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Press Briefing Transcript

CDC Telebriefing on human papillomavirus (HPV) vaccination coverage and vaccine safety monitoring

Thursday, July 25, 2013 at Noon ET

OPERATOR:  Welcome and thank you for standing by. I would like to inform all parties that your lines have been placed in a listen only mode until the question and answer portion of today’s call. The call is also being recorded. If you have any objections, you may disconnect at this time. I would like to turn the meeting over to Mr. Tom Skinner.  Sir, you may begin. 

TOM SKINNER:  Thank you, Calvin.  Thank you all for joining us today for this telebriefing that we're having to update you all on vaccination rates against human papillomavirus.  We're joined today by the director of the CDC, Dr. Tom Frieden, the president of the American Academy of Pediatrics, Dr. Thomas McInerny.  And we're also joined by Dr. Anne Schuchat.  Dr. Frieden and Dr. McInerny will provide some opening remarks and then we'll get to your questions.  So Dr. Frieden, please take it away. 

TOM FRIEDEN:  Thanks very much, Tom.  Before we can do our briefing on HPV vaccination rates, I want to take a moment to address the ongoing outbreak of cyclospora.  I know there is a lot of interest by people in the media, so I do want to just take a moment to provide an update.  We won't be answering questions about cyclospora, but we can certainly put you in touch with our program and press office if you would like more information.  The outbreak investigation is active and ongoing.  We're working closely with partners at the federal, state and local levels to do the investigation.  As of 5:00 p.m. yesterday, July 24th, we have been notified of 285 cases of cyclospora in residents from multiple states, including Iowa, Nebraska, Texas, Wisconsin, Georgia, Connecticut, New Jersey, Minnesota and Ohio.  Illinois and Kansas has also notified CDC of one case each that may have been acquired out of state but in the United States.  We're working closely with our partners to determine if other states and more people have been affected and whether the outbreak is ongoing.  Most of the cases identified to date have been in people who became ill during June or early July.  But it's too early to say whether the outbreak is ongoing or subsiding and we have not yet identified a source, although I’m confident we will in the coming period. 

Cyclospora infection commonly causes a watery diarrhea. People who have an illness that hasn't gone away on its own in several days should see a health provider and discuss the possibility of cyclospora, because the infection needs to be diagnosed by testing stool specimens with special tests that are needed to detect a parasite, not a bacteria or a virus.  So if indicated, testing for cyclospora can be specifically requested for people who have had diarrhea that hasn't gone away over several days.  The best way to prevent infection with a parasite is to avoid food or water that may have been contaminated.  Now although no food item has been implicated for this outbreak, as always, fresh produce should be thoroughly washed before eaten.  Because cyclospora can stick to some food items, washing produce is helpful, but it doesn't eliminate the risk of infection.  If you have questions about the outbreak, follow up with our press office at 404-639-3286, but now I want to move on to today's telebriefing about HPV. 

Just last month, I had a chance to share with you really good news that HPV vaccination works even better than we anticipated.  The types of HPV, that's human papillomavirus, that commonly cause cervical cancer in the U.S., had dropped by about half in girls aged 14 to 19 in the seven years since we recommended routinely vaccinating against HPV.  I noted at that time that the results were striking, and would serve -- should serve as a wake-up call to increase vaccination rates, because we really can protect the next generation of adolescents against cancers caused by HPV.  Unfortunately, today we have disappointing news.  An article in today’s MMWR shows that HPV vaccination coverage for girls getting the anti-cancer vaccine has not increased at all from one year to the next.  Zero.  We're dropping the ball.  We're missing opportunities to give HPV vaccines, and that needs to change to protect girls from cervical cancer.  I'll provide some more detail and then discuss missed opportunities and information about vaccine safety. 

