The national human papillomavirus (HPV) vaccination programme - the move to two-dose schedule

Transcription

1 The national human papillomavirus (HPV) vaccination programme - the move to two-dose schedule August 2014 Quality Education for a Healthier Scotland 1 The HPV immunisation programme was introduced in 2008 at which time the vaccine used was Cervarix. In September 2012 the vaccine used changed to Gardasil. Following a review of the immunological evidence the Joint Committee on Vaccination and Immunisation (JCVI) concluded that the immunogenicity of a two-dose schedule was likely to be the same as the three-dose schedule. This resource is designed to facilitate immunisers already participating in the HPV immunisation programme to update their knowledge in respect of the two-dose schedule. It is not designed for healthcare workers who have no previous experience of the HPV immunisation programme. Such staff should consult with their manager regarding how best to meet their knowledge needs.

2 Aim To ensure that all immunisers involved with the HPV immunisation programme are aware of the move to the two-dose schedule Quality Education for a Healthier Scotland 2

3 Learning outcomes The immuniser will be able to: - Describe the aetiology of HPV infection and cervical cancer - Describe how HPV is transmitted - Describe the epidemiology of HPV infection - Describe the dosage and schedule for Gardasil, contraindications etc - Be aware of all sources of additional information Quality Education for a Healthier Scotland 3

4 Contents 1. Human Papillomavirus (HPV) infection 2. Diseases caused by HPV 3. HPV vaccine 4. The HPV immunisation programme Quality Education for a Healthier Scotland 4

5 1. HPV infection Quality Education for a Healthier Scotland 5

6 Human Papillomavirus Is a small DNA virus Infects the epithelium i.e. the deeper layers of the skin and mucosal lining of organs such as the vagina and mouth More than 100 types, of which 40 infect the genital area Classified into high-risk (HR) which can cause cancer and low-risk (LR) which can cause genital warts Quality Education for a Healthier Scotland 6 There are 13 High risk types of HPV that have been associated with cancer. HPV 16 and 18 together cause over 75% of cervical cancers, along with HPV type 31 they account for the majority of cases. Low risk types, particularly 6 and 11, are thought to cause over 90% of cases of genital warts. Other HPV types are the cause of warts on other parts of body.

7 HPV infection Is often asymptomatic Usually resolves spontaneously - 90% do so within two years Persistent infection with HR types causes the cell changes that can eventually lead to cancer Quality Education for a Healthier Scotland 7 Median time for clearance is eight months.

8 HPV infection is very common HPV is common most women will have been infected at some point in their lives. At least 75% will have been infected by the age of 50 Incidence of infection increases from age 14 Women are most likely to be infected in their late teens and early twenties Scottish data on unvaccinated 20 year olds show that 50% have a current HPV infection with at least one HPV type - So it s unusual not to catch HPV Quality Education for a Healthier Scotland 8 For further information see: Syrjanen K, Syrjanen S. Epidemiology of human papilloma virus infections and genital neoplasia. Scand J Infect Dis Suppl. 1990;69:7-17. The 79% is an estimated lifetime risk based on their long term study of a cohort of Finnish women and from the abstract In unselected Finnish female population at the age of 22 years, the prevalence of clinical (i.e. detectable by PAP smear) HPV infections was about 3%, and the adjusted annual incidence was 8.0%. According to the estimates for the life-time risk, up to 79% of the Finnish females would contract at least one HPV infection within ages 20 to 79 years. This is variously reproduced as the statement at least 75% of women, or at least 80% sexually active women.by the age of 50. Jit M, Vyse A, Borrow R, Pebody R, Soldan K, Miller E. Prevalence of human papillomavirus antibodies in young female subjects in England. Br J Cancer. 2007;97: Based on our sample, less than 5% of girls under the age of 14 years were seropositive for any HPV type. From age 14 years onwards, the seroprevalence increased sharply until the early 20s, and then stabilised or declined. The Scottish data are from the National HPV surveillance programme. A poster publication shows the baseline figures: % had any HPV type, 23. Two had HPV types 16 and or 18, and 20. Eight had another High Risk Type other than 16/18. Most of these infections will be transient, HPV 16 is associated with persistent infection.

