Meeting of Lanarkshire NHS Board Lanarkshire NHS Board 14 Beckford Street 29 February 2012 Hamilton ML3 0TA Telephone 01698 281313 Fax 01698 423134 www.nhslanarkshire.co.uk SUBJECT: HPV vaccination programme update 1. PURPOSE This paper updates the Board on progress with the Human Papillomavirus (HPV) vaccination programme in NHS Lanarkshire, service delivery arrangements, vaccine uptake, current issues and future actions. 2. Background In November 2007, the Scottish Government confirmed that a national HPV vaccination programme to prevent around 70% of future cervical cancers would be offered to all girls in year two of secondary school (S2) from September 2008. This was followed a few months later by a further announcement that girls and young women in S3 to S6, or under 18 years of age (if left school) would be included in a phased catch-up programme that would run for 3 years. The Scottish Government funded the cost of the three dose vaccine course using the Cervarix brand (BNF list price of 240 per course), national advertising, IT changes to the school health system and research monies to analyse before and after impacts of the vaccine programme. A further allocation totalling 1.5m was made to NHS Boards to address some of the costs of implementing the programme in the first three years, for example, public health nursing and general practice costs. In July 2011, the Scottish Government re-confirmed that the vaccination of 12 to 13 year old girls in S2 would continue as a routine element of the childhood vaccination programme, that girls aged under 18 years remain eligible for the vaccine (regardless of school year) and provided detail on bringing the catch-up programme for those 18 years and over to a conclusion. The Scottish Government also advised that a procurement exercise to purchase HPV vaccine for future years would be undertaken.
The procurement exercise has concluded and in November 2011, the Scottish Government announced that Gardasil would be the brand of HPV vaccine for three years from Sept 2012 and which it would provide free of charge to NHS Boards. Gardasil also employs a three dose course (using the same intervals between doses) to achieve full protection and protects against the same two strains of HPV that cause cervical cancer as Cervarix. However, Gardasil protects against two additional strains of HPV which cause genital warts. 3. Service delivery In 2007, a Lanarkshire HPV vaccine implementation group was formed. The development work covered; nursing, general practice, administration, education, pharmacy, and transport. A business case for NHS Lanarkshire for the first three years of the programme and ongoing S2 vaccination was approved. National and local advertising took place in the summer of 2008. Education sessions were held for those administering vaccine, for all head teachers of Lanarkshire secondary schools and pupils in advance of the programme starting. The first HPV vaccination session began at Abronhill High School Cumbernauld on 1 Sept 2008. Since then, five HPV vaccine sessions per year have been provided to all secondary schools under NHS Lanarkshire jurisdiction. Dates are spaced around two months apart and agreed with the schools in advance of the school year to avoid clashing with key dates in the school calendar. The first two dates, usually September and November, are for the first two doses of the course. Ideally the third and final HPV dose is given in March. January and May provide additional opportunities to vaccinate those who have missed doses. In the three and a half years since starting, S2 pupils have continued to be offered five opportunities per year to have HPV vaccine. Pupils in S5 and S6 were vaccinated along with S2 pupils during the first year of the programme (2008/09), followed the next year by those who had moved into S4 and S5 to complete the school based catch-up. Previous experience with MenC vaccine has shown those who have left school education are much less likely to take up the offer of vaccination than those currently attending school. However, those who were aged under 18 years as of 1 September 2008 were eligible for the vaccine, even if they did not attend school. Around 80% of Lanarkshire GPs accepted a local enhanced service (LES) agreement to provide HPV vaccine to girls and young women who had left school. Alternative arrangements were made for those unable to get HPV vaccine from their general practitioner, initially from the NHS Lanarkshire out of hours service and more recently via the NHS Lanarkshire sexual health 2
