HPV prevention in adult women effective communication about national guidelines. Dr. Marc Steben

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1 HPV prevention in adult women effective communication about national guidelines Dr. Marc Steben

2 Contributors Dr. Jennifer Blake Chief Executive Officer Society of Obstetricians and Gynecologists of Canada Ottawa, Ontario, Canada Dr. Nancy Durand Department of Obstetrics and Gynecology University of Toronto Toronto, Ontario, Canada Dr. Susan McFaul Department of Obstetrics and Gynecology University of Ottawa Ottawa, Ontario, Canada Dr. Gina Ogilvie School of Population and Public Health University of British Columbia Vancouver, British Columbia, Canada Dr. Marla Shapiro Department of Family and Community Medicine University of Toronto Toronto, Ontario, Canada Dr. Marc Steben Department of Social and Preventive Medicine Université de Montreal Montreal, Québec, Canada 2

3 Disclosure/Conflict of Interest SPEAKER TO INPUT INFO All planning committee members have completed and signed a disclosure form. This program has been developed with the financial support from Merck Canada in the form of an educational grant to develop its content

4 Mitigating Potential Bias The planning committee for this program have reviewed all course content to be given in this online course to ensure the scientific validity and objectivity of the content and therefore has deemed there to be little potential for bias or conflict of interest in relation to the program content.

5 Objectives Personalize communication about the burden of HPV in an era of social media Communicate about the safety of HPV vaccine Prevent communication gaps between health care professionals and their patients Optimize adherence to Canadian guidelines about HPV vaccine in adult women 5

6 HPV EPIDEMIOLOGY 6

7 Case 1 A 38 year old patient is in a stable monogamous relationship (married with 2 children) She believes she does not need to consider HPV vaccination 7

8 Human Papilloma Virus Group of over 100 viruses Transmission o skin skin o skin mucosa Clinical importance: o 40 types prefer anogenital tract, oropharynx spontaneous resolution latent infection / persistent infection condyloma neoplasia/malignancy 8

9 Human Papilloma Virus Double stranded DNA virus More than 100 HPV types 40+ infect anogenital tract Low Risk HPV: non-oncogenic types High Risk HPV: oncogenic types 6, 11, 42, 43, 44 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82 Malignant transformation requires persistent infection & integration into host DNA Franco EL, et al. CMAJ 2001;164(7):

10 Prevalence of HPV infection HPV is not a reportable infection Most common STI in Canada and worldwide Prevalence in Canadian population is estimated by large international studies 1,2 Lifetime risk: over 80% will acquire a HPV infection 3 1. NACI Guan p et al. Int J Cancer 2012; 131 (10): Munoz et al. J Infect Dis 2004; 190:

11 Case 1 Review A 38 year old patient is in a stable monogamous relationship (married with 2 children) She believes she does not need to consider HPV vaccination The lifetime risk of HPV infection is 80% For any HPV infection, the highest five-year cumulative risk (42.5%) was observed among women aged 15 to 19 years; incidence thereafter decreased monotonically with age, but the lowest level (in women aged 45 years or older) was still 12.4%. 11

12 HPV VACCINES 12

13 Case 2 A 44 year old patient with external genital warts asks if her male partner should consider HPV vaccination 13

14 HPV Vaccine Efficacy Against Vaccine HPV Vaccine/HPV type Bivalent* Type CIN2+ Vaccine N cases Placebo N cases Vaccine Efficacy % (CI) HPV 16/18 7, , % (53-99) HPV 16 6, , % (47-100) HPV 18 7, , % (<0-100) Quadrivalent** HPV 16/18 7, , % (93-100) HPV 16 6, , % (91-100) HPV 18 7, , % (87-100) *Total vaccinated cohort: received at least 1 dose, cases counted day one after dose 1, normal or low-grade cytology at baseline; include prevalent infection at study entry, mean follow-up 14.8 months; 97.9% CIs. **Per protocol population: received all three doses, cases counted day one after dose 3; mean follow-up 3.5 years; 95% CIs CIN2+ = cervical intraepithelial neoplasia grade 2 or higher or adenocarcinoma in situ 1. Paavonen J, et al. Lancet 2007; 369: Kjaer SK, et al. Cancer Prev Res 2009; 2(10):