But the article published today has data from what's called the National Immunization Survey on teen vaccinations.  This is how we measure how we're doing.  It collects vaccine information for 13 to 17-year-olds using a random digit sample of landlines and, starting in 2011, cellular telephone phones as well.  After a teen's parental guardian gives permission, we contact the vaccination provider, doctor, nurse practitioner or other provider and mail a questionnaire to get the vaccination history.  The 2012 survey which we're reporting about today included vaccination records of about 19,000 teens.  And today's article focuses on HPV vaccination among girls from 2007 to 2012.  Next month we'll share the data we collected last year on other vaccines recommended specifically for preteens and teens, and that will include vaccination coverage estimates for HPV vaccinations among boys, something that's only more recently been recommended. 

These national data show no progress, zero, with HPV vaccine coverage in 2012.  We're used to seeing coverage increases of 10 percent per year when a new vaccine hits the market.  Last year we were disappointed at the increase in HPV vaccine was only 4 percentage points.  This year, it's zero percentage points.  The HPV vaccine coverage hasn't kept pace with other vaccines recommended for preteens and teens.  One dose does not provide all of the protection that the HPV vaccine series has to offer so we want all girls to get their second and third doses.  By 2011, 34.8 percent of teen girls finished their three-dose series.  2012 data is not different.  It's 33.4 percent.  Actually, slightly fewer teen girls are given all doses from the previous years.  This is a huge disappointment, but I’m confident that we will turn it around.  And one of the reasons for that is in the next piece of data that we got from this survey. 

We assumed that one of the reasons we had such low rates was that adolescents don't see the doctor regularly so it's hard to get a three-dose series in.  But actually, we found that -- that the data showed that if HPV vaccine were given every single time a young person went to the doctor to get another vaccine, the completion of those series would be at 93 percent.  That's important, because if we get three-dose series to 80 percent, an estimated 53,000 cases of cervical cancer could be prevented over the lifetimes of girls aged 12 and younger.  Now there are lots of ways we can work together to increase vaccination rates.  A key one is to take advantage of every opportunity to vaccinate against HPV.  The teens are in the doctor's office, they're getting another vaccination, but they're not getting the HPV second and third doses. 

We also asked parents why they haven't gotten their daughters vaccinated.  And one of the top reasons is that their doctors didn't recommend it.  This is critical.  Research consistently showed that a provider's recommendation to vaccinate is the single most influential factor in determining whether a parent gets their kid vaccinated.  So we need to step up our efforts by talking to parents about the importance of this vaccine.  Doctors need to recommend this vaccine just as they recommend others, and ensure that they're given every opportunity.  Parents have also told us in other research there are concerns about this -- this may be in some way a license or permission to have sex.  But multiple studies have found that preteens and teens who receive this vaccine do not have sex any sooner than their peers who have not received the vaccine.  HPV vaccine does not open the door to sex.  HPV vaccine closes the door to cancer.  The vaccine has to be given before onset of sexual activity.  We can't let this opportunity go to waste.  And I really would make the analogy to many of our other vaccines.  We make sure that people get vaccinations well before they get exposed.  We're not saying they're going to be exposed immediately after.  Just that we want to make sure they get vaccinated well before. 

Before I turn the call over to Dr. McInerny, I would like to talk about vaccine safety.  And I’m delighted to be joined by Dr. McInerny, president of the American Academy of Pediatrics, one of our most important partners.  Parents also reported safety as a concern for not planning to vaccinate their daughters against HPV.  So I would like to give you the basic information.  Today’s MMWR reaffirmed that the vaccine is safe.  All vaccines used in the U.S., including HPV vaccine, are required to go through years of extensive safety testing before they're licensed by the FDA, the Food and Drug Administration.  Once in use, we at the CDC, along with the FDA, continue to monitor safety through many monitoring systems.  They monitor adverse health events or health problems that may be caused by a vaccine, as well as rare events that may not have been notified or identified previous to licensure.  Since 2006, about 57 million doses of HPV vaccine have been distributed in the U.S. and in the seven years of HPV vaccine safety studies and monitoring that we have been conducting, no serious safety concerns have been identified. 