services. In both cases, up-to-date lists of those who had left school with no doses of HPV vaccine or incomplete courses were given to vaccine providers and letters providing information and encouraging vaccination and were sent to their home addresses. This was repeated in the summer of 2011. 4. HPV vaccine Uptake Rates a. School year S2 Overall uptake of HPV vaccine has been very high in Scotland, with 94.4% of the first cohort of S2 girls (2008/09) having at least one HPV vaccine dose and 91.4% completing all 3 doses of the course. ISD Scotland publishes HPV vaccine uptake data annually. The latest published uptake figures are for the 2010/11 S2 cohort by health board. Uptake for NHS Lanarkshire is around 1% higher for the 1 st and 2 nd doses, and 4% higher for the 3 rd dose compared to the Scotland figures (table 1). Table 1 HPV Immunisation Programme in Scotland - Year 3 (2010/11) Table 1: S2 Routine Cohort HPV immunisation uptake rates by mid-august 2011, for girls in second year of secondary school (S2) in school year 2010/11 1 NHS Board 2 of girls in cohort 3 2nd dose 3rd 2nd dose dose 3rd dose Ayrshire and Arran 2 070 1 924 92.9 1 900 91.8 1 832 88.5 Borders 673 618 91.8 600 89.2 524 77.9 Dumfries and Galloway 820 756 92.2 733 89.4 590 72.0 Fife 1 976 1 781 90.1 1 752 88.7 1 544 78.1 Forth Valley 1 735 1 606 92.6 1 576 90.8 1 422 82.0 Grampian 3 007 2 762 91.9 2 720 90.5 2 506 83.3 Greater Glasgow & Clyde 4 6 619 6 126 92.6 6 025 91.0 5 209 78.7 Highland 1 732 1 561 90.1 1 538 88.8 1 424 82.2 Lanarkshire 4 3 386 3 141 92.8 3 091 91.3 2 891 85.4 Lothian 4 187 3 788 90.5 3 678 87.8 3 118 74.5 Orkney 106 93 87.7 93 87.7 93 87.7 Shetland 164 148 90.2 147 89.6 118 72.0 Tayside 2 278 2 109 92.6 2 080 91.3 2 014 88.4 Western Isles 133 115 86.5 115 86.5 107 80.5 Scotland 5 28 932 26 571 91.8 26 091 90.2 23 432 81.0 1. Uptake rates are based on immunisations recorded on the CHSP School system and SIRS as at 15 August 2011. 2. NHS Board of School. 3. Girls recorded on CHSP-School as being in class year S2 as at 16 May 2011. These girls were in the second year of secondary school (during school year 2010/11) and were around 12 to 13 years of age. 4. NHS Lanarkshire is delivering the HPV programme to schools in Cambuslang and Rutherglen, however HPV data for Cambuslang and Rutherglen are recorded/shown under NHS Greater Glasgow & Clyde on CHSP School. 5. NHS Argyll & Clyde ceased to exist on 31st March 2006 and the administration was split between two sub-areas that now fall under the administration of NHS Greater Glasgow and Clyde and NHS Highland respectively. For the calculation of uptake rates, HPV immunisation data recorded on CHSP School under the former NHS Argyll & Clyde are allocated to their current NHS Board area using child's postcode. There are a small number of records which do not have a postcode recorded and therefore for statistical purposes, NHS Board is unknown. These records are included in the Scotland cohort and uptake rates and therefore the sum of the cohorts for all NHS Boards does not equate to the total cohort for Scotland. Source: CHSP School (May 2011)/SIRS (August 2011) 3
Previous data on S2 year cohorts has shown that uptake for 1st and 2nd doses increases by 2% after a further year as vaccination teams will invite older children who originally missed out due to absence or preference and who are now able and willing to attend. Uptake for the 3rd dose should increase more significantly because there has only been a maximum of one additional session to catch-up i.e. in May if not vaccinated in March. Even beyond a year, it is likely that uptake would creep up higher as vaccination teams will continue to encourage older pupils to take the vaccine, in keeping with national policy. b. S2 uptake by Lanarkshire school Across Lanarkshire, uptake of HPV vaccine in S2 girls ranges from 80.8% to 100%. However, there are four schools below 90% that appear to be out of keeping with an otherwise fairly tight distribution (Graph 1). Schools for additional needs pupils are included in the HPV programme but are not shown on the graph, as small class numbers could convey personal information. Across Scotland, no differences in uptake rate were seen between pupils attending denominational versus non-denominational schools in Scotland. Graph 1 Uptake of HPV vaccine by Lanarkshire secondary school ranked by for girls 2010/11 100 percentage 90 80 Lanarkshire average 70 1 11 21 31 school Uptake rates are based on immunisations recorded on the CHSP School system and SIRS as at 15 August 2011 4
c. Uptake for catch-up cohorts of school pupils and leavers Overall, HPV vaccine uptake rates in the catch-up cohort S4 to S5 and school leavers were good as shown for year 2 (table 2). Uptake rates for NHS Lanarkshire were just above and just below the averages for Scotland of 83.4% and 80.2% for 1st and 2nd HPV doses respectively (table 2). Table 2 HPV Immunisation Programme in Scotland - Year 2 (2009/10) Total Catch-up Cohort (all girls eligible during year 2 of the catch-up) 3 Interim Statistics: HPV uptake rates for girls in S4 and S5 in school year 2009/10 and girls who have left school who were born 2 September 1992 to 1 September 1993 1 NHS Board 2 of girls in cohort 3 2nd dose 3rd 2nd dose dose 3rd dose Ayrshire and Arran 4 748 4 150 87.4 3 993 84.1.... Borders 1 378 1 246 90.4 1 209 87.7.... Dumfries and Galloway 1 860 1 635 87.9 1 613 86.7.... Fife 4 383 3 312 75.6 3 233 73.8.... Forth Valley 3 775 3 229 85.5 3 142 83.2.... Grampian 6 549 5 512 84.2 5 374 82.1.... Greater Glasgow & Clyde 5 14 338 11 918 83.1 11 352 79.2.... Highland 3 833 3 242 84.6 3 109 81.1.... Lanarkshire 5 7 428 6 279 84.5 5 915 79.6.... Lothian 9 083 7 323 80.6 7 079 77.9.... Orkney 4 251 193 76.9 190 75.7.... Shetland 286 250 87.4 244 85.3.... Tayside 4 760 3 977 83.6 3 807 80.0.... Western Isles 342 272 79.5 260 76.0.... Scotland 2,4 63 060 52 578 83.4 50 557 80.2.... 