9 How HPV is spread HPV is spread by direct physical contact Any genital contact is important, not just sexual intercourse Hand to genital contact may cause some infections Anyone who is sexually active is at risk Risk increases with the number of sexual partners Quality Education for a Healthier Scotland 9

10 2. Diseases caused by HPV Quality Education for a Healthier Scotland 10

11 High risk (HR) HPV causes cervical cancer >99% of cases of cervical cancer are caused by HPV HPV 16 and 18 together cause over 75% of cervical cancer 11 other high risk types have been identified that can cause cancer Quality Education for a Healthier Scotland 11 The precise proportion of cervical cancers attributed to each HPV type varies by world region and by individual studies. HPV 16 is consistently responsible for the majority of cases and HPV 18 the second most common. A 2007 meta-analysis by Smith and others provided combined figures from studies in Europe: Ref: Smith JS et al, 2007; Int J Cancer. 121(3): Link: SmithJ.IntJCancer2007,21(3) pdf There is emerging evidence that the vaccines provide a degree of cross protection against other High Risk HPV types that are closely related to the vaccine types. Cervarix - Wheeler et al. Lancet Oncology,, January 2012 Gardasil - Brown et al. J Infect Dis HPV type Cases caused (%) Cumulative cases caused (%) Other No type id d

12 How HPV infection may lead to cancer HPV infection usually resolves spontaneously - 90% do so within two years Persistent infection leads to cells becoming damaged and pre-cancerous HPV infections can t be treated but pre-cancerous changes can be detected by screening and removed Cancer - abnormal uncontrolled growth of tissues can occur after many years Co-factors increase the likelihood of cervical cancer, particularly smoking Quality Education for a Healthier Scotland 12

13 Epidemiology of cervical cancer 3378 cases of cervical cancer diagnosed in the UK in in Scotland 1/3 of these died Third most common cancer of women worldwide* Most cases occur in women in their late 30s or in their 70s/80s (latter group not screened when younger) In developed countries, most cases are prevented by cervical screening (death rates about 60% lower than 30 years ago, mainly due to screening) *Recent evidence: article/ overview) Quality Education for a Healthier Scotland 13 Every year in the UK, over 3000 women will be diagnosed with cervical cancer. Cervical cancer is the most common cancer in women ages 35 and under. Breast cancer is the most common type of cancer diagnosed in women in Scotland and the second in terms of female cancer deaths. New cases of and deaths from breast cancer are 10-fold those of cervical cancer. Most cases of cervical cancer are prevented through the cervical screening programme which detects pre-cancerous changes in thousands of women each year who are then monitored, followed up and treated if necessary and don t go on to develop cervical cancer. Cervical screening is credited with saving the lives of 1 in 65 women in the UK born since Peto 2004, The Lancet fulltext In Scotland the incidence decreased by 47% between the baseline year of 1986 and Scottish statistics are available at the following links: Cervical cancer: Genital-Organ/. Cervical screening:

14 Cervical cancer - cases and rates by age group, in the UK, Cases Cases Rates per Rates per to to to to to to to to to to to to to to Age group Source: Cancer Research UK Quality Education for a Healthier Scotland 14 This figure demonstrates very clearly that the highest number of cases are in young women, as is the highest incidence. The incidence rises in older women because the population is smaller.

15 Cervical screening Cervical screening does not prevent HPV infection, or pre-cancerous changes but allows early detection and treatment Screening remains important for all women as immunisation does not protect against all HPV types All women aged 20 to 60 are currently eligible for cervical screening For unimmunised women screening remains the most effective way to reduce their risk of cervical cancer Quality Education for a Healthier Scotland 15

16 Genital warts in Scotland Number Numbers of diagnoses of genital warts by age and sex, 2009 Males Females Number Trends in diagnoses of genital warts in females by age, > Age Source: ISD Scotland: STISS & NASH Year Quality Education for a Healthier Scotland 16 This slide illustrates the not inconsiderable burden of genital warts on sexual health services. In Australia where the national HPV immunisation programme was implemented using Gardasil there appears to have been a substantial effect in reducing the clinical burden of genital warts. See: Quadrivalent human papillomavirus vaccination and trends in genital warts in Australia: analysis of national sentinel surveillance data. Basil Donovan, Neil Franklin, Rebecca Guy, Andrew E Grulich, David G Regan, Hammad Ali, Handan Wand, Christopher K Fairley. Lancet Infect Dis 2011; 11: Published Online November 9, 2010 DOI: /S (10)

