Preventing Pneumococcal and HPV Infections: Update on recent - - PowerPoint PPT Presentation

Preventing Pneumococcal and HPV Infections: Update on recent progress and research in Alaska

Thomas Hennessy, MD, MPH Michael Bruce, MD, MPH CDC Arctic Investigations Program Anchorage, Alaska

Rosalyn Singleton MD MPH Alaska Native Tribal Health Consortium ris2@cdc.gov 729-3418

Disclosure

 Dr. Singleton has received funding for a clinical

trial from Pfizer, Inc

 CDC Arctic Investigations Program received an

unconditional gift from Pfizer (ne. Wyeth Vaccines) in 1998-2011

 We will discuss a non-licensed use of a vaccine

– PCV13

 We will mention a non-licensed vaccine

Disclosure

 This presentation represents the views of

the authors and do not necessarily represent the official position of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and the Indian Health Service.

Disclosure

 This presentation represents the views of the authors

and do not necessarily represent the official position of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and the Indian Health Service.

 … We could be rogue scientists.

What we will cover….

 Pneumococcal

disease in children

 Vaccine uptake  Disease rates  Nasal colonization  Recent disease in

young children

 What’s new?

 Human

papillomavirus (HPV)

 Vaccine uptake  Research studies

 Immunogenicity study  Preventable cervical

cancers

 Colposcopy clinic study

 What’s next?

Has the Federal Government Shutdown Affected Essential Services at CDC’s Arctic Investigations Program?

Valet Parking in Alaska- Is it really needed?

Pneumococcus (Streptococcus pneumoniae)

 Main cause of

 Bacterial meningitis  Blood infections  Pneumonia  Otitis media

 Reportable disease in

Alaska

 Non-sterile site  Invasive pneumo disease

 “IPD”

 Lab-based surveillance

since 1986



CDC Arctic Investigations Program

Ear infection Pneumonia Brain: meningitis Pneumococcal bacteria

Pneumococcal Invasive Disease Rates, 1996 - 2000

127 18 4.2 5.7 11 17 45.7 97.5 451 83 13 19 43 56 74 112

50 100 150 200 250 300 350 400 450 500 <2 2-4 5-17 18-34 35-49 50-64 65-79 80+ Age (years) Cases/100,000/year Alaska non-Native Alaska Native

Two Pneumococcal Vaccines



Pneumococcal polysaccharide vaccine (PPSV23)

 23 polysaccharide antigens  88% adult disease  No immune memory  No effect on carriage  Not effective <2 yrs  60-70% effective against

invasive disease



Pneumococcal conjugate vaccine (PCV)

 Polysaccharide conjugated to

protein

 7 serotypes: 80% child illness  Boosting/ memory  Decreases carriage  Immunogenic in children  >90% effective against

invasive disease

Pneumococcal Vaccines for Children



PCV7 (pneumococcal conjugate vaccine)



Introduced in 2000



7 serotypes caused 76% of IPD in < 5 year olds



Given at 2,4,6, 12 months



Essentially eliminated the 7 vaccine serotypes



In 2010, PCV13 replaced PCV7



Covers ~ 70% of the remaining invasive pneumococcal disease

10

All Serotypes: -76% (-79,-73) PCV7 Types: -98% (-99,-97)

200 400 600 800 1000 1200 1995-2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Rate per 100,000 PCV7 types non-PCV7 types

Invasive Pneumococcal Disease Western Alaska Children < 2 yrs old

PCV7 vaccine introduced

PCV uptake in U.S. and Alaska

National Immunization Survey, 2008-2012 with tribal reports for 2011 and 2012

Alaska Native rate for 6/30/2013 was 89%

Alaska Adult Pneumococcal Vaccine Recommendations

 19-64 year old– 1 dose PPV23 for High Risk

 Underlying medical conditions

 CHF, CLD, chronic liver disease, diabetes, alcoholism, asthma smokers,

cochlear implant, renal failure, immunocompromise, asplenia, CSF leak

 Cigarette smokers

 50-64 year olds - 1 dose PPV23 for

unimmunized Alaska Natives

 65+ year olds – 1 booster dose for all

 5+ years from any previous dose

http://www.epi.alaska.gov/bulletins/docs/b2012_24.pdf

PCV13 for Immunocompromised Adults

 ACIP recommends PCV13 for: “Adults 19 years

& older with immunocompromising conditions, asplenia, CSF leaks, or cochlear implants” Recommendations:

 Pneumovax (PPV23)-naïve (preferred)

 Give one dose PCV13 first and PPV23 at least 8 weeks after

PCV13

 PPV23-immunized adults

 Give one dose PCV13 at least 1 year after the last PPV23 dose

14

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm

Pneumococcal Vaccines for Immunocompromised Children

 ACIP recommends PCV13 for:

 “children aged 6–18 years with immunocompromising

conditions, functional or anatomic asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants who have not previously received PCV13”  ACIP recommends PPSV23

 Children ≥ 2 years with increased disease risk

 Give PCV13 first, PPSV23 8 weeks later  Previous PPSV23: One dose of PCV13

 Booster does of PPSV23 after 5 years

PCV13 Impact on Invasive Pneumococcal Disease and Nasal Colonization

Michael Bruce MD, MPH Alaska Immunization Conference

October 9th 2013

Objective

 Evaluate the impact of PCV13 on IPD in

the state of Alaska

Methods

 Pre-vaccine period:

 April 2005-March 2008

 Post-vaccine period:

 April 2010-December 2012

IPD by Vaccine Serotype in Children < 5 Years, Alaska, 1986-2012

PCV7 PCV13

10 20 30 40 50 60 70 80 90 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Cases

Unknown Non-PCV13 PCV13, not PCV7 PCV7

IPD Serotypes, Children <5, Alaska, 2001-2012

Year

5 10 15 20 25 30 35 40

Number of Cases

Unknown Non Vax 1 3 6A 7F 19A PCV7

PCV13 Serotypes

20 40 60 80 100 PCV13 Non-PCV13 PCV13 Non-PCV13 AK Native Non-Native

Rate per 100,000

IPD Rates Pre- and Post-PCV13 Introduction, Children < 5, Alaska

Pre (2005-2008) Post (4/2010-2012)

49 9 29 13 29 2 13 9

*

*

Pneumococcal Colonization and IPD Caused by PCV13 Serotypes in Children <5 years — Alaska, 2008–2012

What we will cover….

 Pneumococcal

disease in children

 Vaccine uptake  Disease rates  Studies of nasal

colonization

 Recent disease in

young children

 What’s new?

 Human

papillomavirus (HPV)

 Vaccine uptake  Research studies

 Immunogenicity study  Preventable cervical

cancers

 Colposcopy clinic study

 What’s next?

HPV and Cervical Cancer



HPV genotypes



> 100 types



30 types cause genital infections



HPV a necessary cause of cervical cancer



Genital HPV infection is common:



~50% of sexually active adults get HPV



Most HPV genital infections clear on their own



Persistent infection with "high-risk" types can lead to cervical cancer.

HPV Vaccines in the U.S.

 HPV4, “Gardasil” 

 Includes genotypes 16, 18, 6, 11

 70% of cervical cancer, 90% genital warts

 3-shot series over 6 months

 HPV2, “Cervarix” 

 Genotypes 16, 18  3-shot series over 6 months

 Cost

 Cost/Dose: Quadrivalent: $106 CDC contract, $130 private

 Target population

 Approved for 9 -26 year olds: Recommended for 9-26 year old

females and 9-21 year old males

 Routine use in 11-12 year olds

HPV Vaccine Use



HPV-4 (Gardasil) is licensed for females & males 9 through 26 yrs.

 Other options for non-VFC eligible:

 Many insurance companies reimburse HPV vaccine  Merck Patient Assist. Program – uninsured low-income 19-26 yrs.  Medicaid reimburse for eligible 19-20 year old women

State of Alaska is only providing HPV vaccine to 9-18 year old VFC-eligible males and females (Medicaid eligible, Alaska Native, Uninsured, Underinsured)

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm

ACIP recommends:

• HPV vaccine in females & males

11-12 years, through 21 years for males and 26 years for females.