15 Quadrivalent HPV Vaccine Efficacy Against External Genital Lesions (Per Protocol Population) Endpoint Vaccine Cases N cases Placebo Cases N cases % Efficacy 95% CI HPV 6/11/16/18-7, , % related EGL 3 By type HPV 6-related 2 HPV 11-related 2 HPV 16-related 2 HPV 18-related 2 By disease Genital warts 2 VIN1 or VaIN1 2 VIN2/3 or VaIN2/3 1 1, , , , , , , , , , , , , , % 100% 100% 100% 100% 100% 100% < Kjaer SK, et al. Cancer Prev Res 2009; 2(10): Garland SM., et al. N Engl J Med 2007, 256(19): Markowitz LE., MMWR Recommendations and Reports, March 2007, 56(RR02):

16 Risk of HPV infection by age group Cumulative Risk of HPV Infection (%) Cohort of Colombian Women (n=1 610) Age at Baseline (years) Years Muñoz N et al. J Infect Dis 2004; 190:

17 Quadrivalent FUTURE III Mid Adult Women Trial (24-45 yrs.) HPV 6/11/16/18-related Persistent Infection, CIN, or EGL Quadrivalent Vaccine vs. Placebo Endpoint Quadrivalent vaccine (n = 1,910) Placebo (n = 1,907) # of cases # of cases Observed efficacy % 95% CI Persistent Infection CIN (any grade) CIN 2/3 or worse < EGL Condyloma VIN 2/3, VaIN 2/ NA NA Castellsague X., et al. Brit J of Cancer 2011, 105:

18 Immune Response to the Quadrivalent HPV Vaccine Appears to Prevent Re-infection or Re-activation of Disease with Vaccine HPV Types Endpoint Combined Results From 3 Phase II/III Trials MITT-2 Population* 40 Month Follow-up in Women years Quadrivalent Vaccine n Cases n Placebo Cases * Efficacy (%) 95% CI CIN (any grade) 1, , (29, 100) External genital lesions 1, , (40, 100) *The 15 placebo cases were due to re-infection or re-activation of a latent infection This suggests efficacy against recurrence of disease with same vaccine HPV types (re-activation / re-infection) MITT-2 analysis (Protocols 007, 013 and 015), HPV specific naive population; received at least one dose, case counting starts 30 days after dose 1. Olsson SE, et al. Hum Vaccin 2009; 5(10):

19 Incidence of HPV-related diseases in Canada (number of cases) Penile Cancer Anal Cancer ,300 Anal Cancer Vulvar & Vaginal Cancer Cervical Cancer Oropharyngeal cancer Genital warts 27,143 22,036 MALE 1, FEMALE Oropharyngeal cancer Genital warts Cancer Incidence by Cancer Registry in Canada. (1) Human Papillomavirus and Related Disease Report. CANADA. ICO HPV information Centre. Dec 15, (2) Merck Canada Inc

20 HPV associated cancers; Canada 2012 Canadian Cancer Society, PHAC, Statistics Canada; Oct

21 HPV and Men fewer males develop antibodies to HPV to natural infection than females antibody levels are low; do not protect against subsequent infections with same types; recurrent disease is common male oral and anal HPV prevalence remains constant with age anal cytology for screening has low sensitivity; HPV DNA test has better sensitivity Giuliano et al. Int J Cancer 2015:136,

22 Recurrence rates of AIN after HPV Vaccination 202 MSM pts hx prev RX for HG-AIN followed for 2 years after vaccination either quad vaccine or not vaccinated recurrence HG-AIN: not vaccinated 30.7 % vaccinated 13.6 % (cervix recurrence 10%) Swedish KA et al; CID 2012, 54(7):

