Recommendations on a Human Papillomavirus Immunization Program

Executive summary

The Canadian Immunization Committee's (CIC) Recommendations on a Human Papillomavirus (HPV) Immunization Program is the Committee’s first statement on immunization programs. This statement provides the analysis needed for the implementation of routine HPV immunization programs. Its objective is to provide recommendations to federal/provincial/territorial (F/P/T) immunization program decision-makers with evidence-based information to facilitate program planning in their jurisdictions. Provinces and territories are responsible for the delivery of immunization programs and will consider their own set of circumstances in making decisions about the implementation of HPV immunization programs.

The work of the CIC represents a significant step forward for immunization program planning at the pan-Canadian level. Achieving consensus on goals, targets and routine programs at the start of program implementation has not been done at the national level in the past.

The CIC recommendations on HPV vaccine programs are based on an analysis of the epidemiology of HPV, vaccine characteristics, Canadian disease modeling and economic analyses, as well as on the feasibility and acceptability of HPV immunization programs. The first quadrivalent HPV vaccine was licensed in Canada in July 2006. As new knowledge and new vaccines become available, the recommendations will be reviewed and updated as needed.

The national goal of HPV immunization programs is to decrease the morbidity and mortality associated with cervical cancer, its precursors and other HPV-related cancers in women in Canada through combined primary prevention (immunization) and secondary prevention (screening) programs.

The recommendations on reduction in disease incidence are as follows:

1. 1. To reduce by 60% the incidence of cervical intraepithelial neoplasia (CIN) 2/3 caused by HPV 16/18 in Canada within 20 years of the introduction of a HPV vaccination program.
2. 2. To reduce by 60% the incidence of cervical cancers (and other HPV-related cancers) caused by HPV 16/18 in Canada within 30 years of the introduction of an HPV vaccination program.
3. 3. To reduce by 60% the mortality due to cervical cancer caused by HPV 16/18 in Canada within 35 years of the introduction of an HPV vaccination program.

CIC recommends school-based HPV vaccination of one female cohort to be implemented in all Canadian provinces and territories:

1. To immunize 80% of school-aged girls in either grade 4, 5, 6, 7 or 8 with the required doses of the HPV vaccine within 2 years of program introduction.
2. To immunize 90% of school-aged girls in either grade 4, 5, 6, 7 or 8 with the required doses of the HPV vaccine within 5 years of program introduction.

The Canadian disease modeling and economic analyses indicate that vaccinating a grade 4, 5, 6, 7 or 8 schoolgirl cohort is a cost-effective strategy. Jurisdictions should consider their own population characteristics, such as the age at sexual debut and the ability to reach girls at different ages to achieve maximum vaccine coverage, when deciding on their routine programs.

CIC also indicates that jurisdictions that wish to and are able to consider catch-up programs could proceed with the inclusion of additional female cohorts. Particular efforts should be undertaken to achieve high vaccine coverage for routine programs in hard-to-reach and high-risk populations. Catch-up strategies could also be extended to these populations.

Currently, there are inadequate epidemiological data on the general incidence and impact of anogenital condylomas (warts); there are also no data on the effectiveness of HPV vaccines in males, and the vaccine is not authorized for sale in males. Therefore, the HPV immunization program is recommended for girls and women for cervical cancer prevention only at this time.

Routine HPV immunization programs for the prevention of cervical cancer have been implemented in a number of industrialized countries, including the United States, Australia and western European countries. In general, routine immunization programs target primarily females before adolescence and before debut of sexual activity, with an age range from 9 to 17 years. HPV vaccines are currently licensed in more than 60 countries.

Both the National Advisory Committee on Immunization (NACI) and the CIC have deemed that there is sufficient evidence to support the implementation of routine HPV immunization programs as part of cervical cancer prevention programs in Canada, while recognizing that there are important research questions that need to be further addressed after implementation. Both committees stress that HPV immunization does not replace the need for fully implemented, organized cervical cancer screening programs and the promotion of safe sex practices.