1. All about Human Papillomavirus (HPV)
I am going to be talking about Human Papillomavirus. I will be covering information about HPV, the disease burden and vaccination.

2. HPV infection
Human papillomaviruses are groups of more than 150 related viruses.
About 40 types of HPV viruses cause mucosal and genital infections.
About 80 types of HPV viruses cause cutaneous infection such as common hand and foot warts.
Human papillomaviruses are groups of more than 150 related viruses. Among them about 40 types of HPV viruses cause mucosal and genital infection and about 80 types cause cutaneous infection such as common hand and foot warts.

3. HPV infection Mucosal and genital infections are commonly caused by:
Low-risk HPVs: do not cause cancer but can cause skin warts on or around the genitals or anus.
HPV types 6 and 11
Cause 90 % of all genital warts
High-risk or oncogenic HPVs: can cause cancer
HPV types 16 and 18
Are responsible for the majority of HPV-caused cancers
HPV viruses that cause mucosal and genital infections are divided to two groups, the low-risk and the high-risk HPVs. The main difference between low risk and high risk types of HPV is that low risk types do not cause cancer but may cause skin warts on around the genitals or anus. Whereas high risk types can cause cancer. Two types of low risk HPV are types 6 and 11 and two types of high risk HPVs are 16 and 18.

4. Transmission of HPV
HPV is transmitted through genital contact during vaginal or anal sex.
HPV may also be transmitted during oral sex and genital-to-genital contact.
In very rare instance, a pregnant woman with genital HPV infection can transmit the infection to her baby during delivery which can result in the baby developing Recurrent Respiratory Papillomatosis (RRP).
The main transmission mode of HPV is vaginal or anal sex. HPV can also be transmitted during oral sex and genital to genital contact. It is also possible for pregnant women to pass HPV to their baby during delivery. This can result in Recurrent Respiratory Papillomatosis which is a disease in which tumors grow in the air passages leading from the nose and mouth into the lungs. The tumors often grow back after they are removed.

5. Transmission of HPV HPV infection has also occurred in virgin women. 1
Non sexual mode of transmission might be common.
HPV can be transmitted even when the infected person has no signs or symptoms.
Most people infected with HPV are unaware that they have contracted the disease or that they are passing it on to other partners.
HPV infection has been found to occur in Virgin women which suggests that there may be transmission via nonsexual modes Additionally, HPV can be transmitted when the infected person is experiencing no signs or symptoms. IN fact most people infected with HPV are unaware that they have the disease or that they are passing it on to others.
Looked at virginal women compared to sexually active women and found HPV infection in 69% of sexually active women and 50% of virginal women
1Tay SK., Ho TH., Lim-Tan Sk. Is genital human papillomavirus infection always sexually transmitted?
Aust N Z J Obstet Gynaecol Aug;30(3):240-2

6. Epidemiology
HPV infections are the most common sexually transmitted infections in the United States.
Recent research indicates that at any point in time, 42.5 % of women have genital HPV infections, whereas less than 7 % of adults have oral HPV infections.
Next I want to talk a little about the epidemiology of HPV infections. HPV is actually the most common sexually transmitted infection in the United States. Recent research has shown that at any point in time about 42.5% of women have genital HPV infections whereas less than 7% of adults have oral HPV infections.

7. Incidence of HPV
In 2008, there were about 14,100,000 estimated new HPV infections in US.
49% of the new infections were estimated to be among people years.
People ages make up 24% of sexually active population but account for 49% of new HPV infections
Source:
I just wanted to speak a little bit about the incidence of HPV in the United States. In 2008, it was estimated that over 14 million new HPV infections occurred in the United States. 49% of those infections were estimated to be among the 15 to 24 age group. One interesting thing about this age group is that they only account for 24% of the sexually active population but yet disproportionately account for new infections. Additionally, infection in this group can be prevented by vaccines.

8. Outcomes of infection with HPV
Most HPV infections resolve spontaneously.
In some cases, persistent infections with HPV occur and lead to cancer.
Infection with one type of HPV does not prevent infection with another types of HPV.
No cross-immunity
Of persons infected with mucosal HPV, 5% to 30% are infected with multiple types of the virus.
Most HPV infections do resolve spontaneously; however in some cases persistent infection occur and lead to cancer. One important thing to remember is that one type of HPV does not prevent infection with other types of HPV, so it is possible for a person to be infected with multiple types or recover from one infection and become infected with another. In fact of persons infected with mucosal HPV, between 5 and 30% are infected with multiple types of the virus.