23 HPV and Oropharyngeal Cancer Location: tonsillar carcinoma base of tongue soft palate up to 93% tonsillar CA is now HPV + (84% HPV 16) not associated with smoking or alcohol incidence HPV+ OP cancer in men > women (4 fold higher) prevalence of oral HPV infection prevalence men > women (10.1% vs 3.6%, p <.001) better prognosis if HPV + de-intensification of chemo-radiotherapy Ramqvist T, et al: Emerg Infect Dis November; 16(11): Syrjanen S, J Clin Virol. 2005, 32: Gilison ML, et al. 2012: 307(7):

24 HPV Vaccines : 2v, 4v, 9v 2v HPV Vaccine v HPV Vaccine v HPV Vaccine AAHS 225μg High-risk genotypes Low-risk genotypes (anogenital warts and recurrent respiratory papillomatosis) ADJUVANT AAHS 500μg 1. Cervarix Canadian Product Monograph, GlaxoSmithKline Inc.; November 25, Gardasil Canadian Product Monograph, Merck Canada Inc.; March 10, Gardasil 9 Canadian Product Monograph, Merck Canada Inc.; December 15,

25 High-risk HPV Strains Covered by Vaccines Type of Lesion 6, 11, 16, 18 Contribution 31, 33, 45, 52, 58 Contribution Total 9 Types Cervical cancer * 70% 20% 90% CIN 2/3** 50% 30% 75-85% CIN 1 ** 30-35% 25% 50-60% *based on Sanjose et al 2010; 11: ** Based on placebo cohort in the HPV 6/11/16/18 clinical program and several meta-analyses Presented at ACIP meeting. Oct 24,

26 Efficacy of a novel 9-valent HPV vaccine in year old women Endpoint High grade HPV31/33/45/52/58 cervical/vulvar/vaginal disease Any grade HPV31/33/45/52/58 cervical/vulvar/vaginal disease HPV31/33/45/52/58 6 months related persistent infection 9vHPV vaccine No cases/n 4vHPV Vaccine No of cases/n 1/ /6017 3/ / / /5953 Per protocol population Efficacy (95%CI) 96.7 % ( ) 97.1 % ( ) 96.0 % ( ) Joura E at al: N Engl J Med 2015;372:

27 Health Canada: HPV Vaccines approved indications (Feb 2015) bivalent (types 16, 18) females age CIN AIS cervix cervix cancer quadrivalent (types 6,11,16,18) nonavalent (4v+31,33,45,52,58) females age 9-45 CIN AIS cervix cervix cancer VIN VAIN vulvar and vaginal cancer AIN, anal cancer external genital warts males age 9-26 external genital warts AIN, anal cancer Cervarix Canadian Product Monograph, GlaxoSmithKline Inc.; November 25, 2014; Gardasil Canadian Product Monograph, Merck Canada Inc.; March 10, 2015; Gardasil 9 Canadian Product Monograph, Merck Canada Inc.; December 15,

28 NACI Update on HPV Vaccines July vHPV,4vHPV or 9vHPV recommended for females age 9-26 may be used in females over age 26 (no upper age limit) is recommended for those with current or past history of pap abnormalities, cervical cancer and EGW 4vHPV or 9vHPV vaccine recommended for males age 9-26 for prevention of EGW, AIN, anal cancer, PIN and penile cancer 4vHPV or 9vHPV vaccine may be used in males over age 26 (no upper age limit) NACI Update July

29 Previously Vaccinated Patient require full 3 doses 9-valent (0, 2 and 6 months) to be protected against 5 additional types if have previously received 1 or 2 doses bivalent or quadrivalent, can proceed to 3rd dose 9-valent o however, if given less than 3 doses 9-valent, will only have full protection for previously given vaccine types 9vHPV dose can be used as a substitute for 2vHPV or 4vHPV vaccine dose; 2vHPV or 4vHPV are not substitutes for 9vHPV vaccine doses CDC: HPV ACIP Vaccine Recommendations