1. Interim statistics based on data recorded on the CHI system as at 10 May 2010/SIRS system as at 16 August 2010. Some vaccinations may have been given but have not yet been recorded on CHSP. 2. NHS Board of school for girls in school, and NHS Board of residence for girls who have left school. There are a small number of records which do not have a postcode recorded and therefore for statistical purposes, NHS Board of residence is unknown. These records are included in the Scotland cohort and uptake rates, and therefore the sum of the cohorts for all NHS Boards does not equate to the total cohort for Scotland. 3. Girls recorded on CHSP School as being in class year S4 or S5 as at 10 May 2010, and girls who have left school and were born between 2 September 1992 and 1 September 1993. There will be some girls registered on the Community Health Index (CHI) who are no longer resident in Scotland. These individuals will remain in the denominator figure for the school leavers catch up cohort but are not available to be immunised, and therefore uptake rates for girls who have left school may actually be slightly higher than reported. 4. All NHS boards except NHS Orkney use CHSP School/SIRS to record HPV immunisations. NHS Orkney have provided their own figures. 5. NHS Lanarkshire is delivering the HPV programme to girls in Cambuslang and Rutherglen, however HPV data for Cambuslang and Rutherglen are recorded/shown under NHS Greater Glasgow & Clyde on CHSP School... Not available. Uptake rates for the third dose of HPV immunisation, for the catch-up cohort, will be published in March 2011. Source: CHI (May 2010)/CHSP School (May 2010)/SIRS (August 2010) However, in Lanarkshire and across Scotland, within the catch-up cohort, the school leavers subgroup had significantly lower uptake rates than for those still at school, with rates of 48.0% (45.9%) for 1st dose and 37.1% (38.4%) for 2nd dose in Lanarkshire (and Scotland) (Table 3). In contrast, uptake (measured at the same time) in the S4 cohort still at school in Lanarkshire (and Scotland) was 92.3% (90.4) for and 89.0% (87.9%) for 2nd dose. 5
Table 3 HPV Immunisation Programme in Scotland - Year 2 (2009/10) Table 5: New School Leavers Catch-up Cohort (girls eligible during year 2 of the catch-up who have now left school) 3 Interim Statistics: HPV immunisation uptake rates for girls in the catch up cohort who have left school (born 2 September 1992 to 1 September 1993) 1 NHS Board 2 of girls in cohort 3 2nd dose 3rd 2nd dose dose 3rd dose Ayrshire and Arran 1 034 726 70.2 644 62.3.... Borders 237 174 73.4 163 68.8.... Dumfries and Galloway 218 119 54.6 110 50.5.... Fife 683 149 21.8 132 19.3.... Forth Valley 510 300 58.8 264 51.8.... Grampian 1 050 494 47.0 424 40.4.... Greater Glasgow & Clyde 5 2 444 1 034 42.3 829 33.9.... Highland 537 257 47.9 210 39.1.... Lanarkshire 5 1 122 538 48.0 416 37.1.... Lothian 1 348 450 33.4 368 27.3.... Orkney 4 6 2 33.3 2 33.3.... Shetland 14 10 71.4 8 57.1.... Tayside 822 359 43.7 281 34.2.... Western Isles 37 12 32.4 12 32.4.... Scotland 2,4 10 065 4 624 45.9 3 863 38.4.... 1. Interim statistics based on data recorded on the CHI system as at 10 May 2010/SIRS system as at 16 August 2010. Some vaccinations may have been given but have not yet been recorded on CHSP. 2. NHS Board of residence. There are a small number of records which do not have a postcode recorded and therefore for statistical purposes, NHS Board of Residence is unknown. These records are included in the Scotland cohort and uptake rates and therefore the sum of the cohorts for all NHS Boards does not equate to the total cohort for Scotland. 3. Girls born between 2 September 1992 and 1 September 1993, who have left school. There will be some girls registered on the Community Health Index (CHI) who are no longer resident in Scotland. These individuals will remain in the denominator figure for the school leavers catch up cohort but are not available to be immunised, and therefore uptake rates for girls who have left school may actually be slightly higher than reported. 4. All NHS boards except NHS Orkney use CHSP School/SIRS to record HPV immunisations. NHS Orkney have provided their own figures. 5. NHS Lanarkshire is delivering the HPV programme to girls in Cambuslang and Rutherglen, however HPV data for Cambuslang and Rutherglen are recorded/shown under NHS Greater Glasgow & Clyde on CHSP School/SIRS... Not available. Uptake rates for the third dose of HPV immunisation, for the catch-up cohort, will be published in March 2011. Source: CHI (May 2010)/SIRS (August 2010) In August 2011, the department of public health wrote to 4,342 school leavers who either had no doses of HPV vaccine or incomplete HPV vaccine courses advising that this was their final chance to get HPV vaccination and provided their GPs with lists for additional follow-up. A further 1,300, whose GPs did not sign up for the LES, received similar letters and 323 responded positively. They needed a total of 754 doses of HPV vaccine to complete their courses. Sexual health service will offer these young women HPV vaccine until the end of March 2012. 6
