HPV Update

Mr Jonathan Lippiatt
MRCOG DFSRH MBBCh
Clinical Lecturer Obstetrics & Gynaecology
Cardiff University
 HPV Update
 How HPV leads to cancer
 Impact on UK and world
 Vaccination programme uptake
 Problems with the programme
 Cervical screening
 Prevention in developing countries
 Human
Papillomavirus

Cervical Cancer
 HPV Recap
 Small virus – 100 types
 Low-risk e.g. 6, 11
 High-risk e.g. 16, 18

 Associated with various disease from skin

warts to cervical cancer
 Transmission via skin-to-skin/sexual
 Most common STI
How does HPV cause cancer?
HPV
infection
Persistent HR HPV infection
Normal
CIN Invasive
epithelium
10-20+ years carcinoma

HPV clearance HPV clearance & regression dependent on age,

degree of CIN lesion & immune status
No lesion
> 80%
 Strength of Association
Relative
Risk Carcinogenic Agent

> 500 High Risk HPV and cervical cancer

- Philippines, Costa Rica, Bangkok
50-100 Hepatitis B virus and liver cancer
- Taiwan, Greece
20 Hepatitis C virus and liver cancer
- Italy, Spain
10 Cigarette smoking and lung cancer
Worldwide stats for cervical cancer

 Worldwide 493,000 new cases per year

 1 in 10 female cancers
 Commonest cancer in Sub-Saharan Africa
and parts of South America

 Approximately 274,000 deaths per year

 Mortality rates vary 17 fold
 2.7 million years of life lost in women aged 25-64
 2 opportunities to prevent cervical
cancer
Cervical
Prophylactic screening &
HPV treatment
vaccination

Precursor
disease –
Cervical Cervical
Normal cervix HPV infection
Intraepithelial cancer
Neoplasia
(CIN)
 HPV Immunisation
 Programme in Wales
 From Sept 2008
 routine12-13yr olds
 catch-up for 18yr olds

 From Sept 2009

 routine12-13yr olds
 accelerated catch-up for 15-18yr olds
 Wales Uptake
 In 2008/09 school year 8
 1st dose – 88.9%
 2nd dose – 88.1%
 3rd dose – 85.2%

 18yr olds
 1st dose – 46.8%
 2nd dose – 40.6%
 3rd dose – 27.7%
 UK Uptake

88.9 88.1 85.2

International Uptake
Latest Wales Data (Oct-Dec 09)
 In 2009/10 school year 8
 1st dose – 80.8%
 2nd dose – 62.7%

 Year 10 – 77.8% and 61%

 Year 11 – 76% and 61.6%
 Year 12 – 50.2% and 38.6%
 Year 13 – 42.1% and 31.3%
Schools vs GPs
 Problems?
 Parental rejection
 Prevents a STI
 Girls are too young?
 Vaccine very new

 Patient rejection
 Three injections!
 Arm hurts
 Am I bothered?!?
 Problems?
 Actually uptake results and recent study
show parents are agreeable

 One NHS trust piloting incentives for the

catch-up group
 Media problems?
 Daily Mail: First picture of girl, 14, who
died after being injected with cervical
cancer jab from 'rogue batch‘

 Daily Mail: How safe is the cervical cancer

jab? Five teenagers reveal their alarming
stories
 Media Problems?
 Daily Telegraph: Cervical cancer vaccine
will cut cases by two thirds, experts
calculate

 Guardian: Cancer tests go up after Goody

diagnosis
 Drug safety
 MHRA 8th Apr 2010
 3.5 million doses across UK
 Majority are recognised S/E or due to the
injection process
 Isolated medical conditions appear to be
coincidental
Top 10 reported adverse effects
Dizziness 513
Headache 511
Nausea 511
Pain in extremity 409
Syncope 273
Vomiting 224
Malaise 180
Fatigue 151
Pyrexia 145
Rash 118
Bedridden / feeling drunk / mobility 7
decreased / disturbance in attention
 Drug Safety
 Post hoc study of phase III trials reveal no
statistically significant increase in rate of
miscarriage
 However, it cannot be ruled out and
caution is advised
 Missed opportunity?
 CervarixTM vs Gardasil®
 Genital warts most common STI in UK
 Costs NHS approx £23m/yr
 According to HPA the DoH are saving
£18.6 m a year by using Cervarix
 GSK report that Cervarix induces
significantly higher antibody titres - ?longer
duration of protection
 Missed opportunity?
 What about the boys?
 Herd immunity
 Greater infection risk due to promiscuity
 At risk of penile, anal and oropharyngeal
cancers
 Cervical Screening
 Still required?
 YES – and must be emphasised to girls
 Mothers may be motivated to attend
 Concern also that unvaccinated will
become the unscreened
 Different in the future?
 Age of initial screening
 HPV testing to triage
 Cervical cancers avoidable in different
countries
Screening HPV Vaccine Coverage
efficacy (notably in unscreened women)
Nearly perfect
screening, eg Nordic
85% 50% 10%
countries

85% 95% 91% 86% High-resource

countries

50% 82% 69% 54%

Intermediate
10% 67% 44% 17% -resource
countries
Lowest-
0 resource 64% 38% 8%
countries

Franceschi 2008
 Coverage is vital
 Coverage for vaccination & screening is
crucial for maximising cervical cancer
prevention
 HPV vaccination particularly important for
women unlikely to be screened
 eg rural populations
 Systematic, organised screening required
 Quality and sustainability important
 Summary
 Best practice for vaccine programme is
still being determined
 Schools doing very well for 12-13yr olds
 Catch-up been more challenging
 Implications on future screening
 Potential for developing countries
Questions?
Questions?