30 Case 2 Review A 44 year old patient with external genital warts asks if her male partner should consider HPV vaccination The previous slides illustrate the following: 80-90% of anal cancer cases are HPV related. 73% are associated with HPV subtype 16 The two most equally common HPV related cancers in Canada is cervical cancer in women and oral pharyngeal cancer in men. The 4vHPV or 9vHPV vaccines are recommended for males age 9-26 for prevention of EGW, AIN, anal cancer, PIN and penile cancer 4vHPV or 9vHPV vaccine may be used in males over age 26 (no upper age limit) as per the 2016 NACI statement. 30

31 VACCINE UPTAKE & IMPACT ON DISEASE 31

32 IMPACT ON DISEASE: CANADIAN DATA 32

33 Case 3 A 18 year old freshman attends for birth control advice She is in her first committed relationship She was not vaccinated in school because of her parent s objection 33

34 Reduction in HPV Prevalence Among Those Vaccinated with 4vHPV in Quebec 12 4v Vaccine types PIXEL-Portrait of the sexual health of adults in Québec, Prevalence % Non-vaccinated (N=511) Vaccinated (N=1039) 2 0 6/11/16/18* 16* 31/33/ * p < o Institut National de Santé Publique du Québec. Prévalence des infections au virus du papillome humain (VPH) : résultats de l étude PIXEL-Portrait de la santé sexuelle des jeunes adultes au Québec. Available from: 34

35 Impact on genital warts 0% -5% -10% -15% -20% -25% -30% -35% -40% -45% -50% Manitoba Quebec Ontario -19% Vaccination status -40% -45% -43% Program eligibility Quebec: Steben, M. et al. Abstract presented at IPV, Seattle, USA, Aug , 2014 Ontario: Smith, L. et al. Pediatrics 2015; 135: Manitoba: Willows, K. et al. Abstract presented at the GOC 37 th AGM meeting. Vancouver. June 16-18,

36 Impact on abnormal cervical lesions Cervical dysplasia reduction in Canadian girls: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% -44% -50% -86% Alberta Ontario British Colombia Alberta: Kim, J. et al., CMAJ 2016, 188(12):e281-8 Ontario: Smith, L. et al. Pediatrics 2015; 135: British Columbia: Ogilvie, GS et al. Int. J. Cancer 2015;137:

37 Case 4 A 40 year old patient has a 12 year old daughter She says she is delaying vaccination of her daughter as she is not yet sexually active so doesn t need it 37

38 School-based vaccination programs: higher uptake rates for any vaccine, not just HPV vaccine delivers better coverage of school-age target population than an opportunistic (clinic-based) program population is captive 38

39 Publicly Funded Immunization Programs in Canada: Schedule for HPV Vaccine Programs (Mar 2017) Province/Territory HPV Vaccination Program British Columbia (9v) females Gr. 6 (2 doses) ; males (fall 2017); HIV + females (9-26); high-risk males(9-26) Alberta (9v) females and Males (2014) Gr. 5 (3 doses); catch up gr 9 (ends 2018) Saskatchewan (4V) females Gr. 6 (2 doses); males fall 2017; HIV+ males (9-17) Manitoba (4V) Ontario (4V) Quebec (9v) females and males gr 6 fall 2016 (2 dose); catch up gr 9 boys x 3 years females and males Gr. 7 fall 2016 (2 doses) ; catch up until grade 12; females grade ; high-risk males (9-26) females and males Gr 4 fall 2016 (2 doses); catch-up females <18; immunocompromised men or women (9-26) New Brunswick (4V) females Gr. 7 (2 doses); males (fall 2017) Nova Scotia (4V) Prince Edward Island (4V) Newfoundland (4V) Northwest Territories(4V) females and males Gr. 7 (fall 2015); (2 doses) females and males Gr 6 (2013); (2 doses); high risk males (18-26) and females (18-45) females Grade 6 (2 doses) females Gr. 4 (2 doses); catch-up to age 26 (3 doses) Yukon Territory (4V) females Gr. 6; (2 doses); free for females age 9-18 Nunavut (4V) females Gr. 6 ( 9 yrs) 3 dose 39

