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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
epithelium
HPV clearance
No lesion
> 80%
CIN
10-20+ years
Invasive
carcinoma
HPV clearance & regression dependent on age,
degree of CIN lesion & immune status
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
Prophylactic
HPV
vaccination
Normal cervix
HPV infection
Cervical
screening &
treatment
Precursor
disease –
Cervical
Intraepithelial
Neoplasia
(CIN)
Cervical
cancer
HPV Immunisation

Programme in Wales

From Sept 2008
 routine
12-13yr olds
 catch-up for 18yr olds

From Sept 2009
 routine
12-13yr 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
Bedridden / feeling drunk / mobility
decreased / disturbance in attention
118
7
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
efficacy
HPV Vaccine Coverage
(notably in unscreened women)
85%
50%
10%
85%
95%
91%
86%
50%
82%
69%
54%
Nearly perfect
screening, eg Nordic
countries
10%
0
Lowestresource
countries
67%
44%
17%
64%
38%
8%
High-resource
countries
Intermediate
-resource
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?