Role and Outputs of the Scottish HPV Reference Laboratory

Kate CuschieriScottish HPV Reference Laboratory

PRESENTED AT - SCOTTISH ASSOCIATION OFHISTOTECHNOLOGY

37th SCIENTIFIC MEETING May 2016

http://www.hps.scot.nhs.uk/reflab/VirLabDetail.aspx?id=26

SHPVRL - How and who…..

– Established in 2008. Built on expertise that had developed in NHS Lothian

– Team of 3 (2.2 wte)– The 13 th Reference Lab..– Close affiliation with HPV

Research Group at Uni of Edinburgh

– Significant Catalyst –Immunisation;

Scottish Reference Laboratory Details

NHS Lothian

Scottish Bacterial STI Reference Lab SBSTIRL

Scottish E coli Reference Lab SERL

Scottish HPV Reference Lab SHPVRL

Scottish Mycobacteria Reference Lab SMRL

NHS Greater Glasgow and Clyde

Scottish Haemophilus, legionella, meningococcus and pneumococcus Reference Lab

SHLMPRL

Scottish MRSA Reference Lab SMRSARL

Scottish Parasite Diagnostic and Reference Lab SPDRL

Scottish Cryptosporidium Reference Service SPDRL

Scottish Salmonella, Shigella and Clostridium difficile Reference Lab SSSCdRL

Scottish Trace Element and Micronutrient Reference Lab STEMRL

BBV GGC/Lothian

West of Scotland Specialist Virology Laboratory/GGC BBV Glasgow

Specialist Virology Centre/Lothian BBV Edinburgh

NHS Highland

Scottish Toxoplasma Refrence Lab and National Lyme Borreliosis Testing Lab

Toxo lab

Functions of SHPVRL

1. HPV testing for Epidemiology and Surveillance for the HPV immunisation programme

2. HPV screening / genotyping in individual clinical caseswhere knowledge of HPV status will inform clinical management

3. Provision of quality assurance and assessment materials for UK-wide HPV testing laboratories and beyond

4. Commitment to a research and development programmeTeaching and training of medical, scientific and technical staff

5. Advice and support relating to HPV testing for the Scottish Cervical Screening Programme

6. Consolidation of HPV sample archives to facilitate research, quality assurance, test development, audit and teaching.

Scottish HPV immunisation programme and associated surveillance

• HPV immunisation initiated in September 2008 - schools based programme

• 12-13 year olds girls = routine/ “target” cohort

• Three year “Catch-up” ran for girls ≤18 years

• Bivalent vaccine until September 2012, changed to quadrivalent

• Three dose schedule- changed to two dose in 2014

• Partner programme of longitudinal surveillance to determine impact

Scottish HPV immunisation surveillance

• Programme includes– Baseline assessments (pre-immunised population) 1,2,3

– Monitoring impact of immunisation on disease outcomes over time (histological4, cytological5, colposcopic6)

– Monitoring impact of immunisation on HPV infection • In women attending for first smear (yearly) – residual LBC 7

• In women 20-25 diagnosed with CIN2/3 -residual biopsy• Assessment of < 3 doses of vaccine

1: O'Leary MC, Sinka K, Robertson C, Cuschieri K, Lyman R, Lacey M, Potts A, Cubie HA, Donaghy M. HPV type-specific prevalence using a urine assay inunvaccinated male and female 11- to 18-year olds in Scotland. Br J Cancer. 2011 Mar 29;104(7):1221-6.2:Cuschieri K, Brewster DH, Williams AR, Millan D, Murray G, Nicoll S, Imrie J, Hardie A, Graham C, Cubie HA. Distribution of HPV types associated with cervical cancers in Scotland and implications for the impact of HPV vaccines. Br J Cancer.2010 Mar 2;102(5):930-23: Kavanagh K, Sinka K, Cuschieri K, Love J, Potts A, Pollock KG, Cubie H, Donaghy M, Robertson C. Estimation of HPV prevalence in young women in Scotland; monitoring of future vaccine impact. BMC Infect Dis. 2013 Nov 5;13:519.4: Pollock KG, Kavanagh K, Potts A, Love J, Cuschieri K, Cubie H, Robertson C, Cruickshank M, Palmer TJ, Nicoll S, Donaghy M. Reduction of low- and high-gradecervical abnormalities associated with high uptake of the HPV bivalent vaccine in Scotland. Br J Cancer. 2014 Oct 28;111(9):1824-30. 5: Palmer, T. J., Robertson, C., Cuschieri, K., Nicoll, S. & Pollock, K. G. J. Effect of HR-HPV immunisation on the performance of cervical cytology, presented at EUROGIN 2015 OC12, p2066: Cruickshank M et al “Implications of HPV immunisation on colposcopy services and practice” – IPV 2015 - Fri 18/09/15 and Sun 20/09/15 7: Kavanagh K, Pollock KG, Potts A, Love J, Cuschieri K, Cubie H, Robertson C, Donaghy M. Introduction and sustained high coverage of the HPV bivalent vaccineleads to a reduction in prevalence of HPV 16/18 and closely related HPV types. Br J Cancer. 2014 May 27;110(11):2804-11 .

