The Underused HPV Vaccine, from the New York Times

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The Underused HPV Vaccine, from the New York Times

Category : Advice , Vaccine

The Underused HPV Vaccine

You’d think that when parents are told of a vaccine that could prevent future cancers in their children, they’d leap at the chance to protect them. Alas, that is hardly the case for a vaccine that prevents infections with cancer-causing human papillomavirus, or HPV. The vaccine, best given at age 11 to 12, is currently the most underutilized immunization available for children.

HPV is by far the most common sexually transmitted infection in the United States, and nearly every sexually active person becomes infected at some time in life. The virus in one or another of its variants causes more than 90 percent of cervical cancers, as well as most cancers of the vulva, vagina, anus, penis and oropharynx, which includes the back of the throat, base of the tongue and tonsils. It also causes genital warts.

Every year, the Centers for Disease Control and Prevention reports, about 14 million Americans become infected with HPV, most of them teenagers or young adults, and a cancer caused by HPV is diagnosed in an estimated 17,600 women and 9,300 men.

Yet, when one of my sons was urged to get the HPV vaccine for his boys, ages 11 and 14, he replied, “Why? They’re not yet sexually active.” I reminded him that not all sex is consensual, and exposure to the virus does not require sexual penetration. However, his response reflects a common misunderstanding among millions of parents, and often their children’s doctors, of the value of the vaccine and the fact that it is most effective if given to preteenagers when the immune response is strongest and before they are exposed to an offending form of the virus.

But as of 2014, only 40 percent of girls and 21 percent of boys ages 13 to 17 had received all three doses of the HPV vaccine, whereas 88 percent of boys and girls had been vaccinated against tetanus-diphtheria-pertussis and 79 percent had gotten the meningococcal vaccine.

There are several explanations for the low rate of HPV immunization among young teens. One is that the vaccine is relatively new — it was first approved in 2006 — and expensive. At about $300 a dose, the three-dose series can approach $1,000 a child, although now, as with other government-recommended vaccines, it is covered by insurance with no co-pay, and the federal Vaccines for Children program provides free vaccination for children who are uninsured or underinsured, according to the American Cancer Society.

The society last month updated its immunization guideline for the HPV vaccine, bringing it in line with the advice issued two years ago by the federal Advisory Committee on Immunization Practices. While the committee considered evidence primarily from company-sponsored studies, the cancer society looked at additional studies conducted by independent researchers.

The society also more carefully defined the effect of age at the time of immunization, finding decreased effectiveness with age that underscores the importance of early vaccination.

“If the vaccine is to be given to people 22 to 26, doctors should inform patients that it is less effective,” said Debbie Saslow, the director of cancer control intervention for the cancer society. Still, it is not too late to immunize college students who did not get the vaccine when they were younger, she said.

A second obstacle to wider HPV immunization is the erroneous belief that it would promote teenage promiscuity, an argument more commonly used to counter birth control advice for teenagers. There is no direct connection between the vaccine and sexual activity and no reason to suggest one, said Dr. Saslow, the lead author of the cancer society’s updated guidelines. If asked, a parent or doctor could simply say the vaccine prevents infection by a very common virus that can cause cancer.

Although some early publicity for the vaccine focused on preventing sexually transmitted disease, Dr. Saslow said, “first and foremost, this is a cancer-prevention vaccine. Multiple studies have shown no negative impact on any measure of sexual activity among girls given the HPV vaccine. You don’t tell teenagers learning to drive not to wear a seatbelt because it may encourage them to run red lights.”

Parental support for having 11 and 12 year old children vaccinated against HPV has been very weak, with only one in five thinking it should be required for school entry. Several states have proposed mandatory vaccination for school entry, and a national sampling of 1,501 parents of children ages 11 to 17 showed that including an “opt out” provision would almost triple parental support for such a requirement, according to researchers at the University of North Carolina Gillings School of Global Public Health.

The most pernicious argument against HPV immunization involves postings on the web of undocumented horror stories that some parents attribute to the vaccine, not unlike the misattribution of autism to the vaccine for measles-mumps-rubella. None of the accounts of severe adverse effects parents have linked to the HPV vaccine have been borne out by sound research.