17 Epidemiology of genital warts Genital warts are the commonest viral sexually transmitted infection in the UK 4% of adults aged 18 to 44 reported having been diagnosed with genital warts At least 7000 new diagnoses each year in Scotland Mainly in young adults aged 16 to 24 HPV types 6 and 11 cause 90% of these cases Genital warts can be recurrent and difficult to treat Genital warts are not life threatening but can cause significant distress and substantial healthcare costs Quality Education for a Healthier Scotland 17 Over 90% of genital warts are caused by the low risk HPV types 6 and 11. The majority of genital HPV infections are asymptomatic; the diagnosis of genital warts is based on clinical examination when warts are visible. Over 7000 new cases are diagnosed in GUM clinics in Scotland each year; numbers of new diagnoses have increased over the past ten years. Genital warts can recur, causing significant distress and requiring repeated clinic visits for treatment; in 2007, an additional 4191 episodes of care were provided for people attending GUM clinics for treatment with recurrent infection. Overall there are more new diagnoses in men than women but there are age differences in the distribution of new cases notably a younger age of acquisition in women; two thirds of new diagnoses in women are in those aged compared to 50% in young men. In recent years, the largest increase in diagnoses was observed in those aged Almost 50% of women infected with HPV 6 or 11 will develop genital warts within 12 months, and 64% within 36 months. Winer et al (2005) Development and duration of human papillomavirus lesions, after initial infection. J Infect Dis. 191: Consistent use of condoms decreases the risk of genital warts by 60-70% (WHO 2007).

18 HPV vaccine uptake 2008/9-2011/12 Table 1: Annual HPV immunisation uptake rates for the S2 routine cohort by the end of the school year and one year later. School Year % Uptake Dose 1 End of school year % Uptake Dose 1 1 year later School Year % Uptake Dose 2 End of school year % Uptake Dose 2 1 year later School Year % Uptake Dose 3 End of school year % Uptake Dose 3 1 year later 2008/ / / / / / / / / / / / Routine immunisation of S2 girls exceeds 90% uptake for all three doses. Quality Education for a Healthier Scotland 18

19 Early impact of HPV vaccine on HPV infection HPV type from anonymised LBC samples in cohort: unvaccinated vs vaccinated Percentage of women positive for any HPV Unvaccinated (0 dose) Vaccinated (3 doses) HPV type Three doses of HPV vaccine associated with a significant reduction of HPV 16, 18 and affords cross-protection against HPV 31, 33 and 45*. Quality Education for a Healthier Scotland 19 As Scotland is one of the only countries to screen women for their first cervical smear at age 20, it is now possible to ascertain the impact of the vaccine on HPV infections in the cervix. This figure shows how those women vaccinated with three doses of the HPV vaccine have reduced genoprevalence of infection with HPV 16 and 18. The vaccine is also associated with a reduction in the prevalence of HPV 31, 33 and 45, which suggests that Cervarix offers cross-protection against these other high-risk HPV types. There has been a small increase in HPV 51 in vaccinated women compared with unvaccinated women. *Reference: Kavanagh K, Pollock KGJ et al. Introduction and sustained high coverage of the HPV bivalent vaccine leads to a reduction in the prevalence of HPV 16/18 and closely related HPV types. Brit J Cancer 2014:110(11):

20 3. HPV vaccines Quality Education for a Healthier Scotland 20

21 Vaccine for HPV Immunisation Programme Gardasil From September 2012 Gardasil has been used for HPV immunisation programme Quadrivalent (types 6,11,16,18) Sanofi Pasteur MSD Licensed from age 9 years Pre-filled syringe with needle Container dimensions: 47x23x150mm Basic NHS price when prescribed (contract price unavailable) Quality Education for a Healthier Scotland 21 From Cervarix manufactured by GlaxoSmithKline was the vaccine used in the national HPV immunisation programme. Cervarix is Bivalent vaccine (HPV types 16 & 18). From September 2012 the vaccine used is Gardasil.

22 Pre-filled 0.5 ml syringe Quality Education for a Healthier Scotland 22 The Summary of Product Characteristics (SPC) is available at: medicine/19016/spc/gardasil. 0.5 ml suspension in a pre-filled syringe (glass) with plunger stopper (siliconized FluroTec-coated bromobutyl elastomer or non-coated chlorobutyl elastomer) and tip cap (bromobutyl). Using the pre-filled syringe Shake well before use. Attach the needle by twisting in a clockwise direction until the needle fits securely on the syringe. Administer the entire dose as per standard protocol.