6 11 16 18 26 31 33 35 39 40 44 45 51 52 53 54 56 58 59 66 68 70 82 X

05

10

15

20

Swab - Female

6 11 16 18 26 31 33 35 39 40 44 45 51 52 53 54 56 58 59 66 68 70 82 X

05

10

15

20

Urine - Female

•Assess the suitability of urine as a bio-specimen for HPV surveillance

•Group of young males and females <25 attending drop in services

•Allowed sensitivity and specificity calculations of urine vs gold standard.

Urine testing as a surveillance tool to monitor the impact of HPV surveillance programmes. Cuschieri K(1), Nandwani R, McGough P, Cook F, Hogg L, Robertson C, Cubie H. J Med Virol. 2011 Nov;83(11):1983-7

Pilot study with the Sandyford Initiative in Glasgow

YES

?

NO

?

Don’t know

The aim is to get a true picture of how many young people

in Scotland have human papilloma virus

Assess HPV prevalence in 11-18 year olds, Information leaflet

School presentations -

parent consent formyour consent formurine sample pot

data form

What should you bring back?• Discuss with your parents (if you’re under 16)

• Return tomorrow at 8:15 to theMedical Suite with the following…

2447 urine’s…

Results – National HPV Prevalence Study (young males and females)

• Females Aged 11-14 HPV prevalence was 1.1% overall; 0.9% for HR-HPVAged 15-18 HPV prevalence was 15.2% overall; 12.6% for HR-HPV

• MalesAged 11-14 years HPV prevalence was 1.4% overall; 1.0% for HR-HPVAged 15-18 years HPV prevalence was 3.9% overall; 2.4% for HR-HPV

O'Leary MC, et al Br J Cancer. 2011 Mar 29;104(7):1221-6

Vaccine uptake is high in Scotland

http://www.isdscotland.org/Health-Topics/Child-Health/publications/data-tables.asp?id=1300#1300

As a consequence of vaccination, do we see changes in…

HPV infection in women attending for first smear?HPV infection in CIN2+?Overall rates of CIN?Less than 3 doses of vaccine?

0

5

10

15

20

25

30

35

6 11 16 18 26 31 33 35 39 42 43 44 45 51 52 53 56 58 59 66 68 70 73 82

HPV type

Pe

rce

nta

ge

of

wo

me

n p

os

itiv

e f

or

an

y H

PV

Unvaccinated (0 dose)

Vaccinated (3 doses)

Kavanagh et al BJC 2014

Significant reduction of HPV 16,18,31,33 and 45

In vaccinated women attending for first smear

16 31 33 52 18 51 56 82 39 45 58 59 42 53 66 6 73 70 11 26 35 68 44 43

HPV type

Pro

port

ion p

ositiv

e

0.0

0.2

0.4

0.6

0.8 Unknown

0 doses3 doses

HPV positivity by type and vaccine status in those CIN2+

HPV positivity by type and vaccine status in those with CIN2+ (data aggregated from 2011 & 13)

Significant decrease in HPV 16 disease is associated with vaccination

With 3 doses - significant reduction in diagnoses of:

• CIN 1 (RR 0.71, 95% CI 0.58 to 0.87, p=0.0008) • CIN 2 (RR 0.5, 95% CI 0.4, 0.63, p<0.0001) and• CIN 3 (RR 0.45, 95% CI 0.35 to 0.58, p< 0.0001)

for women who received 3 doses of vaccine compared with unvaccinated women – adjusting for deprivation and age women received vaccine