9. HPV and Cancer
Cervical Cancer is the most common HPV associated cancer and almost all cervical cancer is caused by HPV.
2nd leading cause of cancer deaths of women in the world.
In the US, about 11,000 women get cervical cancer every year and about 4,000 are expected to die from it.
Vulvar Cancer – about 50% of vulvar cancer is related to HPV infection.
The most common cancer associated with HPV is Cervical cancer and in fact almost all cervical cancer is caused by HPV. HPV is also the 2nd leading cause of cancer deaths of women in the world and in the U.S. about 11,000 women get cervical cancer each year. Of these women, 4,000 are expected to die. Vulvar cancer can also be caused by HPV and about 50% of vulvar cancer Is related to HPV infection.

10. HPV and Cancer
Vaginal Cancer – about 65% of vaginal cancer is related to HPV infection.
Penile Cancer – about 35% of penile cancer is related to HPV infection.
Anal Cancer – about 95% of anal cancer is related to HPV infection.
Oropharyngeal Cancer (cancer of the mouth and throat) – about 60% of this type of cancer is related to HPV infection.
In addition to Cervical and Vulvar cancer, HPV can also cause Vaginal Cancer, Penile Cancer, Anal Cancer, and Oropharyngeal Cancer. IN fact about 65% of vaginal cancer, 35% of penile cancer, 95 % of anal cancer and 60% of oropharyngeal cancer Is related to HPV infection.

11. Number of new HPV–associated cancers by sex in the United States, 2009
These are just a look at the number of HPV-associated cancers by sex in the United States. So as you can see, Women do account for the larger proportion of cases but there are a substantial number of cases among men as well. Cervical cancer accounts for the majority of cancer in women while oropharyngeal cancer accounts for the majority of cancer in men.
Total: 21,342
Total:13,446
Source: National Program of Cancer Registries and Surveillance

12. Warts caused by HPV infection
Source: CDC public health image library

13. HPV Vaccines
SO next I want to go over HPV vaccines.

14. HPV Vaccines HPV4 (Gardasil) HPV2 (Cervarix)
contains types 16 and 18 (high risk) and types 6 and 11 (low risk).
approved for females and males 9 through 26 years of age.
HPV2 (Cervarix)
contains types 16 and 18 (high risk).
approved for females 10 through 25 years of age.
There are two types of vaccine available in the US. Gardasil that protects against 4 types of HPV (types 16,18,6 and 11) and Cervarix which protects against 16 and 18, the high risk types of HPV. Gardasil is approved for males and females age 9 through 26 and Cervarix is approved for only females age 10 through 25.

15. HPV Vaccination Schedule
Routine schedule is 0, 2, 6 months.
Third dose should follow the first dose by at least 24 weeks.
Series does not need to be restarted if the schedule is interrupted.
ACIP recommends routine vaccination at 11 or 12 years of age.
The vaccination series can be started as young as 9 years of age at the clinician's decision.
Parental/guardian consent is required when vaccinating children under the age of 18. However, kids 14 years and older can received Hepatitis B and HPV vaccine without parental consent
The routine vaccination schedule for HPV vaccine is three doses with the second given 2 months after the first and the third dose following the second dose by 4 months. One important detail regarding scheduling is that the minimum interval between the first dose and the third dose must be 24 weeks or 6 months. The series does not need to be restarted if the schedule is interrupted or there is a prolonged interval between doses. It is recommended that HPV vaccine should be given routinely between 11 and 12 years of age, however the series can be started as young as 9 years of age if the clinician feels it is necessary. Usually parental or guardian consent is required when vaccinating children under the age of 18 however when it comes to Hepatitis B and HPV vaccines, kids 14 and older can receive these vaccines without parental consent.

16. Catch-up vaccination
Catch-up vaccination is recommended for females 13 through 26 years of age.
Catch-up vaccination recommended for males 13 through 21 years of age.
Males aged 22 through 26 years may be vaccinated.
All immunocompromised males (including HIV infection) and men who have sex with men through 26 years of age should be vaccinated.
So if a child does not receive the vaccine at the recommended age they can still receive the vaccine later and be caught up. Catch up vaccination is recommended for females 13 through 26 years of age and for males 13 through 21 years of age. Males who are between 22 and 26 can also be vaccinated and immunocompromised males or men who have sex with men should be vaccinated through 26 years of age.

