Cervical Cancer Treatment

>>> good afternoon.i'd like to welcome you to the february 2013 session.please to welcome to the grand rounds the georgia state nursingprogram, go panthers. grand rounds content is alsoavailable on facebook and twitter.the whole listing is available at cdc.gov/science.so here is grand rounds, we love data.we love explaining it even more. here is the data point for theaverage number of years i've known the presenters, just under20.

there are only two logicalconclusions i can draw. one is that we all met in gradeschool and that somehow i'm the only one over 30.so in addition to the speakers listed here, we will haveconcluding remarks i by dr. lauri markowitz.now i'd like to introduce dr. thomas frieden. >> hpv is a serious public health problem. but it's one for which wehave a solution. in fact we have several solutions.

the challenge is to scalethem up. so what you'll hear about thisafternoon is the burden of hpv, the progress we've made inscaling up the vaccinations and some of its barriers that we'refacing, barriers in terms of costs, barriers in terms ofhealth care systems and our ability to reach the populationsmost at risk, whether they're in this country or abroad andvarious in terms of continuing innovation and the relationshipbetween vaccination and screening and treatment.so it's an interesting topic and

an important one.it's one of the many topics that shows how essential it is thatwe get the interface between public health and clinicalmedicine right in order to protect people as effectively aspossible. we have an effective anti-cancervaccine. the challenge is that we have not framed it as such nor scaled it up as such.so moving forward, i think it's very important that we recognizethat we can control hpv, the most std in the u.s. and indoing so, we can prevent many

cancers and significantmorbidity as well as health care costs.but it's not going to be easy. because there are realchallenges and, yes, there are enormous opportunities.so the sooner we get on with it, the more people we can protect.thank you very much. >> our first presenter is dr.mona saraiya. >> thank you.good afternoon. i'll be introducing the burdenof hpv associated diseases in the united states.hpv are a family of more than

120 closely related doublestranded dna viruses that are identified with types.hpv infection is restricted and is somewhat shielded from theimmune system. humural and cellular responseshave been identified. not all of those are aneffective immune response. the hpv types differ.there are approximately 40 types found in the general tract andthese are groups of high risk or cancer causing and include hpv16 and 18. persistent infection with thesetypes can result in cancers as

well as low grade cervicaldisease. low risk or can cause gitilewarts. and it can cause hand foot andwarts. hpv infection is very common.almost all sexually active persons will contact hpv in theunited states. genitile hpv are infect withintwo years of sexual activity. infection is usually transientand not associated with symptom. an infection with one type ofhpv is not affected by another type.cancer requires persistent

infections with high risk types.these are data from the national health and nutritionalexamination survey showing prevalence of hpv from vaginalswabs by age. the peak point prevalence ofboth high risk, over 40%, and low-risk types, about 35%, is inthe early 20s. it's important to understandthat point prevalence means current infections and does nottranslate into current cancer risks because most of theseinfections essentially clear. before i focus on the burden ofcancer caused by hpv, i want to

review the burden of diseasecaused by low-risk hpv types. there are over 300 thousand newcases of genitile warts each year.although benign conditions that doesn't progress to precancer orcancer, genital warts may present treatments of psychosocial stigma. recurrent of rrp is a rarecondition in which warts grow in the throat.rrp can occur in children as well as adults and can result inairway obstruction requiring multiple surgeries.this slide shows a step of

cervical carcinogen sis.hpv infections are usually transient and are oftenassociated with mild cry toe logical abnormalities.these mild cytological abnormalities are the basis forscreenings. persist infections with hpvtypes, in the peak of precancer occurs in the late 20s and thepeak of cancer incidents occurs in the late 40s -- mid to late40s. the one hpv associative cancerfor which screening is routinely recommended for is cervicalcancer.

cervical cancer screeningtraditionally has consisted of a pap test where a spatula is usedto collect cells from the surface of the surface.a biopsy may be indicated to prevent next step formanagement. in the past decade, hpv testinghas been added to the screening. with the pap to allow forincreased sensitivity of detention of high gradeprecancer and allowing for state's extension of screeningintervals. in the united states, cervicalcancer recommendations now

include both pap and hpv testingand for the first time recommendations from variousgroups are in near complete harmonzation.the three major organizations, the american cancer society, theu.s. prevent he services task force and the american collegeof obstetricians and gynecologists now recommend allwomen start screening at age 21. between ages 20 to 39, theyshould be screened with a pap only every three years and notthe hpv testing due to the natural history of hpv incervical cancer.