Pollock et al BJC 2014

….and a reduction in lesions

Table 2: Prevalence (unadjusted) of vaccine and cross-reactive HPV types according to number of vaccine doses

No. of

Doses

Unadjusted

VE

[%, (95 CI’s)]

P value Adjusted

VE:

[%, (95 CI’s)]

P value

HPV 16/18

1 25.1 (-5.7,48.0) 0.1093 48.2 (16.8,68.9) 0.0075

2 36 (15.3, 52.3)0.0023

54.8 (30.7, 70.8)<0.0001

3 70.2 (65.0, 74.7)<0.0001

72.8 (63.8, 80.3)<0.0001

HPV

31/33/45

1 -15.9 (-74.6, 25.9) 0.4978 -1.62 (-85.1, 45.3) 0.9588

2 41.4 (12.1, 62.8) 0.0143 48.3 (7.6, 71.8) 0.0287

3 55.5 (45.1, 64.1)<0.0001

55.2 (32.6, 70.2)<0.0001

Even one dose of vaccine is associated with a reduction in HPV 16/18 prevalence

Cuschieri et al BJC 2016

Functions of SHPVRL

1. HPV testing for Epidemiology and Surveillance for the HPV immunisation programme

2. HPV screening / genotyping in individual clinical caseswhere knowledge of HPV status will inform clinical management

3. Provision of quality assurance and assessment materials for UK-wide HPV testing laboratories and beyond

4. Commitment to a research and development programmeTeaching and training of medical, scientific and technical staff

5. Advice and support relating to HPV testing for the Scottish Cervical Screening Programme

6. Consolidation of HPV sample archives to facilitate research, quality assurance, test development, audit and teaching.

Establishing a viral aetiology to cervical cancer has led to

1) cervical disease prevention (vaccination) 2) management beyond traditional cytology screening (HPV testing)

HPV and cervical cancer

HPV (direct) tests in current use for cervical disease

management

Often:• Molecular, frequently based on amplification of HPV sequences• Broad spectrum/consensus tests, detect a pool of HR HPV types in

aggregate*• Consensus tests with limited genotyping• Examples: Hybrid Capture 2 (Qiagen), COBAS 4800 HPV test (Roche),

RealTime High Risk HPV test (Abbott), Cervista HPV HR Test Assay & the Aptima HPV Test (Hologic).

• More than 200 others!• Very sensitive for detecting disease – have a high

negative predictive value

*Detect a common pool of 13-14 types: 16,18,31,33,35,39,45,51,52,56,58,59,68,66.

However - HPV is a common virus that often clears

• Clinical sensitivity of HPV tests often exceeds their clinical specificity– i.e. All individuals that have disease that will test HPV

positive but not all individuals who are HPV positive will have significant disease

• Negative predictive value of HPV tests is higher than their positive predictive value– i.e. individuals who test HPV negative are unlikely to have

the disease but individuals who test HPV positive may not have the disease

18% HR- HPV in women aged 20-60 attending for routine cervical screening

~280,000 infections in screen age women in Scotland.

HPV is common in Scotland

What are the “indications” for HPV testing for the management of cervical disease?

Context is key!

A As a primary screen– With cytology as a triage. Ie START with the more sensitive

test and follow-up with a more specific one.

B As a triage to refer women with low-grade abnormalities to colposcopy for visual examination of the cervix (and biopsy if indicated) .

C As a test of cure of treatment of high grade abnormalities– To indicate treatment success*

Advice and support relating to HPV testing for the Scottish Cervical Screening ProgrammeHPV testing as a Test of Cure of Treatment

2009-12

Input into “Test of Cure” Working Group

Design and user acceptance testing of Virology module for IT system (SCCRs)

Major work stream, HPV testing in women treated for cervical lesions as a “test of cure”. First time HPV testing fully integrated into the Scottish Cervical Screening programme

Pilot Implementation; Highland, Grampian Lothian

National Roll out

2011

2012

Since early implementation received 20,000 +

*Cubie HA, Canham M, Moore C, Pedraza J, Graham C, Cuschieri K. Evaluation of commercial HPV assays in the context of post-treatment follow-up: Scottish Test of Cure Study (STOCS-H). J ClinPathol. 2014

Research to investigate/inform optimal test choice for test of cure*

2010

Advice and support relating to HPV testing for the Scottish Cervical Screening Programme (2)

Further Research to refine and develop Test of Cure processes

MAGS* Project: Gathering evidence base to determine whether patients treated with Micro-invasive cancer or Glandular lesions may benefit from HPV-Test of Cure.

