Affairs Committee (18) • April 18, 2007 • Bill tabled (by Rep. Brady)

  35. Mandatory HPVVaccination in the future? • 2 ways vaccine could be funded • Unfunded mandate (Medicaid) • Funded mandate (DHEC) • 2008 fiscal year • Not in DHEC budget • 2009 fiscal year • Wait and see • DHEC will mandate in 2009

  36. Conclusions • Mandate Premature • Vaccine perceived as too new • not enough data to show safety and efficacy • Parental right interference • should be parents’ choice • Lack of public knowledge

  37. Conclusions • Variation in knowledge levels of HPV, cervical cancer, and an HPV vaccine • Legislators as compared to Physicians, Researchers, and DHEC Officials

  38. Conclusions • Variation in opinions about mandatory HPV vaccination • government’s right versus for the greater good • Consensus that young females should be vaccinated, regardless of mandate

  39. Recommendations • Public health education • HPV, cervical cancer, HPV vaccine • SC Cancer Disparities Community Network • efforts to provide educational materials and programs to address gaps in knowledge • Connect public health researchers with policy efforts

  40. Lessons Learned • Legislative process has many layers • Few legislators make decisions for many people • Timing of policy is key • Opportunities for coordinated public health education and advocacy • Public health education must come before legislation • Physicians and researchers may lack knowledge about the legislative process

  41. Cervical Cancer Prevention and Control Policy Success & Opportunities in South Carolina

  42. Policy Across the U.S.

  43. Policy Success in SC • Best Chance Network • National Breast and Cervical Cancer Early Detection Program • Breast and Cervical Cancer Treatment Act • Expand Medicaid coverage to provide treatment to all uninsured/underinsured women in South Carolina

  44. Policy Opportunities in SC • HPV vaccines • Mandate? • Funding for DHEC? • Follow-up care of abnormal Pap tests (i.e. cervical dysplasia) • HPV DNA testing? • Colposcopy? • Repeat Pap testing? • Treatment of cervical dysplasia?

  45. Next steps…For what policy change can we (SCCA) advocate to eradicate cervical cancer among women in South Carolina?

  46. Educational Resources • HPV educational materials and messages for women (partially informed by results of SC study) • Go to: http://www.cdc.gov/std/hpv/default.htm • HPV educational materials and messages for health care providers (partially informed by results of SC study) • Go to: http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine-hcp.htm

  47. Educational Resources • American Cancer Society • 1-800-ACS-2345 (227-2345) • National Cancer Institute (NCI) Cancer Information Service • 1-800-4-CANCER (422-6237) • NCI Understanding Cancer Series: HPV Vaccine • Go to: http://www.cancer.gov/cancertopics/understandingcancer/HPV-vaccine

  48. Contact Information Heather M. Brandt, PhD, CHES University of South Carolina Cancer Prevention & Control Program 2221 Devine Street, Suite 200 Columbia, South Carolina 29208 Tel: 803.734.4428 Email: hbrandt@sc.edu Complete list of scientific references are available upon request.

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