Of course, as with other vaccines, fainting can occur among adolescents who get the vaccine, which is why we recommend a 15-minute observation period after vaccinating a preteen or teen.  Both the CDC and American Pediatricians think this is a critical vaccine.  We can't continue to let down our nation's adolescents, teens and adults when it comes to protecting them against cancer caused by HPV.  We need to protect the next generation, and we have got a great time to do this, as parents get ready to get their kids back to school.  They can also get their kids protected from cancer.  I'd like to turn it over to Dr.  Thomas K. McInerny, president of the American Academy of Pediatrics. 

THOMAS MCINERNY: Thank you very much, Dr.  Frieden.  We at the CDC and the American Academy of Pediatrics appreciate the work of pediatricians and their efforts to successfully immunize children and many adolescents.  However, we have not been very successful in protecting our adolescents against cervical cancer. The AAP shares CDC's disappointment and concern that we're not providing this life-saving vaccine at the same rates as we do with other immunizations.  As you know, the AAP and the ACIP recommend immunization against HPV in all 11 through 12-year-old children, both boys and girls, as part of the adolescent immunization platform.  Research has demonstrated that HPV [editor’s note: should read HPV vaccine] is safe and effective, but as Dr. Frieden has discussed, we can do a better job of protecting our children from cancer and disease caused by HPV.  The health care community has the ability to achieve high coverage with this vaccine, as we have demonstrated this with other vaccines.  It's up to doctors to have open, honest and frank discussions with parents about the importance of this vaccine and to ensure their adolescents get vaccinated.  We recognize that the conversation about HPV can take extra time in the practice.  Therefore, the AAP and the CDC have resources available that can support physicians in their efforts to vaccinate. 

In the survey Dr. Frieden discussed, some reasons parents gave for not vaccinating tell us that parents don't understand why HPV [editor’s note: should read HPV vaccine] is recommended when a child is 11 or 12 years old.  The AAP has established various times for child immunization, and this timing is dependent on a number of factors.  One, when the infections threaten a child's health.  Two, when the child's immune response responds best to the vaccine.  Three, the duration of protection against the vaccine infection quartered by the vaccine.  And four, how many other vaccines are scheduled at a given age.  Since HPV vaccine works best when given before engaging any type of sexual activity, HPV vaccine should be given as part of the adolescent immunization platform at 11 to 12 years of age.  Parents may not understand that this vaccine needs to be given prior to the onset of sexual activity.  Please explain that we don't wait for exposure to occur when giving any other vaccine. We often vaccinate long before exposure so that children have the time to develop an immune response.  We have been doing this for decades with hepatitis B vaccine. 

Parents may know very little about HPV vaccine and the diseases it can lead to.  They need to know that -- how common HPV is, and what cancers can be prevented.  Recommending HPV vaccine as you would the other vaccines for adolescents is important, as part of a strong recommendation.  There are a number of proven strategies to improve vaccination coverage.  Use every opportunity to vaccinate your adolescent patients at both illness and well child visits.  Use the alert capability in your electronic medical record system so every time a patient is seen, their vaccination status is reviewed.  Ask about vaccination status when they come in for sick visits and sports physicals, as well.  Utilize patient reminder and call systems, such as automated postcards, phone calls and text messages to remind patients about their need for the HPV vaccine.  Ask your nurses to check the vaccine of patients, vaccine status of patients, as they bring them into the exam room.  And implement standing order policies so that patients can receive vaccines without a physician examination or individual physician order. 

As Dr. Frieden pointed out, the CDC data show that 84 percent of unvaccinated girls had a health care encounter when another vaccine was administered.  These are missed opportunities that can be prevented.  Every visit to a health care provider is an opportunity to check vaccination status.  Strongly recommend HPV vaccines, starting with patients who are 11 years old.  Recommend HPV vaccine the same way you recommend other adolescent vaccines.  And tell parents their child needs these vaccines to prevent a number of illnesses, and then list the vaccine preventable illnesses.  If our doctors would give HPV vaccine when they give other vaccines, there would be tens of thousands of fewer cases of HPV cancers and disease in coming years.  Health care providers need to take advantage of every opportunity to offer HPV vaccine.  A strong recommendation for HPV vaccine from a health care provider is effective in helping parents accept the vaccine.  Parents trust your opinion more than anyone else's when it comes to immunizations.  We do have now a powerful tool to prevent cancer.  Let's use it.  