HPS has shown that for year 1 catch-up data, those who are the least affluent have lower uptake rates than those who are most affluent within the cohorts of those registered at school and those who are not. Furthermore, the relative impact of deprivation on those not at school is greater than those at school. (Graph 2). The effects of deprivation should be less in future as those beginning HPV vaccine in S2 will have many opportunities to be vaccinated before they leave school. Final uptake rates for the catch-up cohort will be produced by ISD during 2012. Graph 2 HPV vaccine uptake in year 1 catchup cohorts by dose and SIMD data to 15th February 2010, Source ISD: CHSP-S, SIRS S5/S6 dose 1 S5/S6 dose 2 S5/S6 dose 3 100% 90% 80% school leavers dose 1 school leavers dose 2 school leavers dose 3 Catch up cohorts still at school 70% 60% 50% 40% 30% 20% School leavers 10% 0% simd5 simd4 simd3 simd2 simd1 Least deprived Most deprived 5. Current Issues a. Change to Gardasil in September 12 NHS Lanarkshire is awaiting detailed guidance on the implications the change to Gardasil will have on the HPV vaccination programme. Specifically, there is an immediate possibility that some pupils may wish to defer getting Cervarix, although early indications would suggest this risk is not being realised. Use of Gardasil will also require changes to national information leaflets and IT systems as well as locally produced patient group directions. 7
b. School-based vaccinations The school-based delivery of HPV vaccine has a well established routine, with 5 appointments sessions per year for S2 girls that also include older school girls who have missed doses. The system employs pre-printed consent forms and leaflets and electronic scheduling and is efficient. Although there is generally a very positive attitude to HPV vaccine, the school nurse led HPV education sessions will be reinstated at the start of S2. Uptake in four schools appears lower than and out of keeping with the general uptake distribution for other schools. Attention has been drawn to some working practices, for example, making blank consent forms available on the day of vaccination so pupils can be consented to avoid delays. Pharmacy supplies are based on school health schedules and the supply chain is working smoothly. c. School leavers The sexual health service will continue to appoint girls for HPV vaccine drawn from lists drawn up by public health until the end of March 12. Following that HPV vaccine will not be available through community based clinics as part of the HPV catch-up programme. However, GPs can still administer HPV vaccine on a case by case basis, where there is demand. 6. Future Actions 1) Ensure the smooth transition to the Gardasil brand by September 2012 2) Reinstate pre-vaccination education sessions for S2 girls from September 2012 3) Review the reasons for lower uptake in several Lanarkshire schools 4) Keep HPV vaccination high in public awareness 8
7. Conclusions The HPV vaccination programme in NHS Lanarkshire, and indeed Scotland, has had a very successful first 3 years with over 90% of the first S2 cohort completing the full HPV course. Five vaccination sessions are provided by NHS Lanarkshire school health teams each year. Staff accommodate a minority of pupils specific needs by providing vaccine at the end of a session or off site. Uptake in older school groups is naturally marginally behind as they have had fewer opportunities to be vaccinated, but it is expected that they will catchup. The effects of deprivation on vaccine uptake are less marked in those who attend school than school leavers. School leavers are a more difficult group to achieve high vaccination uptake rates. This is the case with HPV vaccine, as occurred with meningitis vaccine (MenC). However, HPV vaccination rates are around 3-4 times higher than MenC. This has been achieved though public awareness and writing, on several occasions, directly to those due HPV vaccine inviting them to attend their GP or community clinic. 8. FURTHER INFORMATION If Members would wish any further information about the paper, please contact Dr David Cromie, Telephone: 01698 858117 Email: david.cromie@lanarkshire.scot.nhs.uk. Dr David Cromie Consultant in Public Health Medicine 9