November 9, 2011
HPV REPORTING IN CONNECTICUT AND OTHER STATES
By: Nicole Dube, Associate Analyst
You asked if Connecticut requires healthcare providers and laboratories to report positive Human Papillomavirus (HPV) tests to the Department of Public Health. You also wanted to know if any other states had such reporting requirements.
HPV is the most common sexually transmitted disease in the United States. It is not a reportable disease in Connecticut, but since 2008, the Department of Public Health (DPH) has tracked precancerous cervical lesions in order to monitor the impact of the HPV vaccine on these lesions. Because most HPV infections are cleared by the body's immune system, DPH does not track positive HPV results. In addition, the Connecticut Emerging Infections Program, a joint project between DPH and the Yale University School of Public Health, is conducting enhanced surveillance for these lesions in women ages 18-39 years old living in New Haven County.
HPV infections are not nationally reportable by the Centers for Disease Control and Prevention (CDC). However, two states, Florida and New Mexico, require healthcare providers and laboratories to report HPV infections. In addition, some states have made certain HPV-associated conditions reportable. Delaware and Massachusetts require the reporting of genital warts and Florida requires the reporting of HPV-associated recurrent respiratory papillomatosis (RRP) in children under age six.
Cervical and other HPV-related cancers are measured by state cancer registries participating in either the CDC's National Program of Cancer Registries or the Surveillance Epidemiology and End Results program (SEER). Every state participates in at least one program. (Connecticut participates in SEER.) Data are collected and analyzed at both the state and national level.
According to the CDC, approximately 20 million Americans are currently infected with HPV and at least 50% of sexually active people will contract it at some point in their lives. Over 100 types of HPV have been identified, 40 of which infect the genital area, throat, and mouth. HPV types are classified by their association with cancer. Non-oncogenic (low-risk) HPV types, such as HPV 6 and 11 may cause (1) benign or low-grade cervical cell abnormalities, (2) genital warts, and (3) RRP, a respiratory tract disease. Oncogenic (high-risk) HPV types, including types 16 and 18, may cause cervical, vulvar, vaginal, penile, anal, and oropharyngeal (back of throat) cancers.
HPV is transmitted through sexual contact and most people who become infected are unaware they have the virus. According to the CDC, in 90% of cases, the body's immune system clears the virus naturally within two years.
Currently, there are two FDA-approved HPV vaccines. Merck's Gardisil (HPV4) vaccine was approved in 2006 for administration to females ages nine to 26 to protect against HPV types 16, 18, 6, and 11. These four types of HPV cause 70% of cervical cancers and 90% of genital warts. In 2009, Merck received an expanded license for administration to males aged nine to 26 to protect against genital warts.
GlaxoSmithKline's Cervarix vaccine (HPV2) also protects females against cervical cancers caused by HPV types 16 and 18 and was licensed in 2009 for administration to females ages 10 to 25.
The vaccines are most effective when administered at 11 or 12 years of age before an individual becomes sexually active. The federal Advisory Committee on Immunization Practices (ACIP) recommends the routine vaccination of girls ages 11 and 12 with either vaccine, and a “catch-up” vaccination for females 13 to 26 years of age who have not been previously vaccinated.
On October 25, 2011, ACIP expanded its recommendations to include the routine HPV4 vaccination of boys ages 11 and 12 and a catch-up dose for males ages 13 to 21 who have not been previously vaccinated. It also supports the permissive use of the vaccine in men ages 22 to 26. Previous guidance issued in 2009 recommended against the routine use of Gardisil to prevent genital warts in males, instead supporting the permissive use of the vaccine.
HPV REPORTING IN CONNECTICUT
By law, the DPH commissioner must publish an annual list of diseases healthcare providers and laboratories must report to the department. Category 1 diseases, such as tuberculosis, measles, and foodborne outbreaks must be immediately reported by telephone on the day the disease is recognized or strongly suspected. Category 2 diseases, such as Hepatitis C, HIV, or influenza-associated death, must be reported by mail within 12 hours of recognition or strong suspicion of the disease (CGS §§ 19a-2a and 19a-36-A2). (2011 Reportable Diseases and Laboratory Reportable Significant Findings lists are attached.)
HPV is not a reportable disease in Connecticut, but DPH tracks cervical precancerous lesions. In 2008, HPV-related cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) and adenocarcinoma insitu (AIS) were added to the reportable diseases and laboratory reportable significant findings lists in Connecticut. According to DPH, the goal of this surveillance is to monitor the impact of the HPV vaccine on HPV-related pre-cancerous cervical lesions. Since most HPV infections are cleared by the body's immune system, the department feels a positive HPV result in itself is not informative without knowing if there is an associated clinical condition.
In addition, the Connecticut Emerging Infections Program, which is a joint project between DPH and the Yale University School of Public Health, is conducting enhanced surveillance for CIN 2/3 and AIS in women ages 18 to 39 years old living in New Haven County. The project is expected to continue over the next 10 years, allowing public health officials to monitor the impact of the HPV vaccine on population rates of
cervical cancer precursors and the prevalence of HPV types responsible for these lesions. Findings will also help the state determine any changes in cervical cancer screening rates due to the introduction of the HPV vaccine.
HPV REPORTING IN OTHER STATES
We contacted the National Conference of State Legislatures, Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, and examined the reportable diseases lists in all 50 states. We found two states, Florida and New Mexico, that require the reporting of HPV infections. New Mexico requires healthcare providers and laboratories to report all positive HPV tests. Florida requires laboratories to report positive tests for any high-risk HPV type (Type 16, 18, 31, 33, 34, etc.) as well as precancerous cervical, vulvar, vaginal, and anal lesions.
In addition, some states require the reporting of certain HPV-associated conditions. Delaware and Massachusetts require the reporting of genital warts and Florida requires the reporting of HPV-associated RRP in children under age six.
While HPV infections are not nationally reportable by the CDC, cervical and other HPV-related cancers are measured by state cancer registries participating in CDC's National Program of Cancer Registries (NPCR) and the Surveillance Epidemiology and End Results (SEER) program. All states participate in one or both of these federal programs. (Connecticut participates in SEER.) Data are collected and analyzed at the state and national levels.
Association of State and Territorial Health Officials, www.astho.org; website last visited on November 7, 2011.
Centers for Disease Control and Prevention, http://www.cdc.gov/hpv/; website last visited on November 7, 2011.
Connecticut Department of Public Health, Reportable Diseases and Laboratory Reportable Significant Findings Changes for 2011, Connecticut Epidemiologist, Volume 31, No. 1, January 2011; http://www.ct.gov/dph/lib/dph/infectious_diseases/pdf_forms_/reportablediseases.pdf; website last visited on November 7, 2011.
The Council of State and Territorial Epidemiologists State Reportable Conditions Assessment, http://www.cste.org/dnn/ProgramsandActivities/PublicHealthInformatics/StateReportableConditionsQueryResults/tabid/261/Default.aspx; website last visited on November 7, 2011.
National Conference of State Legislatures, www.ncsl.org; website last visited on November 7, 2011.