40 40

41 Cases 3 & 4 Review A 18 year old freshman attends for birth control advice She is in her first committed relationship She was not vaccinated in school because of her parent s objection A 40 year old patient has a 12 year old daughter She says she is delaying vaccination of her daughter as she is not yet sexually active so doesn t need it The previous slides illustrate the following: School based programs have higher uptake for any vaccination program. Patients lost to follow up (for subsequent doses) are higher for clinic based programs. Over the last decade, the impact of HPV vaccination, (reduction in genital warts and abnormal cervical lesions) in real-world settings has become increasingly evident, especially among girls vaccinated before HPV exposure in countries with high vaccine uptake. 41

42 IMPACT ON DISEASE: INTERNATIONAL DATA 42

43 Australia - Reduction of Presentations with warts in men & women <21 years, and MSM all ages, July 2004 to end of June Vaccination program commences Percentage < 21 Female < 21 Male MSM Month period since July 2004 Fig 1. Proportion of patients aged < 21 years, diagnosed as having genital warts by risk group compared with MSM of all ages: MSM, men who have sex with men, men < 21 years excluded MSM, and non resident excluded. Read TRH, Hocking JS, Chen MY, et al. Sex Transm Infect

44 Australia: Impact of 4vHPV on cervical abnormalities Free vaccination offered to women aged 12-26yo in Women of all ages (11-27 years) No. of doses Any other abnormality at cytology/histology High-grade cervical abnormalities (histologically confirmed) Crude OR Adjusted OR Crude OR Adjusted OR 0 Reference Reference Reference Reference %* %* 21%* 46%* OR = Odds ratio Crowe E., et al. BMJ 2014, 348(g1458):

45 Scottish Cervical Screening Program school based program since 2008 girls age 12-13, catch up girls age initially bivalent vaccine; 2012 switched to quadrivalent > 91% routine uptake for all 3 doses; Catch-up uptake 66%collected cytology and HPV DNA at first cervical screen age 20 ( ) tracked those immunized or not immunized followed rates of HR-HPV DNA and CIN Palmer T, Nicoll S, Cuschieri K, Cubie H, Pollock K; presented at Eurogin, Nov 2013 Pollock KGJ et al., British J of Cancer 2014,

46 Scottish Cervical Screening Program 63% reduction in prevalence of all HR-HPV types (p=.004) at first cytology visit age 20 55% reduction in RR of CIN 3 in vaccinated women (p<.0001) due to all types 3 doses superior to 2 doses o Note almost all those with 2 doses were at 0 and 1 month Palmer T, Nicoll S, Cuschieri K, Cubie H, Pollock K; presented at Eurogin, Nov 2013 Pollock KGJ et al., British J of Cancer 2014,

47 Incidence of Genital Warts in California Following Introduction of qhpv Vaccine Trends in genital warts diagnosis by age group, Family PACT program, 2007 through Percentage with genital warts Aged 21-25y Aged 26-30y Aged <21y Aged 31y 10% (P < 0.001) (P = 0.004) (P < 0.001) 35% (P = 0.005) Percentage with genital warts Aged 21-25y Aged 26-30y Aged <21y Aged 31y 11% (P < 0.001) (P = 0.05) 19 % (P < 0.001) No change Year Year Females Males PACT = Planning Access Care and Treatment; qhpv = quadrivalent human papillomavirus. Figure reprinted from Bauer HM et al, Evidence of human papillomavirus vaccine-effectiveness in reducing genital warts: an analysis of California Public Family Planning administrative claims data , Am J Public Health. 2012;102: , with permission of The Sheridan Press. 1. Bauer HM et al. Am J Public Health. 2012;102:

48 Approximate Reduction 4vHPV Vaccine: Systematic Review of 10 Years of Real-world Experience 1 0.0% -10.0% -20.0% -30.0% -40.0% -50.0% -60.0% -70.0% -80.0% -90.0% % A review of 58 publications reporting impact or effectiveness of 4vHPV vaccine HPV 6/11/16/18 infection Genital warts -90.0% -90.0% Low grade cytological cervical abnormalities -45.0% High-grade histologically proven cervical abnormailites -85.0% 4v:quadrivalent 1. Garland et al. Clin Infect Dis. 2016;63(4):

49 HPV VACCINE SAFETY 49

50 Case 5 A father comes to clinic with his 11 year old daughter for follow up of a broken wrist from a soccer game After reviewing her wrist and injury, you ask the father if there are any health questions about his daughter He lets you know that the school nurse was coming the following week and they weren t sure whether to sign the consent form for the HPV vaccine as he had read negative reports in the press 50

51 Safety and Tolerability of 9vHPV Vaccine in Boys/Girls Age 9-15 and Women Age V : Safety findings Day 1-15 following any vaccination visit Injection-Site Adverse Events 9vHPV N(%) (90.7%) 4vHPV N(%) (84.9%) most common AE: 1. pain 90 % 2. swelling 40 % 3. erythema 34 % 4. headache 14 % 9vHPV vaccine displayed an adverse event profile comparable to that of 4vHPV o Except for injection-site adverse events from day 1-15 following administration of the vaccine (most of which were mild or moderate intensity) Joura E at al: N Engl J Med 2015;372:

52 Case 6 A 19 year old female comes in requesting the HPV vaccine She has heard there is an increased risks for clots and she is worried as she is on oral contraceptive for birth control 52

53 Passive Safety Surveillance Programs: US Vaccine Adverse Events Reporting System US VAERS maintained by US CDC and FDA first 2 years of VAERS data following vaccine launch found disproportionate reporting of VTE, but all subsequent evaluations in 3 active surveillance studies found no association between vaccination and VTE Recent review of VAERS: 25,176 AEs (4/100,000) out of 67 million doses reported among females who received the 4vHPV vaccine between June 2006 and March 2014 no previously reported or new medical conditions were identified as safety signals which would require further evaluation safety of 4vHPV vaccine in pregnancy via a search of VAERS: o no safety concern among pregnant women who received vaccine during pregnancy, nor in their offspring Vichnin M., et al. Pediatr Infect Dis J 2015, 34:

54 Pregnancy Registry for 4vHPV Vaccine women from US, Canada and France enrolled if exposure occurred within 1 month before date of LMP or any time during pregnancy o 2802 women enrolled primary outcomes: o birth defects, elective and spontaneous abortions (before week 20), fetal deaths (after week 20) and live births no causal relationship between HPV vaccine and birth defects or other adverse pregnancy outcomes Vichnin M., et al. Pediatr Infect Dis J 2015, 34:

55 Adverse events in Alberta ( ) 195,270 females received 528,913 doses of HPV vaccine rate of (Adverse event following immunization)aefi events in women receiving at least one dose of the HPV vaccine: o 37.4/100,000 (95% CI: ) o 19,531 women had an ED visit within 42 days o 958 women were hospitalized Rates of AEFI were low; consistent with events elsewhere Liu XC. et al., Vaccine 2016, 34 (15),

56 Adverse events in Ontario ( ) 133 AEFI reported in 691,994 doses Common events reported: o rash (22%) o injection site/local reaction (20%) o non-specific, unusual or severe (26%) o 10 cases of serious AEFI: 2 anaphylaxis; 2 seizures; 1 thrombocytopenia; 1 death o anaphylaxis did not meet Brighton criteria o death related to pre-existing cardiac condition No safety signals No reports of VTE Harris T, et al, Vaccine 2014, 32(9):