starting at ages 30 to menactually have a choice between screening with the hpv and thepap test every five years, known as cotesting, or every threeyears, with the pap alone. both oorgzs that consider thisissue recommended screening vaccinated women in the same wayas unvaccinated women. information on the burden ofcancers in the united states comes from our cancer registry.100% of our population is covered with u.s. cancerregistry, whether considered part of a national program ofcancer regular strer i funded by

cdc in green or part of theregistry funded by nci. full coverage allows for goodcharacterization of cancers associated with hpv and willallow examination of geographic, racial as well as otherdisparities. these are data from the annualreports of the nation which is published by three leadorganizations on cancer surveillance, acs, cdc and thenci and this year's focus was on hpv and associated cancer.and it shows the average number of cancers overall and bisectsfrom 0 5 to 2009.

there were approximately 32,000cancers that were hpv associative.35% of which were cervical and 36% were oropharyngeal.55% of associated cancers were cervical.among males, the most common cancers was oropharyngealcancer. since the cancer registries donot routinely collect cancer status, it's defined as canceroccurring at a specific anatomic site.in addition to invasive cancers, we estimate from administrativedata or cancer registry data, an

estimated 1.4 million cervicaldecember of cervical cancer and another 40,000 of the highestgrade of an kral, vulvar and vaginal precancers.there are some differences in the associated cervical cancerrates with higher incident rates among his panic, black andamerican indian alaskan native women compared with whites andthe anogental controls and vaginal cancers are slightlyhigher among black females. in the past decade,oropharyngeal cancers have been increasing in the united states.they have been increasing by

both genders, but more amongmale and female and increasing most among racial ethnic groupsexcept african-american. there's also been an increase inanal cancers among both female and males and across all racialethnic groups. there have been studies thathave been conducted to look at the percentage of cervicalcancers contributed to the specific hpv types using hpv dthis a detection. it was detected in 17% ofcervical cancers worldwide. with the other high risk typesfor a smaller percentage.

these data and other similardata lead to development of vaccines focused on preventionof hpv-16 and 18 as dr. dunne will discuss later.in the u.s., we've conducted special study using populationbased cancer registries to update our estimates for hpvtype specific cervical cancer as well as other cancers.we found 66% of cervical cancer, 55% of vaginal cancer, 79% ofannual cancers and 62% of orophayngeal could be attributedto hpv 16 or 18. 21,000 are attributable to 16and 18.

this slide shows the cost of hpvassociated disease in the u.s. taking into account the burdenof cancers and other hpv associative disease.total costs of hpv associative diseases, $8 billion.including $6.6 billion due to routine screening.with new technologies, it's hoped that there can be moreefficient screening augmented by more organized screening systemsand vaccinations leading to a reduction of the screeningcosts. in summary, hpv is a commoninfection and a cause of both ma

little nant and nonmalignantdisease. the outcomes are burdensome,costly and sigma advertising. approximately 26,000 of thecancers are thought to be hpv attributable with 211,000 peoplepotentially preventable by the current vaccines we have.anal and oropharyngeal cancers, there are new screeningguidelines that are nearly harmonized in the united statesand screening recommendations are unchanged for vaccinatedindividuals. but this might change in thefuture with higher vaccine

updates and is betterinformation. i would like to now introduceyou to dr. eileen dunne. >> good afternoon.i'll be presenting an overview of hpv sacks evens and impactmonitoring in the u.s. with a focus on buy logic outcomes andsafety monitoring. there are two hpv vaccinesavailable. the guardasil and cervarex.both are made with vlps which are made with one of the outervaccines of the virus. and they provide protectionagainst specific types.

the dlps do not include anyinfectious materials. gu ari dasil is made with 16-18blps. the vaccination schedule issimilar. three dozes over six months asnoted. in clinical trials, thesevaccines have demonstrated to have high efficacy in thepopulation, both women and men who did not have evidence ofexposure or infection to specific hpv vaccine typesevaluated. for cervical precancers, theyhad over 92% efficacy in

females.for vaginal and vulvar precancers, quad row valentdemonstrated 100% efficacy in females.for annual cancers, it demonstrated 75% efficacy inmales. there are no clinical trial datato demonstrate efficacy for prevention of oropharyngeal orpenile cancers. however, it is likely to provideprotection for these outcomes, as well.there has been an evolution of hpv vaccine recommendations inthe u.s. over the last seven

years.based on available data and new vaccine licensures andindication. the quadrovalen vaccine wasrecommended in june 2006. it was recommended for females11 through 20 years of age. in october of 2009, the bivalentvaccine was licensed to be used. a recommendation changed to k dquadrovalen through age 26 years.in october 2009, the quad quadrivalent hpv was licensedfor males to prevent genital warts.from 2009 to 2011, more data