17. Minimum Intervals Between Doses
The minimum interval between dose 1 and dose 2 of HPV vaccine is 4 weeks.
The minimum interval between dose 2 and dose 3 of HPV vaccine is 12 weeks.
However, the minimum interval between dose 1 and dose 3 is 24 weeks.
It is important to observe the minimum interval between dose 1 and 3.
I also want to talk a little about the minimum intervals between doses of HPV Vaccine. I touched on this a little earlier but sometimes it helps to see it laid out. The minimum interval between dose 1 and dose 2 is 4 weeks. The minimum interval between dose 2 and dose 3 is 12 weeks. However dose 1 and dose 3 must be separated by at least 24 weeks.

18. VFC Program and Adult Program
North Dakota participates in the Vaccines for Children (VFC) program.
Federal entitlement program which provides free vaccine for children 18 years and younger who are uninsured, underinsured, Medicaid eligible or are American Indian or Alaskan Native.
Provide HPV vaccine free of charge at participating providers.
The North Dakota Immunization Program also has an adult vaccine program.
Provide HPV vaccine for uninsured or underinsured adults.
I also wanted to talk a little bit about the VFC program and State vaccine. North Dakota participates in the vaccines for children program or the VFC program. This program is a federal entitlement program which provides free vaccine for children 18 years and younger who are uninsured, underinsured, Medicaid eligible or American Indian or Alaskan Native. The program can provide HPV vaccine free of charge at participating providers. The North Dakota Immunization program also has an adult vaccine program which can provide HPV vaccine free of charge for uninsured or underinsured adults.

19. HPV Vaccine Special Situations
Vaccine can be administered
abnormal Pap Test
positive HPV DNA test
genital warts
immunosuppression
breastfeeding
HPV vaccine can be administered during all of these situations: if the patient has an abnormal pap test result, if the patient has a positive HPV DNA test, if the patient has genital warts, if the patient is immunosuppressed, they may still receive the HPV vaccine and even if an individual is breastfeeding, it is perfectly acceptable for her to receive the HPV vaccine.

20. HPV Vaccine Contraindication and Precautions
severe allergic reaction to a vaccine component or following a prior dose.
Precaution
moderate or severe acute illnesses (defer until symptoms improve).
If an individual has a severe allergic reaction to a vaccine component or had a severe allergic reaction when they received HPV vaccine previously, he or she should not receive the vaccine. As a precaution, Individuals who are experiencing moderate or severe acute illness should defer the vaccine until symptoms improve.

21. HPV Vaccination During Pregnancy
HPV vaccine should not be given during pregnancy.
No need to do pregnancy test prior to vaccination.
Initiation of the vaccine series should be delayed until after completion of pregnancy.
If a woman is found to be pregnant after initiating the vaccination series, remaining doses should be delayed until after the pregnancy.
If a vaccine dose has been administered during pregnancy, there is no indication for intervention.
Women vaccinated during pregnancy should be reported to the respective manufacturer.
Next I want to talk a little about giving HPV vaccine during pregnancy. HPV vaccine should not be given during pregnancy; however, it is not necessary to do a pregnancy test prior to vaccination. Pregnant women should wait until after delivery to receive the vaccine. If an individual is found to be pregnant after they have initiated the series they should wait until completing the pregnancy before they receive any remaining doses. If the vaccine was accidentally given during pregnancy, there is no indication for intervention; however, this should be reported to the respective manufacturer.

22. Adolescent Vaccination
The ACIP recommended age for HPV vaccination coincides with the recommended age for other adolescent vaccines, Tdap (tetanus, diphtheria and acellular pertussis) and MCV4 (meningococcal conjugate vaccine), but the rate of vaccination for HPV is much lower than both Tdap and MCV4.
ACIP has recommended HPV vaccine for adolescents age which is the same age that both Tdap and Meningococcal vaccine is recommended; however, vaccination rates are much lower for HPV vaccine when compared to Tdap and meningococcal rates. This graph shows the rates for North Dakota compared to the rates for the US. Most of North Dakota’s rates are comparable to the national rates or slightly higher.
± Rates are from the 2013 National Immunization Survey (NIS)

23. NDIIS HPV Rates
11 – 12 year old adolescents
This graph shows the HPV vaccination rates in North Dakota for year olds which is the routinely recommended age for HPV vaccine. The data for this graph was taken from the North Dakota immunization registry or the NDIIS.