57 HPV Vaccine Safety > 217 million doses dispensed worldwide ( ) 1 Major agencies endorsing HPV vaccine safety 2,3 o o o o o o o o o World Health Organization (WHO) Public Health Agency of Canada (PHAC) The Society of Obstetricians and Gynaecologists of Canada (SOGC) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) European Medicines Agency (EMA) Medicines & Healthcare Products Regulatory Agency of the UK (MHRA) Therapeutic Goods Administration of Australia (TGA) International Federation of Gynecology and Obstetrics (FIGO) o International Papillomavirus Society (IPVS) (1) Merck data on file (2) Papillomavirus Research 2016 (2):9-10. (3) Bailey HH. et al. J Clin Oncol 2016; 34(15):

58 Case 5 Review A father comes to clinic with his 11 year old daughter for follow up of a broken wrist from a soccer game After reviewing her wrist and injury, you ask the father if there are any health questions about his daughter He lets you know that the school nurse was coming the following week and they weren t sure whether to sign the consent form for the HPV vaccine as he had read negative reports in the press The quadrivalent vaccine has been made available since trials analyzed the incidence of serious adverse effects and no SAEs were considered to be vaccine related. 58

59 Case 6 Review A 19 year old female comes in requesting the HPV vaccine She has heard there is an increased risks for clots and she is worried as she is on oral contraceptive for birth control The previous slides illustrated: > 217 million doses dispensed worldwide ( ) no reports of VTE common events reported are as follows: o rash (22%) o injection site/local reaction (20%) o non-specific, unusual or severe (26%) 59

60 COUNSELLING 60

61 GPs and OB/GYNs state they discuss HPV and HPV vaccinations at least 25 times per month on average How do discussions about HPV and HPV vaccination come up? I routinely discuss it with all eligible patients 60% 66% I tend to discuss HPV most with patients who ask me about it 12% 27% GPs OB/GYNs GPs (n=337), OB/GYNs (n=101) Durand N, Blake J, Guichon J, McFaul S, Ogilvie G, Steben M; A National Survey of Canadian Physicians on HPV: exploring knowledge, barriers and clinical preventive practices; presented at IPV

62 The Physician s Perspective GPs agree that HPV affects both men and women. 81% say that when they recommend the HPV vaccine to a patient, they usually get vaccinated. 80% say that many of their patients believe HPV is not something that affects someone like them Steben M, Blake J, Durand N, Guichon J, McFaul S, Ogilvie G; A National Survey of Canadian Population on HPV: exploring knowledge, barriers and clinical preventive practices; presented at IPV 2017

63 The Physician s Perspective 80% Physicians believe that cost or a lack of private insurance is the number one barrier to getting vaccinated against HPV 70% 60% 50% 40% 30% 20% 10% 0% GPs OB/GYNs None to Minor Barrier Moderate Barrier Major Barrier Steben M, Blake J, Durand N, Guichon J, McFaul S, Ogilvie G; A National Survey of Canadian Population on HPV: exploring knowledge, barriers and clinical preventive practices; presented at IPV

64 The Patient s Perspective Steben M, Blake J, Durand N, Guichon J, McFaul S, Ogilvie G; A National Survey of Canadian Population on HPV: exploring knowledge, barriers and clinical preventive practices; presented at IPV

65 Provider communication and HPV vaccination: the impact of recommendation quality A high-quality message Makes a Difference Strength of endorsement was most important factor Benefits and urgency contributed 9 fold increase in vaccination with a high quality recommendation M.B. Gilkey et al.; Vaccine 34 (2016)

66 HPV Vaccination Counselling the message keep it simple: 1. effective 2. safe 3. recommended Give info sheet & Rx HPV vaccine to all patients **Emphasize importance of series completion 66

67 Questions?