HPV vaccination: getting the programme back on track

Vaccination against human papillomavirus (HPV) infection provides safe and effective protection from genital warts, most cervical cancers and many anogenital and oropharyngeal cancers. However, HPV vaccination rates in New Zealand could be better; higher rates of vaccination will protect more individuals and offer more effective “herd immunity” against these conditions.

0 comments
save
share
feedback
Log in

Key practice points:

  • Without vaccination, approximately 80% of sexually active adults will be infected by at least one strain of HPV during their lifetime
  • The HPV vaccine (Gardasil 9) protects against nine strains of HPV:
    • Two low-risk strains that cause approximately 90% of genital warts
    • Seven high-risk strains that cause the majority of cervical cancers and many anogenital and oropharyngeal cancers
  • To achieve more effective “herd immunity”, vaccination rates need to be 75–80%; latest figures show 67% coverage in New Zealand
  • Females and males aged nine to 26 years are eligible for a subsidised course of vaccination
  • Vaccination against HPV before the age of 14 years is associated with a stronger immune response therefore only two doses are required in this age group; three doses are otherwise required
  • The school-based HPV immunisation programme aims to vaccinate children in Year 7 or 8 (aged 11–12 years)
  • It is recommended that practices place an active recall for patients aged 14 years to offer the vaccination to those who have not received it; this is also an opportunity to check vaccination status in general
  • Ensure that all young adults, i.e. those aged 26 years and under, are aware that they are eligible for subsidised HPV vaccination; some may have missed out on the vaccine through the school-based programme and are unaware that it is available to them

The human papillomavirus (HPV) vaccine reduces the incidence of diseases associated with HPV infection, including genital warts, most cervical cancers and many anogenital and oropharyngeal cancers. Since January, 2017, all females and males aged nine to 26 years have been eligible to receive subsidised vaccination; previously it was only subsidised for females until age 20 years. At the same time as subsidised access to the vaccine was widened, protection was extended from four strains of HPV to nine strains, by changing from Gardasil to Gardasil 9.

Further information on the nonavalent HPV vaccine is available from: www.bpac.org.nz/2016/hpv.aspx

The number of doses varies by age

Table 1 describes the groups of people eligible for subsidised vaccination and the number of doses recommended. School-based immunisation normally begins at age 11 or 12 years (Year 7 or 8), however, the vaccine can be given early to patients who are immunocompromised or prior to organ transplant.1 People aged 27 years and older who received at least one dose of HPV vaccine before turning 27 years can complete the schedule fully subsidised. The vaccine can be administered unsubsidised to people aged 27 years and over if they are likely to benefit (Table 1).1

Immunocompromised patients can receive the HPV vaccination

HPV vaccination can be safely administered to people who are immunocompromised, e.g. those who have received chemotherapy or with HIV infection, because the vaccine contains non-replicating, non-infectious viral subunits.1, 3

HPV vaccine can be given during pregnancy or while breast feeding

While it is recommended to wait until after pregnancy to administer the HPV vaccine, there is no evidence that it causes adverse effects such as congenital abnormalities or spontaneous abortion.4 The HPV vaccine is safe to receive while breastfeeding.4


Table 1. HPV vaccine schedules adapted from the Ministry of Health (2017)1

Number of doses Schedule Subsidy

Children aged 9–14 years

2

0 and 6–12 months

Yes

People aged 15–26 years

3

0, 2 and 6 months

Yes

People aged 9–26 years with:

  • Confirmed HIV infection

OR

  • Organ or tissue transplant (including stem cells)

3

0, 2 and 6 months

Yes

People aged 9–26 years who are post-chemotherapy

One additional dose

≥ 1 month after the last dose

Yes

People aged 27 and older who may benefit, e.g.:

  • Those with little previous exposure to HPV
  • Men who have sex with men
  • Those with HIV infection

3

0, 2 and 6 months

No

The HPV vaccine is registered for use in females aged 9–45 years and in males aged 9–26 years, however, there are no concerns that the efficacy or safety in males up to the age of 45 years will differ significantly from females of the same age or younger males.1 The unsubsidised cost of three doses varies but is approximately $500 as of February 2019.2

How effective has HPV vaccination been in New Zealand?