SHPVRL represented within HPV Reference Group**, Scottish Cytology Steering Group. Primary Screening with HPV – a priority issue.

Support in the cascade of training, best practice and quality assurance for increased volume of HPV Testing

*Microinvasive Glandular and SMILE

**Set up to consider the case for HPV Primary Screening

- Key phrase: “UK Cervical Cancer Screeing Programme should adopt the test for HPV as a primary screening test”

HPV screening / genotyping in individual clinical cases where knowledge of HPV status will inform clinical management

In Service Level Agreement originally funded to perform 200 tests per year.

Gynae Non Gyane Year62 in total 2009-10106 85 2010-11137 45 2011-12133 37 2012-13129 239 2013-14

HPV screening / genotyping in individual clinical cases where knowledge of HPV status will inform clinical management

In Service Level Agreement originally funded to perform 200 tests per year.

http://www.hps.scot.nhs.uk/reflab/VirLabDetail.aspx?id=26

HPV Testing of Oropharyngeal Cancers can provide insight into prognosis

SHPVRL now have core funding to test Oropharyngeal Cancers from Scottish Health Boards since April 2014

Research and Development (1)

Development and optimisation of new generation of HPV assays through collaboration with basic researchers and industry.

Sheila Graham (cellular and viral mRNA)

Sarah Howie & Juergen Haas (immunological “biomarkers”)

Mark Bradley (Bio-compatible Polymers)

Thomas Wilhem/A Lorincz (Cellular & viral methylationtargets)

Cepheid, Becton Dickinson, GeneFirst (new generations of HPV tests)

Research and Development (2)

To inform the development of cervical screening & disease management including in immunised women

Partners in Health Services Research programme CI M Cruickshank

SHIFT –Performance of HPV primary screening in Scottish (young) women attending for screening

COHGS – Performance of colposcopy in immunised vs non immunised women

VALGENT project – Assessment and validation of new HPV assays which include a genotyping element

SHEVa – Performance of HPV testing in immunised populations

Research and Development (3)

Life beyond the cervix….

Further insight into HPV associations and impact in the development of non cervical ano-genital cancers (K Wakeham)

AND

Head and neck cancers (in addition to oropharynx) hypopharynx, nasopharyx (Ioanna Nixon, Simon Talbot)

HOPSCOTCH – HPV Oral prevalence study – CSO funded feasibility study just completed in dental practices (CI– David Conway)

ScottishHPV Archive

➢ Started in 2009➢ Archive of cervical samples from women in Scotland➢ Associated data linkage capabilities➢ Can be used for HPV related research➢ Over 27,000 and counting…. Multiple aliquots each

INTERESTED IN USING THE ARCHIVE? Get in touch –HPVarchive@ed.ac.uk0131 242 6625 – Dr Ramya Bhatia - archive manager

The Scottish HPV Investigators Network (SHINe, est 2008)

PurposeThe purpose of SHINe is to act as a multi-disciplinary forum for discussion on HPV and HPV-related diseases, identify emerging research and clinical questions, and implement a series of research programmes/projects relevant to HPV disease prevention and management in the future.

The group benefits from the combined expertise of representatives from cervical screening (Primary Care and Cytology), disease management/treatment (Pathology, Gynaecology and Colposcopy) and internationally recognised basic scientists. In addition, representation from the Scottish HPV Reference Laboratory (SHPVRL) and the team at Health Protection Scotland responsible for National Immunisation and surveillance make SHINe a truly relevant and integrated collaboration.

Funding has already been obtained from the Chief Scientist Office of the Scottish Government Health Department with two concurrent programme grants, one of which has ensured the development of a National HPV sample archive.

http://www.shine.mvm.ed.ac.uk

Thanks to

– HPV Surveillance Team at HPS

– All members of SHPVRL and HPV Research Group

– All Scottish Pathology Laboratories

– SHINe