24. NDIIS Rates continued…
year old adolescents
This is a look at the rates of adolescents between 13 and 15 years of age; It is possible that the percentages of females with 2 and 3 doses are higher in this age group because kids are starting the vaccine series at an earlier age and finishing when they reach an older age group.

25. NDIIS Rates continued…
16 – 18 year old adolescents
And this is the graph of HPV vaccination rates for year olds.
It is possible that the percentages of females with 2 and 3 doses are higher in this age group because kids are starting the vaccine series at an earlier age and finishing when they reach an older age group.

26. Barriers to HPV vaccine
The final topic I want to discuss is Barriers to HPV vaccine. I will be discussing myths and misconceptions surrounding HPV vaccine, why they be contributing to low vaccination rates and what we can do to combat them.

27. Myths and Misconceptions
1. People know about HPV vaccine and if they want it, they will ask for it.
Research has shown that approximately 60% of parents have no prior knowledge of HPV vaccine.
Educational studies have indicated that 75% of parents report an increase in knowledge of HPV as well as an increase in vaccine acceptance after having been given just a one page fact sheet about HPV.
It is often assumed by providers that people know about the HPV vaccine and if they want it, they will request it. And that is not necessarily true…
To increase HPV rates within our state, physicians, nurse practitioners and nurses within a particular practice should collectively encourage and recommend the HPV vaccine to males and females
Starting the discussion concerning the HPV vaccine early is also advisable. Offering HPV-related information during kindergarten visits helps parents prepare and research the vaccine prior to the recommended age of vaccination.

28. Myths Continued…
2. Getting kids vaccinated against HPV will encourage sexual activity.
A recent study looking for any correlation between HPV vaccination and sexual activity-related outcomes (i.e. pregnancy, sexually transmitted infection testing or diagnosis and contraceptive counseling) found that HPV vaccination during the ACIP recommended ages was not associated with an earlier onset of sexual activity or an increase in sexual activity-related outcome rates.
Another concern that parents often have is that getting kids vaccinated will lead to them being involved in sexual activity earlier than they would have. However, this has been shown to be a myth by a recent study that was looking for any correlation between HPV vaccination and sexual activity-related outcomes like pregnancy, STI testing or diagnosis and even contraceptive counseling. And it was actually found that HPV vaccination during the ages recommended was not associated with earlier sexual activity or those related outcomes.

29. Myths continued…
3. The vaccine is not safe.
Prior to the FDA licensing the vaccines, nearly 60,000 men and women were studied to ensure the safety.
Both the FDA and CDC monitor vaccine safety continually after licensure.
Fainting and redness and swelling at the injection site are the two most common side effects of this vaccine.
Having the patient sit or lie down for 15 minutes after getting the shot can help decrease the incidence of fainting. Mild fever is also a fairly common side effect but is not a cause for concern.
Another misconception is that the vaccine is not safe. And the truth is that the HPV vaccine has been studied extensively to look at safety concerns. IT was studied before it was even licensed in nearly 60,000 men and women. And After a vaccine is licensed, it is still monitored to ensure safety. The two most common side effects for this vaccine are fainting and redness and swelling at the injection site. Fainting is common in this age group and having the patient sit or lie down for 15 minutes after getting the shot can help decrease the incidence of fainting. Another fairly common side effect is a mild fever which is not considered serious.
References:

30. Myths continued…
Safety…
More that 7 years of post-licensure vaccine safety monitoring in the US provide continued evidence of the safety of HPV4.
Data on the post-licensure monitoring in other countries for both vaccines provide continued evidence of the safety of the vaccines.
Additionally we now have over 7 years of data since HPV4 vaccine has been licensed which shows that it is safe. And Data from other countries for both vaccines corroborates this information.

31. Studies on HPV4 efficacy showed:
Myths continued…
4. The vaccine doesn’t really work.
Studies on HPV4 efficacy showed:
Nearly 100% vaccine efficacy in preventing cervical, vulvar and vaginal pre-cancers and genital warts caused by the types of HPV in the vaccines in women.
90% efficacy in preventing genital warts and 75% efficacy in preventing anal pre-cancers in men.
Another concern people have is that the vaccine doesn’t really work and in actuality studies have shown that vaccine efficacy in preventing cervical, vulvar and vaginal pre-cancers and genital warts caused by the types of HPV in vaccines in women is almost 100%. The vaccine efficacy in men is 90% in preventing genital warts and 75% in preventing anal pre-cancers.