became available to considerrevised recommendations for men, including cost-effectiveness,efficacy for prevention of anal cancer, burden of disease.in october 2011, the it was recommended the vaccine formales 11 through 21 years. these are the current hip/hpvvaccine recommendations. the routine vaccination offemales age 11 and 12 years and routine vaccination of males age11 or 12 years with three doses of quad row valent hpv vaccine.the recommendation for older ages differ with vaccinationthrough 26 years for females and

through age 21 years for males.monitoring of hpv vaccines in the u.s. includes a variety ofdifferent objectives, such as vaccine safety, impact oninfection and disease burden, vaccine coverage and evaluationsof behaviors and attitudes. on the far right are examples ofsome of these activities. for this talk, i will focus onthe first objective, vaccine safety and impact on infectionand disease burden. and shannon and amy will discussvaccination coverage in the u.s. later.there are also ongoing efforts

with national surveys toevaluate behaviors and attitudes, including pap testingbehavior and sexual practices over time.vaccine safety monitoring is important for a number ofreasons. high safety standards arerequired of vaccines as these products are given to healthypopulations for prevention of disease.although there are rigorous safety requirements forprelicensure trials, these trials are often too small todetect rare events.

and special populations may notbe adequately represented. finally, post licensuremonitoring of vaccine safety is critical to maintain publicconfidence and immunizations. there are three main systems inplace for post licensure vaccine safety.these include the vaccine event reporting system or vars.this is a national spontaneous or passive reporting system inwhich providers, patients or others report adverse eventsfollowing vaccinations. the system can detect if there'sa potential vaccine safety

concern or signal.but it's not designed to assess causelty.there's also the vaccine safety data link or bfc which is asystem that evaluates rape and risk estimates for variousoutcomes and provides a near realtime evaluation throughrapid cycle analysis on specific safety concerns.finally, the clinical elimination safety assessmentcan evaluate clinically complex vaccines and research onbiologic mechanisms. i'd like to summarize the safetyevaluation of hpv vaccine.

among over 600,000 doses adminstrered to females age 9 through 26 years, there was no increasedrisk for any of the presess phied events, includingguillain-barre syndrome, squeeze your and syncope.so far, the total doses admin stri sistered through 2013include over 2 million doses. about 270,000 doses given tomales. forecancers, an estimated 70% ofcervical and 90% of noncervical hpv associative cancers arepotentially preventable by either vaccine.and this is about 21,000 cases

of cancer each year.13,000 are in women and 8,000 are in men.in addition, there's a large burden of cervical pap testabnormalities. an estimated 30% to 70% of theseabnormalities detected through routine cancer screening arepreventable by either vaccine. this is about a million cases inwomen each year. finally, 90% of genital wartsare preventable by quad row valent vaccine.cases of genital warts in men and women each year.outcomes are based on the

timeline when reductions may beobserved. this includes early, mid .latemeasures. these evaluations includenational, regional and state specific data and generalpopulations as well as other select populations.there are also ongoing studies conducting effectiveness,including valuations of different number of doses.many of these surveillance or research evaluations will dependon laboratory assessments. some examples include studies ofhpv press lens in the u.s.

population and studiesevaluating hpv type specific precancers and cancers.there are a number of unique challenges to monitoring hpvvaccine impact from biologic outcomes.most outcomes are not nationally recordless and require newsystems and evaluation. many of these outcomes requirecervical cancer screenings, so changes in screeninings,recommendations may impact monitoring efforts.also, there are various stakeholders and finally,laboratory testing is not

routine.it requires professional updates.some of the current activities include evaluations of earlymeasures, such as the national health and nutrition examinationsurvey or enhane in which hpv types are being measured.and evaluations of genital warts.mid measures impact include studies and evaluations ofcervical precancers. .finally, late measures includeevaluations of cervical and other hpv associative cancers,which may take decades to

change.these are the first data reporting impacts of vaccine onbiological impacts from australia.hpv vaccination in australia began for girls in 2006.in 2007 for older girls and young women through a freeprogram. it's important to note thataustralia keeps rapid vaccine updates in females within a fewyears after introduction. about 70% through vaccine dosecoverage in a school-based immunization program.this left the proportion of

women attending sexual healthservices clinics in australia between january 2004 anddecember 2010 with genital warts.there was a 7 % decline in genital warts after vaccineintroduction. of note, there have beendeclines in genital warts in heterosexual men who did notreceive vaccines, possibly indicating herd immunity.these are genital warts trends from a large u.s. healthinsurance claim database from 2003 to 2010 in the u.s.and in the u.s., vaccine was