The number of diagnoses of genital warts has significantly decreased since the introduction of the vaccine; the latest surveillance data reported a 17% decline in diagnoses in primary care in all ages from 2014 to 2015.5 Data collected from the Auckland Sexual Health Service showed an 83% reduction in genital wart diagnoses in young females in 2013 compared with 2008, before the HPV vaccination programme was introduced.6 It is too early to detect any effects of HPV vaccination on cancer rates in New Zealand as this requires lengthy follow-up periods.

Vaccination rates against HPV in New Zealand are too low

The target for HPV vaccination is 75% coverage across all DHBs, which the Ministry of Health hoped to achieve by December, 2017. This level of coverage is considered to provide more effective “herd immunity” where those unwilling or unable to receive the vaccine are also protected.7 This target was not met, with latest figures showing only 67% coverage for females born in 2003.* 8 The lowest rate of vaccination was in European/Others (65%), with higher rates in Māori (67%), Asian (71%) and Pacific peoples (73%).8

* Data are currently unavailable for females born after 2003 and there are currently no statistics for coverage in males

Catch-up vaccinations following the supply shortage

There was a supply shortage of HPV vaccines in New Zealand during late 2017 and through most of 2018. This issue has been resolved and health professionals in primary care are now able to order unrestricted quantities of the vaccine. However, the Ministry of Health indicates that there are a significant number of eligible people, particularly young males, who have not completed the full course of vaccinations due to the shortage. The following guidance is provided for health professionals scheduling “catch-up” vaccinations:

  • If a person has started the course of HPV vaccinations they do not need to begin the course again, regardless of the amount of time that has passed; give the next dose as scheduled
  • If the second HPV vaccination is given at age 15 years or older a third dose is recommended and subsidised
  • People who turned age 27 years after April 1, 2018, who received their first dose of HPV vaccine before 1 April, 2019, and international students who turn age 18 years during this period are eligible to receive a subsidised course of HPV vaccinations*

* A manual claim should be submitted after the first dose. Once this has been accepted the subsequent doses should be processed automatically.

HPV infection is spread via close skin-to-skin contact which can occur during penetrative and non-penetrative sexual contact, e.g. oral sex.9 In very rare cases, HPV can be transmitted from mother to fetus perinatally.1 Approximately 80% of sexually active adults will be infected by at least one strain of HPV during their lifetime, with the risk of infection increasing in proportion to the number of sexual partners.9

The natural history of HPV infection, i.e. without vaccination, is often transient and asymptomatic, with a loss of detectable HPV occurring after 6–12 months.9 However, in some individuals the repeated division of infected cells will result in the development of anogenital warts, often weeks or months after acquiring the infection.9 In 10–20% of people the infection will persist latently over years, strongly increasing their risk of developing a neoplasia, which may eventually progress to invasive cancer.10 The reasons why some people have persistent infections with HPV are not completely understood but may involve genetics and environmental factors such as alcohol consumption and tobacco smoking.10 Consistent use of condoms only reduces the rate of transmission by 30–60% as they may not cover all areas of infection.9

Vaccination protects against nine strains of HPV

The current HPV vaccine prevents infection from nine strains of HPV, including two low-risk strains (6 and 11) that cause approximately 90% of genital warts and seven high-risk strains (16, 18, 31, 33, 45, 52 and 58) that cause the majority of cervical cancers; strains 16 and 18 are associated with approximately 70% of invasive cervical cancers.9

HPV vaccination prevents more than 97% of genital intraepithelial neoplasias and anogenital warts among females aged 16–26 years who have tested negative for prior infection with HPV (see: “Routine cervical screening is still required“).1, 11 Less data are available regarding the vaccine’s efficacy in males, but there is evidence that more than 90% of external genital lesions, including warts and genital intraepithelial neoplasias, are prevented in males aged 16–26 years.12 N.B. Genital intraepithelial neoplasias are rare among young males and females.