Three HPV vaccines have been developed, although only one, which protects against nine variants of the virus, now remains on the market. The C.D.C. has stated unequivocally that clinical trials have shown them all to be “very safe.”

Before being licensed in 2009, the vaccine called Cervarix, which protects against the two variants of HPV linked to cervical cancer, was studied in more than 30,000 females. The four-variant vaccine called Gardasil, licensed in 2006 for females and in 2009 for males, was studied in more than 29,000 recipients, and the newest nine-variant vaccine, called Gardasil 9, licensed in December 2014 and the only one now sold, was studied in more than 15,000 males and females.

“Each HPV vaccine was found to be safe and effective,” the agency has declared.

The most common side effects are local pain, redness or swelling at the site of the intramuscular injection. As with other vaccines given to teenagers, fainting sometimes occurs, and patients should be advised to sit or lie down for 15 minutes after getting the vaccine.

The three-dose vaccines should be given to boys and girls as follows: The first dose should ideally be given at age 11 or 12, but can be given to children as young as 9 or to young adults through age 26. The second dose is administered one or two months after the first. And the third dose is given six months after the first. Protection is not complete until all three doses are received. However, there is no maximum interval; if any dose is delayed, it should be given at the next opportunity. There is no need to restart the series.

The vaccine can be safely administered at the same time as other vaccines are given, like the Tdap, meningococcal or influenza vaccine. Although HPV vaccine should not be given during pregnancy, no fetal harm has yet been shown when pregnancy was discovered after one or more doses of the vaccine were administered.

Thus far, there is also no indication that vaccine protection diminishes with time. Individuals followed for up to 10 years post-immunization have shown no sign of decreased protection, and booster doses are not required.

About HPV and the Vaccine to protect against it (From the CDC)

HPV vaccine for males (from the CDC)


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HPV vaccine for males (from the CDC)

What is HPV?

HPV is the most common sexually transmitted infection. HPV is a viral infection that can be spread from one person to another person through anal, vaginal, or oral sex, or through other close skin-to-skin touching during sexual activity. If you are sexually active you can get HPV, and nearly all sexually active people get infected with HPV at some point in their lives. It is important to understand that getting HPV is not the same thing as getting HIV or HSV (herpes).

How do men get HPV?

You can get HPV by having sex with someone who is infected with HPV. This disease is spread easily during anal or vaginal sex, and it can also be spread through oral sex or other close skin-to-skin touching during sex. HPV can be spread even when an infected person has no visible signs or symptoms.

Will HPV cause health problems for me?

Most of the time HPV infections completely go away and don’t cause any health problems. However, if an infection does not go away on its own, it is possible to develop HPV symptoms months or years after getting infected. This makes it hard to know exactly when you became infected. Lasting HPV infection can cause genital warts or certain kinds of cancer. It is not known why some people develop health problems from HPV and others do not.

What are the symptoms of HPV?

Most men who get HPV never develop symptoms and the infection usually goes away completely by itself. However, if HPV does not go away, it can cause genital warts or certain kinds of cancer.

See your healthcare provider if you have questions about anything new or unusual such as warts, or unusual growths, lumps, or sores on your penis, scrotum, anus, mouth, or throat.

What are the symptoms of genital warts?

Genital warts usually appear as a small bump or group of bumps in the genital area around the penis or the anus. These warts might be small or large, raised or flat, or shaped like a cauliflower. The warts may go away, or stay the same, or grow in size or number. Usually, a healthcare provider can diagnose genital warts simply by looking at them. Genital warts can come back, even after treatment. The types of HPV that cause warts do not cause cancer.

Can HPV cause cancer?

Yes. HPV infection isn’t cancer but can cause changes in the body that lead to cancer. HPV infections usually go away by themselves but having an HPV infection can cause certain kinds of cancer to develop. These include cervical cancer in women, penile cancer in men, and anal cancer in both women and men. HPV can also cause cancer in the back of the throat, including the base of the tongue and tonsils (called oropharyngeal cancer). All of these cancers are caused by HPV infections that did not go away. Cancer develops very slowly and may not be diagnosed until years, or even decades, after a person initially gets infected with HPV. Currently, there is no way to know who will have only a temporary HPV infection, and who will develop cancer after getting HPV.

How common are HPV-related cancers in men?

Although HPV is the most common sexually transmitted infection, HPV-related cancers are not common in men.

