Ontario’s HPV Immunisation Programme

1. Ontario’s HPV Immunisation Programme What Went Wrong? CPHA Annual Conference 2 June 2008 Dr. Ian Gemmill Medical Officer of Health Kingston, Frontenac and Lennox & Addington Public Health

2. OUTLINE • HPV & its consequences • HPV vaccine • Description of Ontario’s programme • Negative publicity about HPV vaccine • Lessons learned

3. Thevirus Human papillomavirus • HPV is one of several species of the genus Papillomavirus in the Papovaviridae family • There are more than 200 types of HPV • HPV is a relatively small virus containing two strands of DNA within a spherical shell (capsid) HPV capsids, approximately 55 nm in diameter Image source: Dr Linda Stannard, UCT/Science Photo Library

4. Natural history of HPV infection The virus HPV infection 16, 18, other high-risk types 6,11, other low-risk types Transient infection Persistent infection Anogenital warts CIN II/CIN III CIN I/CIN II Regression Therapy Cancer Regression CIN = cervical intraepithelial neoplasia

6. 1 A remarkably strong association in cancer epidemiology Bosch FX et al. J Clin Pathol 2002; 55: 244–65.

7. 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

9. QUADRIVALENT HPV VACCINE:GARDASIL™

10. HPV VACCINE An excellent vaccine that promises to decrease HPV cancers dramatically Immunogenicity: ~100% seroconversion Efficacy: nearly 100% type specific efficacy protects against infection and CIN2 Safety: side effects are mild and short-lived fewer reactions than with placebo Duration of protection: unknown but at least 5 years Antibody decay curve looks promising ? 10 years to lifelong Cross-reactivity: HPV 45 & possibly HPV 31 DR. I. M. GEMMILL, MD, CCFP, FRCPC

11. National Advisory Committee on ImmunizationRecommendations for HPV Vaccine • Females between 9 and 13 • 2. 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.

12. 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

13. Hon. Jim FlahertyMinistre de Finance

14. Honourable Dalton McGuintyPremier of Ontario MCGUINTY GOVERNMENT LAUNCHES LIFE-SAVING HPV IMMUNIZATION PROGRAM

15. The programme: • announced on the 2 of August 2007 by premier McGuinty, one month before the beginning of the 2007 provincial election campaign • targets Grade 8 girls (13 to 14 years) • administered in schools

16. administered by local public health agencies • scheduled to begin just weeks after the announcement (1st September in Toronto, because of the large population) • during the same period, public health runs both universal influenza and HBV vaccine programmes

18. Canadian Medical Association Journal28 August 2007 ‘Human papillomavirus, vaccines and women's health: questions and cautions’ Abby Lippman PhD, Ryan Melnychuk PhD, Carolyn Shimmin BJ, Madeline Boscoe inf. DU

20. Maclean’s MagazineCATHY GULLI, 27 August 2007 ‘Our girls are not guinea pigs’ ‘Is an upcoming mass inoculation of a generation unnecessary and potentially dangerous?’ ‘Maclean's cover story re-ignites Gardasil debate’ ‘Canada's top doctor expresses concern’

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23. ‘Showdown in Texas over HPV vaccine order’ AUSTIN, Texas (AP) — Texas lawmakers rejected Gov. Rick Perry's anti-cancer vaccine order Wednesday, sending him a bill that blocks state officials from requiring the shots for at least four years. Perry has said he is disappointed but has not indicated whether he will veto the bill. He has 10 days to sign or veto it, or the proposal will become law without his signature. Lawmakers can override a veto with a two-thirds vote of both chambers. The legislation passed by well over that margin in both chambers.

24. Progress of the Programme • the programme is mostly complete for 2007-2008 • only 50% of eligible girls have accepted the vaccine • in some schools, none has been immunised • some teachers have discouraged girls not to take the vaccine • in some schools, girls who received the vaccine were ridiculed by their peers.

25. What went wrong? • negative publicity almost undoubtedly has contributed to the low uptake • a significant proportion of girls, their parents or both appear to have lost confidence in the vaccine • This reaction is completely different than the experience with HBV vaccine in the 1990’s, when complaints were from parents whose children were not eligible for the vaccine

26. What went wrong? • The large impact of the negative publicity was not anticipated by public health officials • There were some who advised not taking action to avoid giving credibility to the negative publicity • Others underestimated the impact or did not have time to get enough information out

27. Some Measures that Were Taken The Government of Ontario: • The Ministry monitored the co-operation of school boards • It provided web information and fact sheets • a new media campaign has since been launched The Council of Ontario Medical Officers of Health • Letters to both Maclean’s and to the CMAJ

28. Some Measures that Were Taken • Local action: • press conference • letter from the MOH to girls & their parents • increased information on HPV & the vaccine • questions answered by telephone and at clinics • support for the programme was solicited from other health professionals

29. Lessons Learned • Pay attention to negative and untruthful stories in the media • Do not underestimate the potential power and effect of the media to influence the public • Respond quickly and forcefully to counter mistruths or misinformation that is promulgated about vaccines

30. Lessons Learned • The public can quickly become mistrustful of a vaccine • People are prepared to believe mistruths about vaccine • Ensure that populations that are targeted for vaccine receive lots of information that is: • simple & clear • timely, accessible & plentiful

31. Next Steps Ontario needs to reconsider its HPV programme: extend eligibility of Grade 8 girls who have turned down the vaccine this year extend the programme to all female high school consider providing the vaccine to boys consider providing the vaccine to women out of high school

32. Next Steps Need to assess what factors were more important in parents’ decisions Ontario needs to promote its HPV programme better: more prominence of media ads better communication to students & parents timely provision of materials to local public health agencies

33. THANK YOU. QUESTIONS?