Long-term immune responses occur in almost all people

One month after completing the HPV vaccination schedule, 99.6% – 100% of people aged 9–26 years will have antibodies present against all nine strains covered by the vaccine.11 It is unclear how long protection lasts as studies are ongoing, however, it is known to persist for at least ten years with no decrease in efficacy, therefore booster vaccinations are not considered necessary if the full schedule has been completed.11

Vaccination at an early age is associated with greater protection

Vaccination against HPV is associated with a stronger immune response in younger people.13 For this reason, only two doses of the vaccine are required for those aged under 14 years, compared with three in older groups. It is important that young people and caregivers understand that the reason why vaccination is recommended at age 11–12 years is to maximise the recipient’s immune response and avoid the need for additional doses, rather than it being a predictor of imminent sexual activity.

Vaccination is also beneficial for people who are sexually active

People who are sexually active, including those who have already been infected with HPV and those who have developed HPV-related conditions, may also benefit from vaccination. Most significantly, the vaccine will provide these people with protection against strains of HPV they have not encountered. It may also prevent reinfection with a strain they have been previously exposed to if they cleared the infection without producing antibodies against that strain. Many people who are infected with HPV do not develop immunity as seroconversion is poor.9 Immunity from vaccination is more effective than immunity post-exposure to the wild virus. There are no safety concerns associated with vaccination in people who are already infected with HPV or who have developed an HPV-related condition.1

Some people in New Zealand are unaware they are entitled to fully subsidised HPV vaccinations or were not eligible at the time and have therefore not participated in the school-based programme. General practices should identify any eligible enrolled patients who have not received HPV vaccination.

A routine recall at age 14 years is recommended. For example:

  1. Schedule an automatic reminder to occur when a patient turns 14 years and send a recall letter if appropriate
  2. Establish a monthly recall for all people who have turned 14 in the previous month

People aged 15–26 years who have not received the full schedule of HPV vaccines (or any at all) can be flagged in the patient management system to be offered the vaccine at their next consultation. Patients who do not regularly attend primary care may require a recall offering them subsidised vaccination.

Best practice tip: use the recall as an opportunity to also check for completion of two measles, mumps and rubella (MMR) vaccines, tetanus-diptheria-pertussis (Tdap) vaccination (usually given in a school-based programme at age 11 years), and a history of varicella or varicella vaccination.

The ASK approach to vaccination discussions

Health professionals sometimes meet resistance when discussing vaccination. The ASK approach is one option clinicians can use when discussing potentially emotive issues:

  • Acknowledging the person’s concerns
  • Steering the conversation
  • Knowing the facts

Not every person will express the same concerns, so acknowledging differing viewpoints and being non-judgemental is important when discussing vaccination.

Setting the story straight about safety

More than 100 million doses of the HPV vaccine have been administered worldwide, and it has been well-tolerated in females and males across all age groups.2 The risks associated with the HPV vaccine are similar to other vaccines. The most common adverse effect is mild-to-moderate injection-site pain which occurs in 83% of people within five days.11 Other possible adverse effects are generally transient, including swelling, erythema, pruritus and bruising around the injection site, as well as headaches and pyrexia.2 The risk of anaphylactic reaction after administering the vaccine is approximately three cases per million doses.1

There is no evidence linking the HPV vaccine to rare adverse effects

There have been case reports describing an association between administration of the HPV vaccine and the development of some rare conditions, e.g. autoimmune disorders, complex regional pain syndrome (CRPS) and postural orthostatic tachycardia syndrome (POTS). However, as vaccination is widespread and these conditions are relatively rare it is not possible to analyse the potential relationship between the two without performing large epidemiological studies.

A large Canadian cohort study of more than 290,000 females aged 12–17 years found no increased risk of autoimmune disorders following vaccination with the quadrivalent HPV vaccine.21 An extensive review of the evidence by the European Medicines Agency (EMA) found no evidence that the HPV vaccine causes CRPS or POTS.22 The prevalence of both conditions in the general population is approximately 150 cases per million people each year, and the occurrence of CRPS and POTS in young females who had been vaccinated was no higher than would be expected.22

Patient information on HPV and the HPV vaccine are available from:

Acknowledgement

Thank you to Dr Nikki Turner, Director of the Immunisation Advisory Centre for expert review of this article

N.B. Expert reviewers do not write the articles and are not responsible for the final content.


Published: 29 March 2019 | Updated:

There are currently no comments for this article.

Please login to make a comment.

Made with by the bpacnz team