TOM SKINNER:  Are you there, Dr. McInerny? 

THOMAS MCINERNY: Yes. 

TOM SKINNER:  Okay.  I think you cut out toward the end of your remarks.  You concluded? 

THOMAS MCINERNY: Yes. 

TOM SKINNER:  Okay, great.  Calvin, I believe we are ready for questions, please. 

OPERATOR: Thank you, sir.  At this time, if you would like to ask a question, please press star1 on your telephone key pad.  Star 1 to ask a question. 

TOM FRIEDEN: And before we -- while we're waiting for questions, I would just like to remind doctors – Dr. Frieden, step up their efforts by talking to parents about the importance of this vaccine.  Parents, protect your children through vaccination, and for parents who’ve gotten their children their first or second dose, don't just start the series, finish it.  It's not too late.  Back to school season is hectic for everyone, even your pediatrician's office.  But it's critical to make time for priorities like vaccinations.  HPV vaccination is cancer prevention.  So on that checklist of things to get ready for school, put fighting cancer, preventing cancer in your child.  And now we'll be happy to take questions. 

OPERATOR:  Our first question comes from Mike Stobbe with AP News.  Your line is open. 

MIKE STOBBE: Hi.  Thank you for taking my question.  On the heels of what doctor Frieden just said about checklists back to school, Dr. McInerny talking about strategies proven to improve vaccine coverage, aren't school attendance requirements a strategy proven to improve vaccine coverage?  Can you speak to why aren't more states requiring this vaccination for school attendance for middle school-aged kids and what efforts are under way to increase that. 

TOM FRIEDEN:  The decision of what vaccines to require for school entry is one that's made by each individual state, and takes into account a broad range of issues, including whether or not the disease in question may be spread in the school, such as measles or other conditions.  I would like to turn it over at this point to Dr. Anne Schuchat who’s the Director for our National Center for Immunization and Respiratory Disease for any further comments. 

ANNE SCHUCHAT: Yeah, thank you.  Mike, you're right.  The school recommendations or requirements have been associated with higher vaccination rates.  But the critical thing with today's report is that because we have high vaccination coverage with the other teen vaccines, children and their parents are in the doctor's office, and they can be vaccinated at the same time.  So that systemic check of has my child gotten the required vaccines is also a prompt to check into all of the recommended vaccines.  If every time a child was getting a Tdap or meningitis vaccine they also got an HPV vaccine, our first dose coverage would be over 90 percent.  So I don't think we're going to need to go the school recommendation -- or I’m sorry, the school requirement route to raise coverage with HPV.  We have people in the right place.  The vaccine is safe and effective.  We need doctors to recommend it and deliver it. 

MIKE STOBBE: Okay, thank you.  

TOM SKINNER: Next question? 

OPERATOR:   Our next question comes from Jonathan Serrie with Fox News.  Your line is open. 

JONATHAN SERRIE: Thank you, good afternoon.  My question is about vaccine safety.  The report indicates there are approximately 21,000 adverse events reported out of 56 million doses.  I'm wondering if that number represents a confirmed link to the vaccine or if it's possible many of these adverse events fall within the baseline of people who would suffer these types of symptoms with or without the vaccine. 

TOM FRIEDEN:  Dr. Schuchat? 

ANNE SCHUCHAT:  Thanks for that question.  You're very right that the vaccine adverse event reporting system that has data in today's report is just looking at the occurrence of events after vaccination.  There is no ability to link cause and effect with this system.  There are other studies that look more closely at expected rates of adverse events versus observed and look for discrepancies.  And so with this extensive experience that we have with the 56 or 57 million doses of HPV vaccine in this country, and even more in other countries, we don't have safety concerns about the vaccine.  The VAERS system looks for patterns and then we follow up with something called a vaccine safety data link here in this country.  And so far we have very reassuring news. 

