CPHA Preventing Cervical Cancer- Making it Happen

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CPHAPreventing Cervical Cancer- Making it Happen

• Cathy OKeefe
• Gillian Butler
• May 29, 2014

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Disclosures

• Disclosures
• I have no financial interests to disclose

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Acknowledgements

• Gillian Butler, CDC Nurse Specialist, GNL
• Peggy Allan, CDC Nurse, Western Health
• Hayley Cooze, CDC Nurse, Central Health
• The dedicated Public Health Nurses in NL who take
  ownership to make sure every child is immunized

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Outline for May 29

• Provide an overview of the first six years of the
  HPV female immunization program in NL
• Discuss the research available regarding herd
  immunity with HPV programs
• Describe current practice for informed consent
  and administration

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Outline continued

• Compare coverage rates with other provinces and
  countries
• Discuss the need, or not, for evaluation and
  program expansion

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Newfoundland and Labrador
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What do you think ?

• Best age for HPV vaccine
• Consent no consent
• Females and males
• Catch-up for males
• Best way to optimize uptake

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NACI recommendations

• NACI initial statement February 2007
• Prevent cervical cancers caused by HPV infection
• NACI statement updated in 2012
• HPV4 (Gardasil) is recommended in males between
  9 and 26 years of age for the prevention of anal
  intraepithelial neoplasia (AIN) grades 1, 2, and
  3, anal cancer, and anogenital warts (NACI
  Recommendation Grade A). NACI has determined that
  there is good (Grade A) evidence to recommend the
  use of Gardasil in males between 9 to 26 years
  of age.
• To date PEI and Alberta have announced programs
  for males

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Research

• The impact of vaccinating males, compared to that
  of improving vaccination uptake in existing
  female cohorts or vaccinating additional female
  cohorts.
• Inclusion of males in routine programs
  facilitates vaccination of males at a young age
  when the potential benefit of the vaccine is
  greatest.
• There are no studies that directly demonstrate
  that HPV vaccination of males will result in less
  sexual transmission of vaccine-related HPV types
  from males to females and in reduced incidence of
  cervical cancer.
• While current models predict that addition of
  males to a routine HPV vaccination program would
  prevent additional cases of genital warts and
  cervical cancer among females to varying degrees,
  
• Provinces and territories will need to compare
  the impact of vaccinating males with that of
  vaccinating additional female cohorts.
• While not directly comparable, lessons learned
  from gender-targeting e.g. rubella vaccine

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Getting started

• 21 March 2007
• Canadian Cancer Society Applauds Funding for HPV
  Vaccine Announced in Federal Budget
• TORONTO - The Canadian Cancer Society applauds
  the federal budget announcement of 300 million
  to help implement the HPV vaccine across Canada.
  The vaccine will help protect young women and
  girls from cervical cancer.

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Choosing a cohort

• Jurisdictions have approached the age to provide
  immunization in different ways
• The NACI statement keeps the range broad
• NL decision made by looking at varied factors

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Getting the best coverage

• NL factors for choosing a cohort
• Age of initiation of sexual activity
• Impact of school size and class attendance
• Duration of protection
• Ongoing surveillance and connection with cancer
  registry

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Regional Participation

• The key component of making this work is
  collaboration with Regional Health Authorities in
  planning
• Some of the questions- What works best
• Grade - Age
• Timing - Involving teachers
• Materials for parents and teachers
• PH Nurse training
• Should we involve media

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NL The process 2007

• Fall 2006 Communicable Disease Nurses and
  Regional Medical Officers of Health were provided
  scientific information on HPV infection and
  vaccine
• Once NACI announced
• managers had heard that implementation was most
  likely going to be fall 2008, but nevertheless
  did pass this info on to lower level managers who
  had been asked to work out the logistics...
• so when the announcement was made, there was
  little difficulty mobilizing because much of the
  work was done

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HPV NL Implementation August September 2007

• Policy developedMaterials Education for health
  professionals Informed consent Fact sheet to
  facilitate consent Post immunization fact
  sheet Information package for teachers
• Flexibility in regions for operationalization

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Consent
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Implementation

• PH Nurses in-service on science and responding to
  parental concerns
• Materials printed
• Policies revised and distributed
• Work with Department of Education to develop an
  information package for school boards and
  teachers on HPV program
• Regions provided with vaccine, materials for
  education

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Adding another Cohort

• As many of the PT came on board and costs reduced
  the key was to ensure equitable use of all the
  NIS trust funding
• Add cohort grade 9 for 2 years
• Already completing a consent for Tdap
• Not covered in 08-09 by the grade 6 program
• 2 years
• Result 90 of females born 1994 and after have
  been immunized

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Challenges at Regional level

• Hiring nurses on a casual basis
• Remote communities covering several cohorts
• Public vs. private access
• HPV not reportable

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Uptake First 3 years
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2007-2010
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Reaching the goal
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Why this works

• All post natal referrals in this region are sent
  to PH nurses for follow-up.
• PH nurses use this opportunity to provide an
  appointment for child health clinics. The first
  vaccinations are at 8 weeks, two weeks later than
  the doctors the 6 week appointment.
• Also since the parent is called and an
  appointment is provided for immunization, the
  parent is made to feel it is important to have
  vaccines.
• All school based immunization programs are
  completed by PH nurses allowing physicians to
  work toward their scope of practice.

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Why this works

• Single service provision of Childhood
  immunization Program
• Only one group responsible for provision of this
  service
• Public Health Nurses cover all communities
• Clear lines of communication for issues that
  arise
• They are directed and follow provincial policies
  and procedures.
• Have our immunization manuals to follow so there
  are clear consistent messages
• Strong support from provincial office prompt
  response to concerns that arise

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Why this works

• Issues and concerns were dealt with promptly.
  PHNs fell their work is valued and they take
  ownership of the immunization program.
• Vaccine products are changing continuously
• PHNs are immediately educated about any program
  changes or changes to vaccine product
• Written materials such as tear off sheets are
  provided promptly as well as product information
• Semi-monthly Public Health memo send from the
  CDCN keeps the PH nurses abreast of changes

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What do you think?

• Revisit our questions and reflect on how this
  could work in your jurisdiction

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Opportunities

• Linking immunization records to the cancer
  registry
• HPV monitoring and Surveillance Committee
• Reviewing policy related to immunizing males

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Discussion Questions
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References

• CCDR NACI 2007 2012
• Rosberger, Perez King, Franco Oncology exchange
  May 2013 Vol 12 No 2
• Tabrizi, Brotherton, Kaldor, Cummins, Lui Journal
  of Infectious Diseases 2012206
• Brotherton, Fridman The Lancet 2011