1. Partnerships in HPV Prevention
High Sierra AHEC
American Cancer Society
Intermountain West HPV Coalition
April 19, 2017

2. Closing the HPV Vaccination Gap:  The Fundamentals of HPV for Oral Health Care Providers
Presented By:
Christina A. Demopoulos, DDS, MPH
Diplomate, American Board of Dental Public Health
Associate Professor, UNLV School of Dental Medicine
High Sierra AHEC, American Cancer Society
April 19, 2017

3. Background UNLV undergrad
University of Southern California (USC) School of Dentistry
UNLV (Master of Public Health)
University of Texas, Health Science Center at San Antonio (UTHSCSA) [Dental Public Health Residency]

4. Learning Objectives
Describe the relationship between HPV and oropharyngeal cancer. 
Describe evidence-based strategies for increased awareness and prevention of HPV-related oropharyngeal cancer. 
Understand how community/clinical linkages can increase health promotion efforts regarding the HPV vaccine. 
Describe Best Practices that can be used by
oral health care providers to increase the
acceptance of the HPV vaccine in a clinical
setting. .

5. HPV and Oropharyngeal Cancer

6. HPV
Human papillomavirus (HPV) can cause serious health problems (such as genital warts and certain types of cancers).
In most cases, HPV goes away on its own without causing too many health problems.
Oral HPV is the name given to the HPV found in the mouth and throat.

7. Natural History of HPV Infection
~80-85% of people acquire any HPV infection at some point in their lives
~90% of infections clear in 1-2 years in healthy individuals
Almost all cervical cancers are caused by HPV infections that persist more than 2 years.

8. HPV Virology Mucosal (genital) ~ 40 types
High-risk (HR) HPV strains: HPV16, 18, 31, 45…others
Cervical (70-95%) and other cancers
Low-risk (LR) HPV strains: HPV6, 11….others
Genital warts (>90%)
Cutaneous (skin) / non-mucosal ~60 types
Skin (epithelial) wart
Mainly hands, feet (common in children)
HPV1-4

9. Oral HPV HPV in mouth and throat “High Risk”: head and neck cancers
“Low Risk”: warts in the mouth and throat
7% of people have oral HPV
Only 1% have HPV type 16 (type causes oropharyngeal
cancer)
Oral HPV is about 3 times more common in men than in women

10. HPV
Every day in the US, about 12,000 people ages 15 to 24 are infected with HPV
Approximately 26 million Americans have an oral HPV infection on any given day
Of those, approximately 2600 are HPV 16
The fastest growing segment of the oral and oropharyngeal cancer population are otherwise healthy, non-smokers in the age range.
When you consider both anatomical sites, HPV is driving the growth in numbers of oral cancers.
oral-cancer-facts/

11. HPV-Associated Oropharyngeal Cancer Prevalence
Some cancers of the oropharynx (back of the throat, tongue and tonsils) have been linked with HPV
Recent studies report that about 70% of oropharyngeal cancers are caused by HPV (previously tobacco and alcohol alone)
Approximately 3,100 new cases in females each year in US
12,638 new cases in males each year in US

12. Oral Cavity and Oropharynx

13. Oropharyngeal Cancer Signs/Symptoms
Persistent soar throat
Earaches (usually unilateral and last for a few days)
Hoarseness/persistent sore throat
Enlarged lymph nodes
Pain when swallowing/chewing
Unexplained weight loss
An ulcer or sore that does not heal within 2-3 weeks
A red, white, or black discoloration on the soft tissues in the mouth
Some people may have no signs or symptoms

14. HPV-Associated Oropharyngeal Cancer Rates by Race and Ethnicity

15. Racial/Ethnic Disparities
Among whites, about 1.8 women and 8.0 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer.
Among blacks, about 1.5 women and 6.9 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer.
Among American Indian/Alaska Natives, about 0.9 women and 4.4 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer.
Among Asian/Pacific Islanders, about 0.6 women and 2.0 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer.
Among Hispanics, about 0.9 women and 4.2 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer.
Among non-Hispanics, about 1.8 women and 8.0 men per 100,000 were diagnosed with HPV-associated oropharyngeal cancer