JONATHAN SERRIE: Thank you. 

OPERATOR:  Our next question comes from Ashita Ganguly with CNN Medical Unit.  Your line is open. 

ASHITA GANGULY: Good afternoon.  Thank you for taking my question.  I was wondering, will there be further information regarding the safety of the bivalent HPV vaccine?  So far I’ve only seen data about the quadrivalent HPV vaccine. 

TOM FRIEDEN:  Thank you, we’ve obviously had a lot more experience the quadrivalent than the bivalent with the Dr. Schuchat? 

ANNE SCHUCHAT:  That’s right.  The vast majority of doses used so far here in the United States has been from the quadrivalent vaccine.  But our safety system routinely looks at the data from both VAERS and the Vaccine Safety Data Link Project and so we update that as more information becomes available.  So far we don't have any worrisome signals with the bivalent vaccine.  But as you mentioned, the number of doses is much smaller at this point. 

ASHITA GANGULY: Thank you. 

OPERATOR: Our next question comes from Dennis Thompson from Health Day.  Your line is open. 

DENNIS THOMPSON: Thank you for taking my question.  In asking parents reasons why they aren't getting their kids vaccinated, is cost a factor at all? 

TOM FRIEDEN:  Well, the HPV vaccine, because it is recommended by the Advisory Committee on Immunization Practices, is required to be covered without co-pay for health plans.  For new health plans.  So I think we have good news in terms of reducing barriers in cost.  It's also covered under the Vaccine for Children’s program, a program run by CDC, which provides about half of all vaccines in the country.  I'll ask Dr. Schuchat to provide more information. 

ANNE SCHUCHAT:  That’s right.  We don't think cost is a barrier, and it's not showing up as a main response in our survey that's done together with the National Immunization Survey of Teens.  And that is, as Dr. Frieden suggests, because people without insurance or economic problems are mainly eligible for the Vaccines for Children’s program.  And the insurance plans cover this vaccine.  So we do ask -- that's one of the responses they might offer, but we're not seeing that for this particular vaccine. 

TOM SKINNER: Next question? 

OPERATOR:  Our next question comes from Robin Erb with the Detroit Free Press. Your line is open. 

ROBIN ERB: Hi. Thanks for taking the time.  I'm wondering, when you were speaking earlier about the parents' reluctance to have their child vaccinated because they think that the vaccine gives their child the go ahead to have sex, how much of a pushback are you still facing in that?  You know, to say -- let's say five or six years ago.  Are parents' attitudes changing at all?  Thanks. 

TOM FRIEDEN:  I’m hopeful that people will understand that this is an anti-cancer vaccine, and that the age at which it’s given is just so we can make sure that it's well before there is exposure.  I know the issue of kids having sex is an uncomfortable one for many parents.  But this isn't about sex.  This is about preventing cancer.  And I think -- I detect that the dialogue on that, and the -- how people are talking about is expanding, and I think getting us to where we need to be.  This is a health issue.  It's about preventing cancer.  Dr. Schuchat, would you like to add to that, or Dr. McInerny? 

THOMAS MCINERNY: I will.  As a practicing primary care pediatrician, I can confirm what doctor Frieden has said.  When we first started giving HPV vaccines 12 years ago, the parents' eyebrows did raise quite a bit and they asked quite a few questions about this.  But we're not seeing that as frequently then as we did many years ago.  Parents are beginning to understand that this is an anti-cancer vaccine and it is important to give it at this age.  And that it's not -- it's not about sexuality. 

ROBIN ERB: Thanks so much. 

TOM SKINNER:  Next question, please? 

OPERATOR:  Our next question comes from Ali Gorman with WPVI.  Your line is open. 

ALI GORMAN: Thank you so much for taking my question.  I know that we have discussed safety and the statistics.  I'm wondering, there are also some anecdotal stories out there about some severe reactions.  I think a lot -- there's a few stories out there about girls suffering convulsions after getting one or two of the vaccinations.  I'm wondering if this turned up as a concern on the survey. 