32. Myths continued…
5. Males don’t need to be vaccinated against HPV because they can’t get cervical cancer.
Although male cancers related to HPV infection are less common than female cancers, the strains of HPV the vaccine protects against can still help in the prevention of:
400 HPV related penile cases annually
1,500 HPV related anal cases annually
5,600 HPV related oropharyngeal cases annually
Women benefit from vaccination of male indirectly due to reduced risk of transmission.
Another myth about the HPV vaccine is that males don’t need to be vaccinated because the vaccine just prevents cervical cancer and that is not true. Although the cancers caused by HPV infection are less common in men there is still a disease burden among men. There are 400 HPV related penile cancer cases annually, 1500 HPV anal cancer cases annually, and 5600 HPV related oropharyngeal cancer cases annually. In addition, women benefit from men being vaccinated because it decreases the risk of transmission.

33. Myths continued…
6. Males and females who are already sexually active will not benefit from this vaccine.
Because HPV vaccine protects against more than 1 type of HPV, individuals who may have been exposed to any strain of HPV through sexual activity can still benefit from the vaccine’s protection against other strains of the disease.
One other misconception about the HPV vaccine is that individuals who are already sexually active would not benefit from the vaccine and that is not true. As we already discussed, there are several types of HPV so even if an individual has already contracted one type of HPV they should still be protected from other types. As I mentioned earlier, it is not uncommon for a person to become infected with several types of HPV.

34. Myths continued…
7. Often parents say “my teen is not sexually active, so he/she does not need HPV vaccine."
Boys and girls need to develop immunity before exposure.
Vaccine is more effective at younger age.
The incidence of HPV is high in ages years.
Parents often do not think that their child needs HPV vaccine because they are not sexually active and the truth is that the best time to receive the vaccine is before there is any risk at all so that they are protected against future exposures. Additionally the vaccine has been shown to produce better immunity if it is given at a younger age. Incidence of HPV is high in the age group. So giving this vaccine before individuals reach that age is always best.

35. Other barriers Some providers are not offering the HPV vaccine
In on survey parents were asked why
Some providers are not offering the HPV vaccine
Research consistently shows that a provider's recommendation to vaccinate is the single most influential factor in determining whether a parent gets their child vaccinated.
A strong recommendation from providers is important.
Other barriers that may be hindering the coverage of HPV vaccine in the United States is that some providers are not offering the vaccine to their patients. It has been consistently shown in research that a provider’s strong recommendation to vaccinate is the single most influential factor in determining whether a parent gets their child vaccinated.

36. Other barriers
Some parents say “the vaccine is not required for school entry”
Inform parents about the importance of the vaccine.
Since the HPV vaccine was introduced in 2006, vaccine-type HPV prevalence has declined 56% among female teenagers years of age.
A lot of parents think that the vaccine is not important because it is not required for school and that is not true. All recommended vaccines are important to receive. These recommendations are made by the ACIP or Advisory Committee on Immunization Practices which is a group of medical and public health experts who develop recommendations on how to use vaccines to control diseases in the United States. Since the HPV vaccine was introduced in 2006, vaccine type HPV prevalence has declined 56% among female teens years of age. And that is with the extremely low coverage rates that I showed you before. SO the vaccine is important and it does work.

37. Other barriers The way providers make the recommendation also matters
One of the best ways to reach parents is to recommend HPV vaccine in the same way you recommend any other vaccine.
Try saying, "Today your child needs 3 vaccines… Tdap, MCV and HPV.
HPV vaccine is cancer prevention message also resonates with parents.
As I mentioned before, it is important for providers to make a strong recommendation for HPV vaccine. One of the best ways to do this is to recommend HPV vaccine in the same way that other vaccines would be recommended. Such as today your child needs the Tdap, Meningococcal and HPV vaccines. Another important message that parents should hear is that HPV prevents cancer.