16. Rates of HPV-Associated Cancers and Median Age at Diagnosis Among Women in the United States, 2004–2008

17. Rates of HPV-Associated Cancers and Median Age at Diagnosis Among Women in the United States,

18. Rates of HPV-Associated Cancers and Median Age at Diagnosis Among Men in the United States, 2004–2008

19. Rates of HPV-Associated Cancers and Median Age at Diagnosis Among Men in the United States,

20. HPV Attributable Cancer Cases Each Year
Cancer site
Average number of cancers per year in sites where HPV is often found (HPV-associated cancers)
Percentage probably caused by HPV
Probably
Caused by
HPV 16, 18
Male
Female
Both Sexes
Number
Anus
1,750
3,260
5,010
91%
79%
4,000
Cervix
11,771
66%
7,800
Oropharynx
12,638
3,100
15,738
70%
60%
9,500
Penis
1,168
63%
48%
600
Vagina
802
75%
55%
400
Vulva
3,554
69%
49%
1,700
Rectum
237
513
750
TOTAL
15,793
23,000
38,793
24,600

22. Overview
Approximately 70% of oropharyngeal cancers may be linked to HPV
3100 new cases in females
12638 new cases in males
Approximately 60% are associated with HPV 16, HPV 18
Median age at diagnosis for women: 62 yo
Median age at diagnosis for men: 59 yo
White, non-smoking males age 35 to 55 are most at risk, 4 to 1 over females

23. HPV and Nasopharyngeal Cancer

24. Nasopharyngeal Cancer (NPC)
0.6% of all cancers worldwide
Highest prevalence in Southeast Asia, Southern China, and Northern Africa
Epstein-Barr Virus (EBV)
Recent reports attribute NPC with HPV
Oncogenic HPV is associated with a subgroup of NPC patients, predominantly whites (HPV 16)
No significant difference in survival between patients with HPV + and HPV – NPC

25. Prevention of HPV-related Oropharyngeal Cancer

26. Risk Factors Associated with Oral and Oropharyngeal Cancer
Tobacco
Alcohol
Prolonged sun exposure
HPV
Poor diet/nutrition (low fruit/vegetable intake, Vit A deficiency, chewing betel nuts)
Weakened immune system
Marijuana use

27. U.S. Preventive Services Task Force Issues Draft Recommendation Statement: Screening for Oral Cancer
WASHINGTON, D.C. – April 9, 2013 – The U.S. Preventive Services Task Force (Task Force) today posted a final evidence report and draft recommendation statement on screening for oral cancer
The Task Force found that there is not enough evidence to recommend whether or not primary care professionals should perform oral cancer screenings on all of their adult patients

28. HPV-Related Oropharyngeal Cancer
Soft palate
Tongue

29. Screening for Oropharyngeal Cancers
Difficult to detect at early stage (5 yr survival, <50%)
No standardized screening test
No FDA approved test for oral HPV infection
No evidence that detection of oral HPV could be used to predict development of oropharyngeal cancer

30. HPV screening Oral Brush biopsy Saliva sampling Histology
Immunohistochemistry
Saliva sampling
PCR
Serology (IgA)
Commercial kits/labs

31. Diagnostic Aids Tolonium chloride/toluidine blue dye
Oral CDx brush biopsy
Salivary diagnostics
Optical imaging systems

32. HPV Vaccine

33. HPV Vaccines
In 2006, the FDA licensed a quadrivalent vaccine that protects against HPV 6, 11, 16, 18 for females to prevent genital warts and cervical cancer.
In 2009, the FDA licensed a bivalent vaccine that protects against HPV 16 and 18 for females.
In 2009, the quadrivalent vaccine was recommended for use in males to prevent genital warts.
In 2010, the quadrivalent vaccine was approved by the FDA for prevention of anal cancers in males and females.
In 2014, the 9-valent vaccine was approved by the FDA for males and females. [HPV 16, 18, 31,33,45,52,58]

34. HPV Vaccines
Gardasil (Male, Female); genital warts and other types of cancer
Gardasil 9 (Male, Female); genital warts and other types of cancer
Cervarix (Female only); cervical cancer
Recommended years of age (males, females) [can be given at age 9]
Female catch up: years of age
Male catch up: years of age [can go to age 26 if didn’t complete the 3 doses]
** Advisory Committee on Immunization Practices (ACIP)

35. HPV Vaccine Schedule
According to the Centers for Disease Control and Prevention (CDC), the HPV vaccine has been demonstrated to be safe, effective and offers long lasting protection against HPV-associated cancers.
Most benefit is to complete series before initial exposure to HPV infection.
The number of doses and the time period are dependent upon the age of the recipient when the process begins.

36. HPV Vaccine Schedule
In 2016, new recommendations for use of a 2-dose schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years were published. (2nd dose between 6 and 12 months after the first dose)
Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons.