first introduced in late 2006.so these data cover a prevaccine and a post vaccine period.most notable is the decrease in incidents of genital warts in 15to 19-year-old females noted in dark pink since late 2006, whichis evidence of potential early impact of vaccine.this is a 38% reduction in genital warts from 2.9 cases per1,000 in 2006 to 1.9 cases per 1,000 in 2010.the vaccine uptake is considerably lower in the u.s.making the decline less than that seen in australia.these reduction in genital warts

could be even greater withcoverage in the u.s. to summarize, we have two verysafe and effective vaccines that are routinely recommended forall 11 or 12-year-olds and there is the poeshl to prevent a largeburden of cancer diseases through vaccination.ongoing surveillance and research are important for anumber of reasons. this includes post licensuresafety surveillance as well as impact of vaccination on buylogic outcomes. special violations, for example,measuring less than 3% dose

vaccine effectiveness are underway. it's only about seven yearssince the vaccine was first licensed.and this is very early to measure outcome on said outcomessuch as cancers. however, there is evidence ofintact of occurrence of genital warts from the u.s. andaustralia. increasing hpv vaccines coveragein the u.s. is important to reduce cancers and diseases dueto hpv. i'd like to introduce our nextspeaker, shannon stokley.

>> thank you and good afternoon.today i'll describe the u.s. vaccination program and reviewcoverage levels among adolescents in the u.s..finally summarize some of the factors contributing to lessthan optimal vaccinaels. within the u.s., hpv is one ofseveral vaccines that are recommended for adolescents withthe other vaccines being t-dap, ma anyone goccal vaccine and anannual flu vaccine. primary care providers,including pediatrician and family physicians.and but publicly funded clinics

including federally qualifiedhealth centers, public health departments.and the hpv vaccine is widely available.according to a national survey, 98% pediatricians.and the vaccine is covered by most private health insurancecompanies in government and insurance companies.and when discussing the u.s. vaccination program, it'simportant to mention the vaccines for children programalso called vfc. that was enacted in 1994 byfederal legislation and the

purpose of the program is toremove the barriers to vaccination.and the program providing federally purchased vaccinesrecommended by the advisory committee on immunizationpractices at no cost to eligible children.and these children eligible for vfc include those who are 18years or younger, medicaid eligible, uninsured or americanindian or alaska native devent. that means their private healthinsurance did not cover the full cost of the vaccine.approximately 39% of adolescents

13 to 17 years of age areeligible for vfc vaccine. nationally, there areapproximately 44,000 provider sites enrolled in the programand provide vfc vaccine. so in the u.s., we monitorvaccination coverage among the adolescent population throughthe national immunization survey team, also called nis teens.and the nis team was implemented in 2006 and in 2008 the surveywas expanded to provide state level estimates.and the nis team had a random television survey of u.s.households with an adolescent 13

to 17 years of age.all analysis are limited to adolescents with providerimmunization histories. and shown on this slide arenational vaccination coverage levels among adolescentes from2006 through 2007 by vaccine. and for this slide and the onesthat follow, vaccination coverage for hpv is amongadolescent girls only. and as of 2011, 78% ofadolescences have received the t-dap vaccine and 70% hadreceived the meningococcal vaccine.but in contrast, only 53% of

girls have received one or moredoses of hpv and only 35% had received all three doses of theseries. and so each year we see gains ofabout 10 percentage points or more for t-dap and ma anyonegoccal conjugate vaccine. but for the past year, we'veseen very little for hpv. as you can see, there'stremendous variation in coverage across the country.and coverage ranges from a low of 32% to a high of 76% in rhodeisland. and here we show vaccinationcoverage by poverty status.

and hpv is one of the mostexpensive vaccines available, costing around $130 a dose.and when the vaccine was first licensed, there was concern thatmany low income teens would not be able to receive this vaccine.however, we see that vaccination coverage is significantly higheramong girls living below the poverty level compared to girlsliving at or above the poverty level.this is an unusual pattern and that's something we observedwith other vaccines. and we think this fundinghighlights the importance of the

vps program to help providevaccines for children who may not otherwise be able to affordthem. now, for one or more doses ofhpv, coverage of significantly higher among blas black and hispanic girls compared to white nonhis panic girls.for three doses of the vaccine, his panic girls havesignificantly higher coverage compared to white nonhis panicgirls. similar is the result forpoverty status. this is an unusual pattern withthe hpv vaccine.