TOM FRIEDEN:  Dr. Schuchat? 

ANNE SCHUCHAT:  The VAERS system reports any event -- can gather information about any event that occurs after a vaccination.  But there have been a number of deep looks at associations between possible adverse events and the vaccination.  And so seizures are not showing up as something that's cause and effect at all.  There has been episode -- there have been episodes of fainting or syncope.  That happens with many vaccines given to teenagers and may have nothing to do with the actual vaccine.  And so we strongly recommend that the teen be observed sitting down for 15 minutes after the shot is given, just to make sure they're not dizzy or passing out.  So there have been some investigations of unusual events, falling out and so forth.  But when we look at the data statistically, that's not -- that issue of seizures doesn’t pan out. 

ALI GORMAN: Okay, thank you. 

OPERATOR: As a reminder, if you would like to ask a question, please press star 1 on your telephone key pad.  One moment for our next question. 

TOM SKINNER:  Calvin, if there are no more questions, I’ll ask Dr. Frieden or Dr. McInerny if there is anything else they would like to add before we conclude.  If not, we'll conclude.  Calvin, are you showing any more questions? 

OPERATOR:  Yes, sir, we do have a few questions that came in.  The next question comes from Dennis Thompson with Health Day.  Your line is open. 

DENNIS THOMPSON: Hi.  I know this -- going back to your remarks at the beginning regarding cyclospora, Dr. Frieden, are we any closer at this point to figuring out what is causing the cyclospora outbreak?   

TOM FRIEDEN: As I said at the outset, we are doing the investigation.  We do anticipate being able to identify the source, but we have not identified that yet.  We're working in close collaboration with other federal, state and although partners.  I think we'll have time for just two more questions on the topic of HPV.  If you want more information about cyclospora, please contact our press office. 

TOM SKINNER:  Next question, Calvin? 

OPERATOR:  I’m showing no further questions at this time. 

TOM FRIEDEN:  Dr. McInerny, would you like to make a concluding remark? 

THOMAS MCINERNY: Yes.  We at the American Academy of Pediatrics are very concerned about the statistics showing a leveling off of our immunization at a relatively low level, and we plan to try and encourage our pediatricians in several different ways, both through our print media and our online media to this problem.  And we expect that they will respond promptly and we'll see an improvement in the rates in the near future. 

TOM FRIEDEN:  Thank you very much.  And we really value the partnership we have with the American Academy of Pediatrics and our other partners in other areas.

I would like to just wrap-up with a couple of key points.  HPV vaccine works.  It works even better than we had hoped.  HPV vaccine is safe, more than 57 million doses without identifying a problem.  And it's effective at reducing cancer.  We know that our vaccination rate now is only -- it's stuck at one-third of our teen girls.  The country of Rwanda has vaccinated more than 80 percent of their target population.  If our rate were that high, and we know that the HPV vaccine were simply given when kids are getting other vaccines, it could get to that level.  If we had that level, we would have more than 50,000 fewer cases of cervical cancer in the coming years.  And for every year we delay, and increasing our rates, we have 4,400 more cases of cervical cancer in girls who are aging into a later age groups.  So now is the time to make sure that we use every opportunity to get every teen vaccinated against HPV.  Doctors need to make the kind of system changes that Dr. McInerny so clearly described.  Parents need to talk about the HPV vaccine with their provider and make sure their children get vaccinated.  Thank you very much for joining us today.  Dr. Skinner? 

TOM SKINNER: Yeah, thank you.  Thank you, Calvin.  This concludes our call.  We'll be posting a transcript of this briefing to the CDC newsroom website later this afternoon.  And should reporters have follow-up questions or need additional information, please call the CDC press office at 404-639-3286.  Thank you, once again, for joining us today. 

OPERATOR:  That concludes today's conference.  You may disconnect at this time.  Thank you for your participation.  

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