Delaying HPV Immunization is a Deadly Waiting Game Sharon G. Humiston, MD, MPH, FAAP Margaret C. Fisher, MD, FAAP Like most pediatricians, we do not typically see children with cancers caused by Human Papillomavirus (HPV) in patients, although we have cared for patients with juvenile-onset respiratory papillomatosis. Our motivation for trying to improve HPV vaccination rates now largely has to do with what we have seen HPV do to the lives of friends, colleagues, and the parents of our patients. HPV-associated cancers of the oropharynx are a growing US problem. The incidence of these cancers tripled between 1988 and 2004. The President s Cancer Panel, citing work published in the Journal of Clinical Oncology, emphasized that the number of new oropharyngeal cancer cases caused by HPV likely will exceed the number of cervical cancer cases by 2020. Conization of the cervix, i.e., excision of a wedge from the cervix, is important conservative treatment of cervical intraepithelial neoplasia (CIN). However, it can lead to obstetric morbidity, a phrase that seems far removed from the heart break of miscarriages and preterm deliveries. Of course, the cancers associated with HPV infection (shown in Figure 1) are dreaded: cancer of the cervix, oropharynx, anus, vulva, vagina, and penis. If you want to want to develop a feeling for HPV vaccination, imagine for one full minute that your doctor just told you that you had any of these cancers. Fortunately, infection with some important strains of HPV infection can be prevented in young people through vaccination. 1 What a privilege it is to be a pediatrician at a time when we can really make a difference in our patients lives! But not all of us are shouting about this from our office rooftops. While most doctors report that they recommend HPV vaccine, a lot of mothers hear a provider recommendation that sounds like this: My doctor said my adolescent should get the pertussis vaccine because whooping cough is going around again and the meningitis vaccine because that s a dreaded disease. He said she should get the HPV vaccine at some point, but it can wait for now. With respect to effective strategies, waiting is right behind hoping. Here are eight thoughts to make to make you reconsider The Waiting Game : 1 Routine HPV vaccination is recommended for both males and females ages 11-12 years; catch up vaccination is recommended for males (ages 13-21 years) and females (ages 13-26 years). At the provider s discretion, the HPV vaccine can be given starting at age 9 years of age for both males and females and can be given to males ages 22-26 years. 1
1. HPV can be transmitted without vaginal-penile sexual intercourse. According to CDC, HPV is transmitted by having vaginal-penile intercourse, but also may be spread during oral or anal sex with an infected person, even one who is asymptomatic. Some young people who choose not to have sex (vaginal-penile intercourse) engage in these alternative practices and so are susceptible to infection. Importantly, condoms do not completely stop transmission of HPV. 2. If you wait to start the series until high school, fewer patients will benefit. Figure 2 shows the proportion of adolescents who have had sex by each grade, and Figure 3 shows the data by race. Regardless of race, ethnicity, or socio-economic status, the take-home message is clear: a high proportion of adolescents have sex early in high school so the HPV vaccine series should be completed well before they get there. 3. You can give HPV vaccine without having the sex talk just as you give polio vaccine without having the gastrointestinal talk. Some providers avoid starting the HPV vaccine series because they don t want to have the sex talk with an 11-year old. So don t. Just as you can give MMR without describing droplet transmission, you can give HPV vaccine without describing sexuality. (If you are not sure you have the right words, see Talking With Your Young Child About Sex at http://patiented.aap.org/content2.aspx?aid=5063.) 4. Patients should complete the entire three-dose HPV vaccine series before any chance of exposure to this dangerous virus just as they should secure their bike helmets and seat belts before pulling out of the driveway. We would never say, Let s hold off giving polio vaccine until you are actually going to meet someone from or board a plane to Nigeria. We can t predict the future, so we try to prevent infection with potentially disastrous viruses without trying to guess the exact moment of exposure. 5. The duration of immunity following HPV vaccination is certainly sufficient to get young people through the highest-risk years and monitoring will have to be on-going. To date, studies of HPV vaccine indicate that its protection lasts at least 8 to 10 years and studies are in progress to monitor the duration of immunity. 6. Primary prevention is essential because, as wonderful as regular PAP smears are, they do not prevent all deaths from cervical cancer, nor the need for cervical conization. They certainly do not address other HPV-associated cancers or HPV-associated cancers in males! Primary prevention aims to prevent a disease such as cervical cancer from occurring. Most of us would consider this far superior to secondary prevention, i.e., finding and treating the disease early in 2
its course, with the hope of curing it. Again, hope is not a strategic ace and prevention will always be better than treatment of disease. 7. Even if parents are staunchly against all sexual contact before marriage, most of us don t want our children to suffer these kinds of cancers because they or their marital partner made a mistake. 8. This time-tested vaccine is protecting many tens of millions of people around the world. Maybe you didn t want to be the first doctor to give HPV vaccine, but after 100 million doses have been given, isn t NOW the right time to offer it to all your adolescent patients? 3
FIGURE 2. 4
FIGURE 3. 5