37. HPV Vaccine Schedule
Adolescents between 9 through 14 that have received 2 doses of HPV vaccine less than 6 months apart will still require a third dose
The vaccines are most effective when given to children before they become sexually active and are not recommended for anyone with a history of severe allergic reactions to any of the HPV vaccine components or women who are pregnant.

38. HPV Immunization Rates

39. 60% of girls received at least one HPV dose (2015)
42% of boys received at least one HPV dose (2015)

40. Nevada Rates (2015) Immunize Nevada Report
72% of girls received at least one HPV dose (US: 60%)
42% of girls received the 3 doses of HPV
44% of boys received at least one HPV dose (US: 42%)
24% of boys received the 3 doses of HPV
Healthy People 2020: 80% of year olds complete the 3 dose series

41. Source: 2014 National Immunization Survey (NIS) Teen Survey (CDC, 2015)
Series Completion: 3 doses by 13th birthday

42. Community and Clinical Linkages

43. Oral Health Care Educators
There is no current practice behavior to council patients on the benefits of HPV vaccine.
Dental health care providers are now being encouraged to become more familiar with HPV and its connection with oropharyngeal cancer.
Dental health care providers play a very important role in the prevention of oral HPV.
Dental providers must have reliable foundation knowledge of basic clinical medicine to safely and effectively treat individuals with chronic and other diseases (health care educators).

44. What Oral Health Care Providers Can Do to Close the Gap
Promote risk-based oral cancer screenings (children/adults)
Talk to parents/caregivers about HPV vaccine (cancer prevention)
Promote integrated health care model
Oral HPV infections need to be studied and investigated thoroughly to help promote HPV awareness in oral health settings.

45. Public/Private Partnerships
Dental school/dental hygiene school curriculum (Higher Ed)
Medical school curriculum (Higher Ed)
Health care providers (dentists, dental hygienists, physicians, pediatricians, physician assistants, nurses, etc.)
Allied health care providers (Community Health Workers, Community Health Nurses)
Community clinics/immunization clinics
Community-based immunization clinics associated with health fairs/back to school fairs

46. Best Practices

47. Medical History
Ask about HPV vaccinations in the medical history (reminders to ask about completion of required doses)
Conduct a thorough oral cancer screening frequently
Discuss HPV and oropharyngeal cancer with patients

50. Association between human papilloma virus (HPV) and Oral Health
Christina A. Demopoulos, DDS, MPH1 Tanis Stewart, PhD.2 Marcia Ditmyer, PhD 1§
1 UNLV School of Dental Medicine, 1001 Shadow Lane, MS 7425, Las Vegas, NV 89106
2 University of Maryland, College Park, MD 20742

51. Email: Christina.Demopoulos@unlv.edu

52. Any Questions?

53. References and Resources
Centers for Disease Control and Prevention. CDC Grand Rounds: Reducing the Burden of HPV-Associated Cancer and Disease. MMWR 2014;63:69-84.
Centers for Disease Control and Prevention. HPV-Associated Cancers Diagnosis By Age (2016). Retrieved August 22, 2016 from the World Wide Web:
Centers for Disease Control and Prevention. HPV-Associated Oropharyngeal Cancer Rates by Race and Ethnicity (2016). Retrieved August 22, 2016 from the World Wide Web:
Centers for Disease Control and Prevention. HPV Vaccine Information for Clinicians-Fact Sheet (2015). Retrieved August 22, from the World Wide Web:

54. References and Resources
Centers for Disease Control and Prevention. Human Papillomavirus (HPV)- Associated Cancers (2016). Retrieved August 22, 2016 from the World Wide Web: :
Centers for Disease Control and Prevention. Human Papillomavirus (HPV) and Oropharyngeal Cancer-Fact Sheet (2016). Retrieved August 22, 2016 from the World Wide Web: hpvandoropharyngealcancer.htm.
Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405–1408. DOI: 
U.S. Preventive Services Task Force. USPSTF Bulletin U.S Preventive Services Task Force Draft Recommendation Statement: Screening for Oral Cancer (2013). Retrieved August 13, 2014 from the World Wide Web:

55. https://smhs.gwu.edu/cancercontroltap/resources/hpv-cancer-and-prevention-profiles-2017

56. For more information and resources contact: Andrea Gregg, Executive Director High Sierra AHEC, Reno NV   June Hunter, MPH Health Systems Manager American Cancer Society, Reno, NV Laura Martel Cancer Control Coordinator Intermountain West HPV Coalition, SLC, UT