>>> and another importantmeasure we evaluate with respect to hpv is vaccine completion.and by completion, we mean among the girls that start the series,how many actually complete the series?and nationally, 71% of girls who start the series receive allthree doses. but while encouraging, and thishighlights that 30% of girls who initiate the series do not comeback to complete the series, and when we look at completion byrace ethnicity, we see that black nonhis panic girls areless likely to complete the

series when compared to whitenonhis panic girls. and we're currently conductingresearch to better understand the barriers like completing thehpv series, especially among the different racial and ethnicgroups. as mentioned previously, theroutine recommendation for boys was not approved until the endof 2011 and, therefore, the data we have available to usrepresents vaccination activities under the permissiverecommendation. and based on 2011 nis teen data,approximately 8% of boys have

initiated the hpv series.and so far, i've taken the vaccine among boys is followingthe same pattern as observed for girls, meaning coverage ishigher among boys living below the poverty level and higheramong black and his panic boys. and now i want to brieflydiscuss some of the challenges with achieving high levels ofhpv vaccination coverage and this really is a complex issueand are many factors involved. but today, i'll focus mainly onparental and environmental factors.and so one issue affecting hpv

vaccination coverage arevaccination intentions among parents of adolescent girls.since 2008, we have a suspect seeing intentions among parentsof unvaccinated girls. and this includes the totalpopulation of girls for survey years 2008 through 2011.and this bar graph shows the percentage of girls vaccinatedwith intentions to receive the vaccine among the unvaccinated.and each year, the proportion of vaccinated girls has increased,subsequently decreasing proportion who report that theyare somewhat or very likely to

have their daughter receive thevaccine. and the proportion of parentswho report that they are not likely to receive a vaccinewithin the next 12 months has remained consistent around 25%.and we don't know from the survey if this means that parenthave no intentions forever of vaccinating their daughter or ifthey are waiting until sometime in the future to have this cantheir daughter vaccinated. and within the nis team, we alsoask parents why they did not intend to vaccinate theirdaughter in the next 10 to 12

months.the main reasons include the vaccine is not needed ornecessary, their daughter is not sexually active, they areconcerns over the safety of the vaccine or concerns over sideeffects of the vaccine, lack of knowledge about the disease orthe vaccine itself and no recommendation by the provider.and it's been shown in many studies that a providerrecommendation is very important to vaccine acceptance.and most parents will follow the guidance of their provider.so when we have studied hpv

vaccine intent for practicesamong physicians, we see provider res less likely torecommend the hpv vaccine to their younger adolescentpatients. this slide shows results of thenational survey of physicianes and pediatricians.only a 51% of providers strongly recommend the hpv for theirrecommendations 11 to 12 years of age.and the percent who strongly recommend theccine increaseswith age. communication during the healthcare encounter is very important

to vaccine acceptance.common themes found from these studies show that the vaccine isoften presented as optional, whereas the other vaccines arerecommended. and also some providers expressmixed or negative opinions about the vaccine.and when parents express reluctant to the vaccine,providers were hesitant to engage in discussion.finally, some providers share the parents' view that it wasacceptable to delay the vax naep nation until the teen was older.one last challenge i wanted to

discuss was mixed vaccinationopportunities and a missed opportunity is defined as ahealth care encounter where one vaccine is administered, but notall vaccine res administered. based on 2011 nisp data, amongthose vaccinated for hpv, 70% had a missed opportunity.this means that the girl had a health care encounter andreceived a vaccine. they just didn't receive an hpvvaccine. vaccination coverage for thefirst dose of hpv could be as high as 90%.limb flating missed

opportunities requires that weaddress the parental ask provider attitude and practicesthat i previously mentioned. but this slide highlights thatit's possible to obtain high vaccination coverage for hpvkevin good the current vaccine delivery system.so in summary, hpv vaccination coverage among adolescent girlsis increasing, by slowly. and efforts are needed toachieve high coverage including provider coverage and attitudestoward the vaccine and increasing communication skillsamong primary care providers and

implementing the evidence-basedstrategy to increase opportunities.and with that, i'd like to introduce our next speaker, dr.amy middleman. >> thank you, shannon, and goodafternoon. this has been shown to play apart in increasing adolescent vaccination coverage rates inthe united states. these approaches include thedevelopment of an adolescent immunization platform, definedreally as a specific time period during which there is anexpectation of vaccine xlooes

completion, public policystrategies and provider strategies, including thoseimplemented at the practice levels and those that are morespecific to individual provider communication.one of the most important first steps in improving immunizationrates among teens really was the creation of the adolescent 11 to12-year immunization platform. this platform was first createdin 1996 when the recommended age for the tetanus dip thea vaccinewas moved from 14 to 11 to 12 years of age.since 2005, the cdc has added

meningococcal, t-dap and hpvvaccines to this platform, which are all recommended at this age.influenza vaccine is recommended for all adolescents, as well.building a platform and creating a health care visit with animmunization focus allows providers to focus on diseaseprevention, wellness and health promotion among this age group.in particular, there's the opportunity to provide improved,comprehensive health care, including screening andprevention of adolescent risk behavior.in addition, these specific age