23 Gardasil - composition Brand and generic name - Gardasil suspension for injection - Human Papillomavirus Vaccine [Types 6, 11, 16, 18] (Recombinant, adsorbed) Gardasil composition - Active ingredients - HPV type 6 L1 protein (20 microgram) - HPV type 11 L1 protein (40 microgram) - HPV type 16 L1 protein (40 microgram) - HPV type 18 L1 protein (20 microgram) - Adjuvant is amorphous aluminium hydrophosphate sulphate (225 microgram Al) Excipients - Sodium Chloride - L-Histidine - Polysorbate 80 - Sodium borate - Water for injections Quality Education for a Healthier Scotland 23 Gardasil is not a live vaccine it cannot cause infection. Gardasil does not contain thiomersal. Gardasil is latex free.

24 Storage of HPV vaccine Cold chain must be maintained - Store in original packaging - Protect from light - Transport between +2 C and +8 C Store vaccine in schools in validated cool boxes Quality Education for a Healthier Scotland 24 Gardasil must be stored and transported between +2 C and +8 C. There is no other stability data for Gardasil routinely. Across the UK, if vaccine wastage is even only 1%, it will cost 2million. Re-enforce message to take good care of it! Validated cool boxes and related items such as cool packs should be used when transporting and storing vaccine for use in situations such as school immunisation sessions. Cool boxes should be used in accordance with manufacturer s guidelines to ensure that vaccines are stored at the correct temperature. A realistic calculation of how much vaccine is needed for a particular immunisation session should be made prior to transporting vaccine to a session. During the session care should be taken to remove only the required amount of vaccine from the cool box in order that unused stock may be returned to pharmacy.

25 Gardasil Dosage and Schedule Two-dose schedule should only be used in girls who can receive first dose before they are 15 years of age Two-dose schedule: - First dose of 0.5ml - Second dose of 0.5ml at least six months after the first dose Best completed within 24 months If course is interrupted, resume; do not repeat Quality Education for a Healthier Scotland 25 In 2014, the JCVI considered data concerning a potential move to a two-dose schedule in adolescent girls. JCVI noted that the immunological evidence supported a move to a two-dose schedule. JCVI noted the duration of protection in adolescents vaccinated using a two-dose schedule with the second dose given at least six months after the first was likely to be the same as a three-dose schedule ( Subcommittee_meeting_ Jan_2014_final.pdf). The modelling and cost effectiveness analysis comparing a two-dose schedule to a three-dose schedule indicated a third dose would no longer be cost-effective provided that the duration of protection of a two-dose schedule lasted for twenty years. The minimum time between the first and second dose should be six months with 24 months as the upper limit. The two-dose schedule should be used in adolescent females who commence the HPV vaccination course before they reach 15 years of age, i.e. the first dose must be given before the 15 th birthday. Adolescent females who start a course of HPV vaccination from the age of 15 years should be offered a three-dose schedule. There are no data with two-dose schedules for immunocompromised individuals. Therefore a three-dose schedule should be offered to individuals who are HIV positive or are known to be immunocompromised at the time of vaccination. This recommendation is endorsed by WHO SAGE ( government/publications/human-papillomavirus-hpv-the-green-book-chapter-18a). Revaccination should be considered after treatment is finished and/or recovery has occurred. Specialist advice may be required.

26 Gardasil Dosage and Schedule Three-dose schedule should be used in girls who: - Start a course of HPV vaccination from age 15 years - Are HIV positive or are immunocompromised at time of vaccination Three dose schedule - First dose of 0.5ml - Second dose of 0.5ml at least one month after the first dose - Third dose of 0.5ml at least three months after the second dose Best completed within 12 months If course is interrupted, resume; do not repeat Quality Education for a Healthier Scotland 26 The three-dose schedule should be used in adolescent females who commence the HPV vaccination course from 15 years of age, i.e. where the first dose is given after the 15 th birthday. There are no data with two-dose schedules for immunocompromised individuals. Therefore a three-dose schedule should be offered to individuals who are HIV positive or are known to be immunocompromised at the time of vaccination. This recommendation is endorsed by WHO SAGE (see Green Book). Revaccination should be considered after treatment is finished and/or recovery has occurred. Specialist advice may be required. For planning purposes, a schedule of 0, 1, 4 to 6 months is appropriate. With regard to any variations, please always consult the latest version of the Green Book chapter online at: If there is any discrepancy between the SPC and the Green Book, remember the advice on page 38 of the latter: Healthcare professionals are reminded that in some circumstances the recommendations regarding vaccines given in the Green Book chapters may differ from those in the Summary of Product Characteristics (SPC) for a particular vaccine. When this occurs, the recommendations in the Green Book are based on current expert advice received from the JCVI and should be followed.

