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Herpes Papillomavirus (HPV) and Varicella-zoster Virus (VZV) Vaccination

Herpes Papillomavirus (HPV) and Varicella-zoster Virus (VZV) Vaccination. Ellen Barbouche, MD Primary Care Conference 18 April 2007. Learning Objectives. No financial disclosures Review HPV and VZV vaccination efficacy, adverse effects, and guidelines. Case 1.

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Herpes Papillomavirus (HPV) and Varicella-zoster Virus (VZV) Vaccination

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  1. Herpes Papillomavirus (HPV) and Varicella-zoster Virus (VZV) Vaccination Ellen Barbouche, MD Primary Care Conference 18 April 2007

  2. Learning Objectives No financial disclosures Review HPV and VZV vaccination efficacy, adverse effects, and guidelines

  3. Case 1 • 24 year old female for preventive health exam • “Should I get that HPV vaccine?” • History of cervical dysplasia treated with cryosurgery • On oral contraceptive

  4. HPV virulence • Low risk types (6 and 11) cause low grade cervical cell changes and genital warts • High risk types detected in 99% of cervical cancers • Types 16 and 18 cause 70% of cervical cancers • HPV associated with cancers of vulva, vagina, penis, anus, oral cavity and pharynx

  5. Sexual Activity

  6. Risk of HPV Transmission • Most consistent predictor of HPV infection is number of sexual partners • Females age 15-19 with median 1.4 lifetime male partners; age 20-24 median is 2.8 • Of sexually active women, 5.7% of 9th graders & 20.2% of 12th graders had >4 sex partners

  7. HPV Natural History • 70% of new infections clear within 1 year, 90% within 2 years • Persistent infection varies by HPV type

  8. HPV prevention • Correct and consistent condom use reduces HPV rates by 70% • Abstinence • Quadrivalent (types 6,11,16,18) vaccine

  9. HPV Vaccine Administration • 3 dose series: now, 2 month and 6 months • Contains no thimerosal or antibiotic

  10. HPV Vaccine Efficacy • 95.2% efficacy against CIN 1, CIN 2/3, or adenocarcinoma in situ • 98.9% against HPV 6,11,16, or 18 genital warts • 89.5% against persistent HPV infection • 100% effective against other types in women previously HPV exposed • Duration of protection studies now at 3 years

  11. HPV Vaccine Immunogenicity • After completion of 3 doses, >99.9% of participants had antibody to all 4 HPV types • Antibody titers after vaccination are higher than those after natural infection

  12. HPV Vaccine Adverse Events • 83.9% pain • 2.8% severe pain • 2% swelling • 0.9% erythema • 4% fever • <0.1% serious events, vaccine equal to placebo

  13. HPV Cost Effectiveness • Assume $377 per dose series, 90% lifetime efficacy: 58% reduction in lifetime cervical cancer risk and $24,300 per quality-adjusted life-year (QALY) • Assume $300 per dose series, $100 booster at 10 years, same efficacy: 62% reduction in lifetime cervical cancer risk and $14,600 per QALY

  14. HPV Vaccine Recommendations • Routine vaccination at 11-12 years • Catch up vaccination for age 13-26 Would you vaccinate Case 1?

  15. Case 2 • 71 year old male for hypertension follow up • “Should I get that shingles vaccination?” • Meds: Aspirin and Atenolol • PMH: HTN and THA

  16. Varicella-Zoster Virus (VZV) • Reactivation of latent VZV causes herpes zoster (shingles) • Risk of zoster increases with increasing age, beginning at 50 • Zoster develops in 30% of people over lifetime, and up to 50% of 85 year olds

  17. VZV Infectivity in US(prior to use of primary varicella vaccination)

  18. VZV Complications • Cranial or peripheral verve palsies • Encephalitis • Myelitis • Post-herpetic neuralgia • Most likely to occur if host > age 50 • Of people > age 60 with zoster, 40% have post-herpetic neuralgia

  19. Host Factors in Latent VZV Infection and Reactivation Kimberlin D and Whitley R. N Engl J Med 2007;356:1338-1343

  20. VZV Vaccine Strength • Varivax 1,350 plaque-forming units/dose • Proquad (MMR + VZV) 9,772 pfu/dose • Zostavax 19,400 pfu/dose • Higher titer due to decreased cell-mediated immunity in older population

  21. VZV Vaccine Efficacy Evidence • 38,546 subjects over age 60 followed for 3 years • Incidence of zoster 5.4 vs. 11.1 cases per 1,000 person-years, vaccinated vs. placebo (51% decrease) • Post-herpetic neuralgia: 0.5 vs.1.4 cases per 1,000 person-years, vaccinated vs. placebo (67% decrease)

  22. Adverse Effects of VZV Vaccine(All % vaccinated vs. placebo) • Injection site phenomena: • Varicella-like rash (0.1% vs. 0.04%) • Erythema (36% vs. 7%) • Pain or tenderness (35% vs. 9%) • Swelling (26% vs. 5%) • Pruritus (7% vs. 1%) • Cardiac events (0.6% vs. 0.4%)

  23. VZV Vaccine Contraindications • Prior anaphylactic reactions to gelatin, neomycin or other vaccine component • Immunodeficiency condition or immune suppressive therapy • Active, untreated tuberculosis • Pregnancy

  24. VZV Vaccine Cost • $14,877-$34,852 per QALY (assumes $150 per vaccination) • 17 vaccinations to prevent single case of zoster • Cost per prevented case $3,330 • 31 vaccinations to prevent single case of post-herpetic neuralgia • Cost per prevented case $6,405

  25. VZV Vaccine Questions • Vaccinate 50-59 year olds • Shifting VZV epidemiology • Primary vaccination • Duration of zoster vaccine efficacy • Immunocompromised quagmire • Diabetes mellitus • Steroids • Anticipated immunesuppression • Prior zoster

  26. VZV Vaccine Recommendations • Single dose to adults age > 60, regardless of prior varicella history Would you vaccinate Case 2?

  27. Bibliography Markowitz, LE et al. Quadrivalent Human Papillomavirus Vaccine. MMWR. 2007:56(RR02);1-24. Kimberlin, DW and Whitney, RJ. Varicella-zoster Vaccine for the Prevention of Herpes Zoster. NEJM. 2007;356:1338-43.

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