recommendations for vaccinationvisits create a parental and provider expectation ofadherence to staep establish vaccine recommendations.once the platform has been built, public policy to supportimmunization can go a long way in improving immunization range.policy changes initiated by state and federal laws have beenimplemented to support hpv vaccination.policies have included school requirements, support for theutilization of alternative immunization sites and thesupport of insurance forms to

help strengthen reimbursementsfor vaccines. all states have requirements forchildhood vaccines and many states have passed legislationrequiring vaccines from the adolescent platforms for middleschool entries. as of the ends of 2012, 41states had a td or t-dap recommendation.while 13 states require meningococcal vaccine for middleschool students. in contrast, only two states,washington, d.c. and virginia, now have a school requirementfor hpv vaccine and both of

these requirements have broadopt out provisions. seven states require theeducation related to the hpv vaccine be provided to patientsof parents prior to middle school entry.14 states have passed legislation requiringdissemination of hpv vaccination education materials to parentsand the general public. past experience with schoolrequirements has shown great success in improvingimmunization rates and recent is he search has shown similarresults with respect to

adolescent vaccines.a 2012 study showed that for both t-dap and ma nij nij cmeningococcal vaccine have higher coverage than states withno requirements. among states who are onlyeducation requirements, there are no differences in coveragelevels when compared to states with no requirements.while school vaccination requirements improveimmunization rates, education requirements along did notresult in similar improvement. it's important for providers touse those visits to administer

school-required vaccinations asan opportunity to strongly recommend and add 34i7b sisterany remaining vaccines not currently required in theirstates. policies supporting the use ofalternative immunization sites may help improve immunizationcoverage among adolescences. the potential benefits of usingalternative sites improve the availability of vaccinations andproprovide referrals to facilities that accept patientsfor jog ongoing care. alternative sites can beparticularly helpful for

adolescents to complete multipledose regimens. alternative sites also provideexpanded hours, that provide greater access for adolescentswho have very busy schedules with school and extracurricularactivities. the safety of vaccination atalternative sites has been documented and by usingimmunization information systems, information regardingvaccines administered at alternative sites can bedocumented and then shared with the patient's medical health.while many parents may prefer to

have their child vaccinated inthe medical home, various study ves shown that parents of middleschool students are willing to utilize alternative site toescare to complete the vaccinations for theiradolescent. in this survey of 1838 parentsof middle school students attending schools in lowsocioeconomic status areas, while the majority of parentswere willing to use their medical home for immunization, 441% indicated that they were willing to use a school-locatedsite.

nearly all parents had receivedvaccines in the medical home, but very few parents had theopportunity to use the school's immunization program.the benefits of school-located vaccination are clear.a majority of adolescents who attend school can be immunizedand the potential is there to vaccinate a large number of addless ends. it's possible to reach manyadolescents who have not had access to health care.there are some challenges, as well.adolescent participation may be

limited to specific subgroups.there is a cost to provide vaccination in schools and itcan be quite high. it's difficult to builddifferent health plans for different immunization servicesand obtaining parental consent was one of the most commonlycited barriers when school nurses were asked about theirschool location program. the school located immunizationprograms can be challenging, but among those who choose aschool-located immunization program, hpv vaccination isdesired.

in a recent school locatedimmunization program, 522 middle school students eligible for thethe vfc program were immunized. among the 522 studentsimmunized, 410 students received a dose of hpv vaccine.insurance reforms are part of the affordable care act and mayalso impact adolescent vaccine updates by decreasing out ofpocket expenses for both patients and providers.the aca dictates that insurance plans provide first dollarcoverage for all recommended vaccines when provided by anin-network provider, thus

decreasing cost barriers forparents and patients. for providers, an increase inreimbursement will help offset provider costs associated withadolescence vaccines. now i'd like to talk about theimportant ways that practices can improve uptick of hpvpractices through education, communication and qualityimprovement. providers can increase their ownknowledge regarding vaccine recommendations and the safetyof recommended vaccines using credible sources such as thecdc.

it's critical that providersimprove communication with parents and patients tostrengthen their hpv vaccine recommendations by providingaccurate, overall messages about the hpv vaccine and anticipatingand preparing to respond to specific concerns from parents.providers can also utilize clinical practice strategiesshown to improve immunization rates such as recall systems,screening tools and standing orders.the use of immunization information systems and the useof vaccination quick visits are

also helpful.quick visits in particular save time for families coming in forvaccinations only. here we see the recall systemsignificantly affects vaccination rates amongadolescents. adolescents who received areminder recall messages experience higher coverage ratesfor adolescent vaccines, including an approximately 73%higher rate for hpv vaccines than those who did not receiveminor recall messages. again, provider recommendationis key to improving immunization