27 Minimum interval for third dose There is no clinical data on whether the interval between doses two and three can be reduced below three months - Where the second dose is given late and there is a high likelihood that the individual will not return after three months or if, for practical reasons it is not possible to schedule a third dose within this timeframe, then a third dose can be given at least one month after the second dose. Quality Education for a Healthier Scotland 27 Please refer to Chapter 18a v2.0 of Green Book for further detail. This advice applies to both Cervarix and Gardasil.

28 Administration of Gardasil Vaccine comes as a suspension - shake before use to form a white cloudy liquid Given by intramuscular injection into the deltoid Can be given at same time as other vaccines such as Td/IPV, MMR and hepatitis B - In separate site, preferably in a different limb Quality Education for a Healthier Scotland 28 If more than one vaccine is given in same limb, they should be given at least 2.5cm apart. The site at which each vaccine was given should be noted in the individual s records.

29 Contraindications Confirmed anaphylactic reaction to a previous dose Confirmed anaphylactic reaction to any component of the vaccine Defer immunisation if recipient has fever or is acutely unwell HPV vaccine is not advised in pregnancy Quality Education for a Healthier Scotland 29 There are very few individuals who cannot receive HPV vaccine. Where there is any doubt advice should be sought from Immunisation Co-ordinator on the circumstances under which vaccine could be given. Gardasil is latex free. (This is in contrast to Cervarix in which the rubber plunger and tip cap may contain some latex and therefore Cervarix should not be given to individuals with a history of severe (anaphylactic) allergy to latex.) Yeast allergy is not a contraindication to Gardasil. Even though Gardasil is grown in yeast cells, the final vaccine product does not contain any yeast. There is no known risk associated with giving inactivated/recombinant viral or bacterial vaccines or toxoids in pregnancy or whilst breast feeding. Since inactivated vaccines cannot replicate they cannot cause infection in either mother or foetus. However on a precautionary basis HPV vaccine is not advised in pregnancy. If a women finds out she is pregnant after she has started a course of HPV vaccine, she should complete her pregnancy before finishing the three-dose schedule. Termination of pregnancy following inadvertent immunisation is not recommended. In order to follow up any cases where HPV vaccine is inadvertently given in pregnancy all such cases should be reported to Health Protection Scotland on

30 Immunosuppression Girls with immunosuppression can be safely immunised, although immunisation may be less effective Quality Education for a Healthier Scotland 30 Individuals with immunosuppression or with HIV infection (regardless of CD4 counts) should be considered for HPV vaccines in accordance with the recommendations in the national programme. However, individuals who are immunosuppressed may not develop a full antibody response. Specialist advice may be required on re-immunisation when treatment is finished and/or recovery has occurred.

31 Reported vaccine side effects Vaccines undergo rigorous safety testing as part of licensing process. The most common adverse reaction after HPV vaccines - Mild to moderate short lasting pain at injection site - Redness and an immediate localised stinging sensation has been reported at injection site - Headache, fatigue, muscle aches and low grade fever have been commonly reported Anaphylaxis is possible but extremely rare Quality Education for a Healthier Scotland 31 For a full list of adverse reactions associated with Gardasil refer to the Marketing Authorisation holders Summary of Product Characteristics. Anaphylaxis is a very rare, recognised side effect of most vaccines and facilities for its recognition and management must be available.

32 HPV vaccine safety: pharmacovigilance Yellow card scheme - Voluntary reporting system for suspected adverse reaction (ADR) to medicines/ vaccines - Success depends on early, complete and accurate reporting - Report even if uncertain about whether vaccine caused the condition - Will require brand name, batch number and as much information about the incident as possible See chapter 8 of Green Book for details Quality Education for a Healthier Scotland 32 As with all vaccines and other medicines, healthcare professionals and patients/parents/carers are encouraged to report suspected adverse reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) using the yellow card reporting scheme.

