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 Human disease in children papillomavirus (HPV) Vaccine uptake Vaccine uptake Disease rates Research studies Immunogenicity study Nasal colonization Preventable cervical Recent disease in cancers young children Colposcopy clinic study What’s new? 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 Pneumonia Brain: meningitis Reportable disease in Alaska Non-sterile site Invasive pneumo disease “IPD” Lab-based surveillance since 1986 Ear infection Pneumococcal bacteria CDC Arctic Investigations Program
Pneumococcal Invasive Disease Rates, 1996 - 2000 500 Alaska non-Native 451 450 Alaska Native Cases/100,000/year 400 350 300 250 200 150 127 112 97.5 83 100 74 56 43 45.7 50 18 19 17 13 11 5.7 4.2 0 <2 2-4 5-17 18-34 35-49 50-64 65-79 80+ Age (years)
Two Pneumococcal Vaccines Pneumococcal conjugate Pneumococcal polysaccharide vaccine (PCV) vaccine (PPSV23) Polysaccharide conjugated to 23 polysaccharide antigens protein 7 serotypes: 80% child illness 88% adult disease Boosting/ memory No immune memory Decreases carriage No effect on carriage Immunogenic in children Not effective <2 yrs >90% effective against 60-70% effective against invasive disease 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 All Serotypes: -76% (-79,-73) PCV7 Types: -98% (-99,-97) In 2010, PCV13 replaced PCV7 Covers ~ 70% of the remaining invasive pneumococcal disease 10
Invasive Pneumococcal Disease Western Alaska Children < 2 yrs old 1200 PCV7 types non-PCV7 types 1000 Rate per 100,000 PCV7 vaccine 800 introduced 600 400 200 0 2001 2002 2003 2004 2005 2006 2007 2008 1995-2000 Year
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 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm 14
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 9 th 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 Unknown 90 Non-PCV13 80 PCV13, not PCV7 70 PCV7 PCV7 60 Number of Cases PCV13 50 40 30 20 10 0 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
IPD Serotypes, Children <5, Alaska, 2001-2012 40 35 30 Number of Cases 25 Unknown Non Vax 20 1 15 PCV13 3 Serotypes 6A 10 7F 5 19A PCV7 0 Year
IPD Rates Pre- and Post-PCV13 49 Introduction, Children < 5, Alaska 100 Pre (2005-2008) 80 Rate per 100,000 Post (4/2010-2012) 29 60 40 13 9 29 20 13 9 * * 2 0 PCV13 Non-PCV13 PCV13 Non-PCV13 AK Native Non-Native
Pneumococcal Colonization and IPD Caused by PCV13 Serotypes in Children <5 years — Alaska, 2008 – 2012
What we will cover…. Pneumococcal Human disease in children papillomavirus (HPV) Vaccine uptake Vaccine uptake Disease rates Research studies Immunogenicity study Studies of nasal Preventable cervical colonization cancers Recent disease in Colposcopy clinic study young children What’s next? What’s new?
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 ACIP recommends: • HPV vaccine in females & males 11-12 years, through 21 years for males and 26 years for females. HPV-4 (Gardasil) is licensed for females & males 9 through 26 yrs. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm State of Alaska is only providing HPV vaccine to 9-18 year old VFC-eligible males and females (Medicaid eligible, Alaska Native, Uninsured, Underinsured) 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
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