What’s all the fuss about the Human Papillomavirus Virus (HPV) Vaccine? There is some controversy about whether or not school age children should be vaccinated against a sexually transmitted disease with many parents choosing not to vaccinate. It is a touchy subject for many patients and their children. Given the cost of the vaccine, general suspicion concerning vaccines in the US, and how uncomfortable many parents are with discussing matters of sexuality with their children it is probably not surprising that many children have not yet received the recommended vaccine series.
According to a study by the Center for Disease Control (CDC), HPV so common that nearly all sexual active adults will be infected at some point in their lives. About half of all those infected are between the ages of 15 and 24.
Furthermore about 21,300 females and 12,100 males are diagnosed with HPV-associated cancers annually. Nearly all cervical cancers are caused by HPV and cancers in other areas of the body can also be caused by HPV. For example 90% of anal cancers, 65% of vaginal cancers, 60% of oropharyngeal cancers, 50% of vulvar cancers, and 35% of penile cancers are thought to be caused by HPV. Over 20 million people in the US are infected with HPV.
There are over 40 HPV types that infect humans. The quadrivalent vaccine Gardasil protects against types 16, 18, 6, and 11, which are considered the most virulent. The quadrivalent HPV vaccine shows nearly 100% efficacy in preventing cervical precancers, vulvar and vaginal precancers, and genital warts in women caused by the vaccine types, as well as 90% vaccine efficacy in preventing genital warts and 75% vaccine efficacy in preventing anal precancers in men. The vaccine has demonstrated efficacy in younger woman as well as the recommended ages of 11 to 12, in immunogenicity studies conducted in girls between the ages 9 to 15 years of age. Over 99% of vaccinated girls in these studies developed antibodies after vaccination. In women already infected with a targeted HPV type, the vaccines do not prevent disease from that HPV type but does protect against other types. The vaccine is not meant to replace other prevention strategies such as Pap test and it does not treat a preexisting infection.
Given these statistics it is probably not surprising that the CDC, the American Academy of Pediatrics, and other professional organizations recommend vaccinating all boys and girls between the ages of 11 or 12. The vaccine can be started as young as 9 years of age and is recommended up to age 26 in females and 21 in males. The vaccine is indicated for ages up to 26 years of age. The vaccine has been shown to be safe in patients older than 26 years of age however there was no benefit detected in the prevention of disease.
Given the prevalence of the infective agent and the safety and efficacy of the vaccine, it may be shocking to know how few of the recommended population have been vaccinated. Only 35% of girls between 13 and 17 have completed the three course series. In a survey published in March of this year about 44% of parents surveyed did not intend to vaccinate against HPV. The second most commonly cited reason was “Safety concerns/Side effects.” The safety concerns are likely unfounded, as over 56 million doses of the vaccine have been distributed in the US with no serious long term complications associated with its use being reported.
The rates for boys are worse, much worse, with only about 1% of boys having completed the series and about 8% having received one or two doses. This is likely due to confusion about the vaccines use in males. The original recommendation was for woman with most media attention being paid to the reduction in risk for cervical cancers. The benefit in males is less obvious and until it is well known that vaccinating males helps to both prevent the spread of HPV and reduce the risk of other HPV caused cancers the rates of vaccination in males will remain low.
There is race disparity as well. Hispanic girls have the highest rates of vaccination despite having the lowest rates of health insurance. Only 48 percent of white teenage girls have received the first dose of the vaccine, compared with 56 percent of blacks and 65 percent of Hispanics. But the rate falls steeply by the third dose. In all, 42 percent of Hispanic teenage girls have been fully vaccinated. About a third of whites have received all three doses, similar to the share of black girls. According to Dr. Walter A. Orenstein, who ran the CDC immunization program for 16 years, this pattern is very unusual, saying, “I can’t remember a vaccine where I saw a pattern like this.”
Not surprisingly, one reason is money. A federal inoculation program that covers vaccines for the poor and underserved gives the HPV vaccine to clinics for free. Private insurance coverage is less reliable, and many patients have high co-pays or have to pay the full price, generally up to $500 for a complete cycle of the vaccine. The new Affordable Care Act requires insurers to cover the vaccine, a change that has the potential to even out the disparity and increase the vaccination rate.
Dr. Tom Frieden says it best when he says, “…countries such as Rwanda have vaccinated more than 80 percent of their teen girls. [The U.S. rate] is simply unacceptable. Our low vaccination rates represent 50,000 preventable tragedies; 50,000 girls alive today will develop cervical cancer over their lifetime that would have been prevented if we had reached our goal of 80 percent vaccination rates. For every year we delay in doing so, another 4,400 girls will develop cervical cancer in their lifetimes.”
One of the most commonly cited reason for not vaccinating is that the child is not sexually active or that the vaccine is not necessary. It is important to educate patients that the vaccine is most effective when given at an early age. The vaccine is not permission to begin having sex nor is it a free pass to engage in risky sexual behaviors. The vaccine is only effective if given before the virus is contracted plus the body needs time to develop antibodies. So the simple truth is that the earlier the vaccine is given the more effective it is.
In the US, virtually all vaccines are victims of their own success. Most people in the US have no concept of the risk for diseases like polio or measles. As memory of the diseases fade people become skeptical of the vaccines against them and of vaccines in general. This is not the case in many other countries. As one Hispanic patient puts it, “In my country, if a baby doesn’t get vaccines, the baby dies. Why would I not do this?” This cultural discrepancy may also partially explain the differences between the rates of vaccination between ethnicities.
This is a vaccine against cancer. How can the US not be embracing this life saving vaccine? Every health care provider is encouraged to educate and recommend vaccines, including the HPV vaccine when indicated, at every visit and at every opportunity. We owe it to the over 4,500 patients who will develop HPV caused cancers annually if the rates of vaccination do not improve.
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