coverage and should be based onclear messages to parents about the importance of the vaccinefor disease prevention. there are data clearlyindicating that hpv vaccine can prevent cancer, includingcervical, vaginal, vulvar and anal cancer.the vaccine is safe and effective and there are noserious adverse events associated with theadministration of the hpv vaccine.the vaccine is only effective if given prior to exposure to thevirus, so giving the vaccine at

a younger age is ideal.further support for immunizing is that vaccine introduceshigher antibody levels when given to younger patients.the vaccine is recommended for both girls and boys to recollectfrom the outcomes. and while a discussion of modeof disease transmission may be appropriate, the way the diseaseis transmitted should not be a factor in determining the valueof preventing disease. the vaccine is extremelyeffective and it prevents cancer.this is primary prevention truly

at its best.despite the power of these key messages, many parents andproviders still worry about what should be discussed with a youngadolescent patient regarding the hpv vaccine.how much information should be given regarding the disease thevaccine prevents and whether it's necessary to discuss othersexual health issues. the discussion with patientsabout the mode of viral transmission should be ageappropriate. if the patient isdevelopmentally young

11-year-old, an in-depthdiscussion regarding the sexually transmitted nature ofthe virus is not necessary or even necessarily appropriate.although the vaccine is ideally administered to 11 to12-year-olds, for youths who are more developmental advanced orwho are chronologically older, it provides a great opportunityto enter into a larger discussion about sexual healthand sexual health maintenance. and for those who needreassurance, multiple study ves shown that vaccination with thehpv vaccine does not increase

sexual risk taking behaviors.so in summary, new immunization recommendations provide enhancedprimary prevention opportunities for adolescents.public health policy at the state and federal levels can beimplemented to support adolescent immunization andimportantly, providers can implement communication andquality improvement strategies in the office to improve addless enimmunization rates. .i'd like to turn the podiumover to dr. lauri markowitz. >> thank you.well, this grand round has

focused primarily on the u.s.vaccination program, i will very briefly mention some globalissues. the largest burden of hpvassociated cancer worldwide is from cervical cancer.and of note, cervical cancer is the second most common cancer inwomen worldwide responsible for over half a million cases and aquarter of a million deaths each year.and most of these occur in developing countries wherethere's no cervical cancer screening programs.and as you can see on this map,

the burden of cervical cancer isgreater in parts of africa, asia and south america.now, since hpv vaccines were first licensed in 2006,vaccination programs have been introduced in more than 40countries worldwide. and most of these countries andthe first country to introduce vaccines were developedcountries in north america, western europe and australia.in the past few years, other countries in latin america andsome other middle income countries have also introducedvaccines.

and challenges to theintroduction of the vaccine include expense of the vaccine,competing priorities with introduction of other newvaccines and the adolescent target age group.now, there were a variety of efforts supporting hpv vaccineintroduction worldwide and cervical cancer prevention,particularly in countries with high burdens of disease.of note, w.h.o. recommendses intrux of hpc vaccine as part ofa strategy for prevention of cervical cancer and this year,the global alliance on vaccines

and immunizations will find thehpv vaccine for the first time in selected eligible countriesand support for cervical cancer prevention throughpublic/private partnership and focusing on the screening isalso ongoing. one of the examples is theinitiative which seeks to provide screening and treatmentin low resource countries with high burden of disease.the capacity for cervical cancer screening, of course, will varyby country. so in summary for the entiresession, i just want to say

there's a substantial burden ofhpv associated with disease that can be decreased by use of areavailable safe and ekive hpv vaccine.in the united states, vaccine coverage is below target goals,but programs are in place as we heard today to monitor coverage,safety and impact post licensure as well as measures that can beimplemented to improve vaccine uptake.and provers being made in low income countries where cervicalcases and death occur and a large burden exists.thank you.

>> okay.well, thank you all for your attention.and i'd like to open the session now to the question and answerperiod. >> thank you very much to theentire panel for an excellent set of presentations.my question is, well, this is encouraging, but slow progressso why don't we go where the money is inspect the mostsuccessful programs in the united states are vaccinatingchildren under the age of 2. wasn't considered that thisvaccine might be given to very

young children when it was firstbeing looked at? if not, why can't we consider itnow? >> as you know, the vaccineright now is licensed down to 8 to 9 years of age.that's because the trials were done in -- down to that agerange. and i think one of the mainconsiderations when the vaccine trials were designed was to tryto do the studies, first of all, in individuals where you wouldbe able to see impact from the disease and to focus on the agegroup where you would be able

to -- backing programs weretargeted at age group, you would be able to see impact soon.i think there are consideration, there has been a lot ofdiscussion about lowering the age for vaccination.there are some i think manufacturers start to go lookat this issue of being able to do trials in youngerindividuals. data on duration of protectionwas felt to be important early on before those trials wereundertaken. i think there's accumulatingevidence that there's very good