33 Longer term protection The immune response to HPV vaccine is expected to be long-lasting Data are still being reported from long term follow up of women in the vaccine trials The latest data for Gardasil was reported in 2011 and shows a trend of continued protection in women who were vaccinated up to seven years previously. Follow up will continue for ten years Quality Education for a Healthier Scotland 33 Presented at EUROGIN 2011, Lisbon Susanne K. Kjaer for the HPV Vaccine Nordic Follow-Up Team 1 Institute of Cancer Epidemiology, Danish Cancer Society, Strandboulevarden 49, 2100 Copenhagen, Denmark 3 Gynecologic Clinic, Rigshospitalet, University of Copenhagen, Copenhagen, DENMARK Background The Gardasil long-term follow-up (LTFU) study is an ongoing extension of a pivotal randomized, placebo-controlled, double-blind, 4-year study to investigate the safety, immunogenicity, and effectiveness of quadrivalent Human Papillomavirus vaccine (qhpv) on the incidence of HPV 16/18-related cervical intraepithelial neoplasia (CIN) 2 or worse in 16-to 23-year old women (Protocol 015). Methods Follow- up of subjects will be accomplished in two ways: 1) registry-based follow-up for effectiveness data as well as safety data including but not limited to deaths, cancer, and hospitalizations; 2) active follow-up for blood collection for immunogenicity assessments at years five and 10 of the LTFU study. Effectiveness and safety analyses will occur approximately two years following completion of Protocol 015 and approximately every two years thereafter for 10 years. The current report represents the first of these efficacy and safety analyses. continued overleaf

34 Longer term protection The immune response to HPV vaccine is expected to be long-lasting Data are still being reported from long term follow up of women in the vaccine trials The latest data for Gardasil was reported in 2011 and shows a trend of continued protection in women who were vaccinated up to seven years previously. Follow up will continue for ten years Quality Education for a Healthier Scotland 33 (cont.) Cohort 1 included approximately 2,700 subjects who received qhpv vaccine at the start of Protocol 015. Cohort 2 consists of approximately 2,100 subjects who received placebo at the start of Protocol 015 and qhpv vaccine prior to entry into the LTFU. Vaccine effectiveness against HPV 16/18-related CIN 2 or worse was estimated by calculating the expected incidence of CIN 2/3 or worse in an unvaccinated (placebo) cohort using historical registry data. The primary analysis approach was perprotocol. Results There were 1,080 subjects that contributed to the follow-up period out of a total of 2,195 eligible subjects in the per-protocol population in Cohort 1. In these subjects there were no cases of HPV 16/18-related CIN 2 or worse observed. There were also no cases of HPV 6/11/16/18-related CIN, vulvar cancer, and vaginal cancer observed. However, the follow-up time in person-years is still insufficient to make a definitive statement about the effectiveness of the HPV vaccine for the current time period. Conclusions The HPV vaccine shows a trend of continued protection in women who were vaccinated up to seven years previously, although there is as yet insufficient data to confirm that protection is maintained. The HPV vaccine continues to be generally safe and well tolerated up to seven years following vaccination.

35 4. The HPV immunisation programme Quality Education for a Healthier Scotland 34

36 Child Health Surveillance Programme School (CHSP-S): key functions NHS (CHI) based data pupil data downloaded from education systems data (school, year, class) Pre-printed consent forms issued via schools Produces attendance registers for use in school immunisation sessions Written confirmation of immunisation returned to girls/ parents School immunisation data recorded on CHSP-S Quality Education for a Healthier Scotland 35 CHSP-S will be populated with data supplied from LA Education departments. CHSP-Schools system is updated in Oct/Nov and the class lists are generated from the previous year. It will also be populated with information requested from GPs re girls who may already have received HPV vaccine.

37 Resources Leaflets Health Scotland. A guide to the human papillomavirus (HPV) vaccine (2014) is available from: Health Scotland. What to expect after immunisation: young people (2013) is available from: Online video A video to support group sessions in the school setting is available from: immunisationscotland.org.uk/hpv Q and A for professionals A resource for professionals can be found at Quality Education for a Healthier Scotland 36 Leaflets To order more copies of the materials, please contact nhs.healthscotland-publications@nhs.net. For alternative formats, including an easy-read version, please nhs.healthscotlandalternativeformats@nhs.net. These leaflets were distributed to school health teams in June Online Video The online video detailed in the slide replaces the DVD Together we can fight cervical cancer which was produced by NHS Health Scotland for the last campaign. This DVD is no longer current and should be withdrawn from use.

38 Further information NHS inform helpline Green Book: human-papillomavirus-hpv-the-green-book-chapter-18a Chief Medical Officer s letter, Human papillomavirus (HPV) vaccination programme: change in schedule from 3 to 2 doses is available from: CMO(2014)20.pdf Quality Education for a Healthier Scotland 37