38. “what you say and how you say it matters
“what you say and how you say it matters. A half-hearted recommendation to a patient may not only result in the patient leaving your practice unvaccinated but may lead the patient to believe that HPV vaccine is not as important as the other adolescent vaccines.”
Taken from a letter recently written to address providers on HPV vaccine from ACIP members available at:
ACIP recently addressed providers in a letter about HPV vaccine. In that letter ACIP stated:

39. Tips for Talking with Parents
HPV Vaccine is cancer prevention.
It is important to vaccinate before children are exposed.
Research has shown that getting the HPV Vaccine does not make kids more likely to be sexually active.
Emphasizing your personal belief in the importance of HPV vaccine helps parents feel secure.
HPV is so common that almost everyone will be infected at some point. It is estimated that 79 million Americans are currently infected with 14 million new HPV infections each year.
HPV vaccine has been shown to safe and effective.
Inform parents that the series consists of 3 shots.
Here I have just listed some tips for talking with Parents about HPV vaccine, a lot of these were taken from the CDC but they are just important points that should be emphasized. So the first one is that HPV vaccine prevents cancer, I think that is a really important message. Also, it is important to vaccinate children long before they become exposed, that is how vaccines work you have to get them before you are exposed to the disease. Its also important for parents who are concerned about increased or early sexual activity to understand that receiving the HPV vaccine is in no way related to sexual activity. Its also important for parents to know that you believe in the importance of the vaccine. Another important fact that I think a lot of people don’t know is just how common HPV is. It is so common that almost everyone will be infected at some point in their lives. It is estimated that 79 million Americans are currently infected and that there will be 14 million new infections each year. So even if a person never has sexual contact with anyone until after marriage, it is quite possible that the person they marry may have HPV. Another key point is that the vaccine is safe and effective. And finally it is important for parents to understand that it is a three dose series. Sometimes parents are unaware of this and do no realize that their child will have to come back to receive the remaining doses.

40. Ideas for Increasing Rates
Reminder Recall
Giving the vaccine during Sports Physicals
School Clinics
Giving the vaccine during doctor’s visits
Scheduling appointment for subsequent doses
Implementing tips
Strong provider recommendation
HPV vaccine is cancer prevention
Recommending along with adolescent vaccines
So here I have just listed some ideas on how to increase your HPV vaccination rates. So the first one I have listed is reminder recall, this is just the process of contacting individuals due for doses of vaccines and reminding them to receive them. The next idea I have listed is giving the vaccine during sports physicals. A lot of schools require that students have a yearly physical if they are participating in sports, this is an excellent time to vaccinate. Especially since adolescents are not seen that often in the doctor’s office. School clinics are also a way to reach children who may not be going in to the doctor and it is convenient for parents so they may be more likely to consent to their children receiving vaccine. Another good option is vaccinating children when they come in for other reasons to the doctors office. Again this age demographic is not seen at the doctor’s office as often as younger children so if you see them at all it is a great opportunity to vaccinate. A lot of parents are unaware that their children even need vaccines at that age. Another really great strategy is scheduling their next dose when you have them in the office so they know exactly when they need to come in for subsequent doses. And finally just implementing the tips on the previous slide so making a strong recommendation for the vaccine maybe even reassuring them by telling them how you or your loved ones have received the vaccine and then emphasizing that this vaccine prevents cancer, I think that is a really important message to get out there and finally just recommending the vaccine along with all the other vaccines recommended for the child so today your child is going to need the Tdap, Meningococcal and HPV vaccine.

41. Coming up! New HPV vaccine
Merck is in the process of licensing a new HPV vaccine.
9-valent HPV vaccine (V503)
V503 includes five more HPV types (31, 33, 45, 52, 58) in addition to the four original HPV types (6, 11, 16, 18) in GARDASIL.
In clinical trials it prevented approximately 97 percent of cervical, vaginal and vulvar pre-cancers caused by HPV types 31, 33, 45, 52, and 58.
ACIP may recommend the vaccine in 2015.
One new exciting thing I wanted to mention was that Merck is in the process of licensing a new HPV vaccine which protects against 9 types of HPV, so this vaccine would protect against an additional 5 types along with the types that are in the HPV4 vaccine right now. This vaccine has been effective in clinical trials preventing 97% of cervical, vaginal and vulvar pre-cancers caused by HPV types 31,33,45,52 and 58. So this vaccine may be recommended next year.

42. Resources
North Dakota Cancer Coalition HPV Talking Points:
North Dakota Immunization Program HPV Vaccination Brochure:
CDC’s HPV Vaccination website:
Brochures
Vaccine Recommendations
Materials for Patients
Materials for Media
And finally, I have listed some resources that may be helpful in speaking with parents and finding out more information about the HPV vaccine. The North Dakota Cancer Coalition has released some talking points, and the immunization program has HPV vaccination brochures available for order. Additionally CDC has some great resources on their website including brochures, the full vaccine recommendations, materials for patients and materials for media.

43. Questions?
And that concludes the presentation, are there any questions?