duration of protection aftervaccination. so i think some of these issuesare being discussed. but i think the main issue wastargeting the age group where the benefit would be able to beseen initially sooner than targeting at the youngest agegroups in early childhood. >> from our grand rounds socialmedia audience, are there states that have passed law toes allowteenagers to receive hpv vaccine without parental consent?>> hi. there -- you know, this theunited states, they have laws

about minor consent for healthcare and it really varies state by state.there are certain situations where minors can consent fortheir own health care. i know california recentlypassed a law that allowed adolescents as soon as age 12 toconsent to the hpv vaccine without parental consent.that's probably the youngest i've seen.most states, it really is you need parental consent.but there are a few exceptions, but they're few and far between.>> it looks like most of the

data you have on vaccine updateis for girls. i'm wondering if there's data onboys and whether parents are more likely to expressvaccination regarding sexual activity for their young son.>> because of the timing of the survey of when we conduct thenis team, the most recent data we had available was 2011.that really represented activity under the permissiverecommendation, not the routine acip recommendation.we're hoping with the 2012 data we'll have better informationabout a take young boys with

that routine recommendation.and as we saw, about 8% of boys have initiated the series underthe recommendation. we're starting to do more work,you know, surveying parents to understand their attitudes foradolescent boys compared to adolescent girls.i think right mow the most important thing is to do theeducation of the parents. most may not know their sonsneed this vaccine, too. they may think, yeah, thatvaccine is for girls. but we need to put it out thereand educate the parents that

they need this vaccine for theirsons, as well. i don't know if amy wants tocomment. >> from our twitter followers,do patients need to repeat the whole series of vaccinations ifthey miss a dose? >> they do not.no, they do not have to. they can just give a second doseor the third dose. a lot of people remain onschedule, but they do not have to repeat the entire series.>> my name is jim muler. given that there are either twoor four strains of hpv targeted

by these vaccines, yet there aremany more strains of hpv circulating, can you comment onconcerns that strains that are admitted in prevalence by thevaccine might be displaced by the emergence of other prevalenthpv strains and is that a concern?the question is really about type replacement?>> yeah. >> so that's something that'sbeing evaluated, but it's not hypothesizes to be an issue withhpv because of large cohort studies haven't shown that typesreplace each other.

but that is an ongoing --evaluations are ongoing around that question.>> john douglas. so i had a question regardingthe ideas about increased coverage for either dr.middleman or dr. stokley. given the difference in t-dapand mining for which many of those strategies wouldpresumably be appropriate, as well, what do you think isreally the best place to put our money and effort?in other words, you've got school based immunizations.you've been able to achieve high

coverage without school base,without recall systems. we seem to be dealing with areasonably unique situation that's got to do with parentalnervousness, provide r need. >> that's a great question.i think there are a number of -- i think there are data we stillneed. i'm not sure parents really dofeel that it is such a unique vaccine.i think a lot of provider hesitancy about this vaccine isassociated with the idea that perhaps parents are wary.but i'm not sure we have data to

support that.in fact, at my sthuginstitution we've done a study looking atthe difference in the way parents think about theimportance of hpv vaccine and the way providers think parentsthink about the hpv vax each. and we find that parents ratethe importance of hpv vaccine significantly higher thanproviders rate the parents' ratings.if you can follow that. .for the importance of hpv vaccine.so i think a lot of it does

switch to making sure providersunderstand that it's okay to divorce the sess message fromcancer prevention, disease prevention to the vaccine thatsaves lives and move on from there 37 i think we need to helpproviders get used to doing that because i think some of theiranticipatory fear of parental concerns may not always bewarranted. >> yeah.i mean, i really think, you know, the strategies is reallyworking with the primary care providers.we know the teens are going

there because they're gettingt-dap and meningococcal gone argue gconjugate vaccine. so they're going to theproviders, reminders for the physicians themselves, not justfor the parents, but with the system in place to remind theproviders to look at the immunization history andrecommend the vaccines that may be missing and try to give themduring that visit. and i really think strengtheningprimary care providers should be the priority.>> from twitter, when do you

expect to have data about thetrends in prevalence in cervical cancer as a result ofvaccination? >> we anticipate toward invasivecervical cancer, around 20 to 30 years.and it's highly dependent on the vaccine coverage.so the better the coverage, we will hopefully see an impact.but for preinvasive cancers, we expect to see that impact asearly as 10 to 15 years. >> thank you all for attendingpublic health grand rounds. please join us march 19th at1:00 p.m. for our next session

of public health grand rounds.