Certain men are more likely to develop HPV-related cancers:

  • Men with weak immune systems (including those with HIV) who get infected with HPV are more likely to develop HPV-related health problems.
  • Men who receive anal sex are more likely to get anal HPV and develop anal cancer.

Can I get tested for HPV?

No, there is currently no approved test for HPV in men.

Routine testing (also called ‘screening’) to check for HPV or HPV-related disease before there are signs or symptom, is not recommended by the CDC for anal, penile, or throat cancers in men in the United States. However, some healthcare providers do offer anal Pap tests to men who may be at increased risk for anal cancer, including men with HIV or men who receive anal sex. If you have symptoms and are concerned about cancer, please see a healthcare provider.

Can I get treated for HPV or health problems caused by HPV?

There is no specific treatment for HPV, but there are treatments for health problems caused by HPV. Genital warts can be treated by your healthcare provider, or with prescription medication. HPV-related cancers are more treatable when diagnosed and treated promptly. For more information, visitwww.cancer.org.

How can I lower my chance of getting HPV?

There are two steps you can take to lower your chances of getting HPV and HPV-related diseases:

  • Get vaccinated. HPV vaccines are safe and effective. They can protect men against warts and certain cancers caused by HPV. Ideally, you should get vaccinated before ever having sex (see below for the recommended age groups). HPV vaccines are given in a series of three shots over a period of about six months.
  • Use condoms the correct way every time you have sex. This can lower your chances of getting all STIs, including HPV. However, HPV can infect areas that are not covered by a condom, so condoms may not give full protection against getting HPV.

Can I get an HPV vaccine?

In the United States, HPV vaccines are recommended for the following men:

  • All boys at age 11 or 12 years (or as young as 9 years)
  • Older boys through age 21 years, if they did not get vaccinated when they were younger
  • Gay, bisexual, and other men who have sex with men through age 26 years, if they did not get vaccinated when they were younger
  • Men with HIV or weakened immune systems through age 26 years, if they did not get vaccinated when they were younger

What does having HPV mean for me or my sex partner’s health?

See a healthcare provider if you have questions about anything new or unusual (such as warts, growths, lumps, or sores) on your own or your partner’s penis, scrotum, anus, mouth or throat. Even if you are healthy, you and your sex partner(s) may also want to get checked by a healthcare provider for other STIs.

If you or your partner have genital warts, you should avoid having sex until the warts are gone or removed. However, it is not known how long a person is able to spread HPV after warts are gone.

What does HPV mean for my relationship?

HPV infections are usually temporary. A person may have had HPV for many years before it causes health problems. If you or your partner are diagnosed with an HPV-related disease, there is no way to know how long you have had HPV, whether your partner gave you HPV, or whether you gave HPV to your partner. HPV is not necessarily a sign that one of you is having sex outside of your relationship. It is important that sex partners discuss their sexual health, and risk for all STIs, with each other.

Where can I get more information?

STD information

HPV Information

Gay and Bisexual Men’s Health

CDC-INFO Contact Center
1-800-CDC-INFO (1-800-232-4636)
TTY: (888) 232-6348
Contact CDC-INFO

CDC National Prevention Information Network (NPIN)
P.O. Box 6003
Rockville, MD 20849-6003
E-mail: npin-info@cdc.gov

American Sexual Health Association (ASHA)
P. O. Box 13827
Research Triangle Park, NC 27709-3827
1-800-783-9877


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About HPV and the Vaccine to protect against it (From the CDC)

Why is the HPV vaccine important?

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most sexually active people will get HPV at some time in their lives, though most will never even know it. HPV infection is most common in people in their late teens and early 20s. There are about 40 types of HPV that can infect the genital areas of men and women. Most HPV types cause no symptoms and go away on their own. But some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts. Genital warts are not life-threatening. But they can cause emotional stress and their treatment can be very uncomfortable. Every year, about 12,000 women are diagnosed with cervical cancer and 4,000 women die from this disease in the U.S. About 1% of sexually active adults in the U.S. have visible genital warts at any point in time.

Which girls/women should receive HPV vaccination?

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years.

Will sexually active females benefit from the vaccine?

Ideally females should get the vaccine before they become sexually active and exposed to HPV. Females who are sexually active may also benefit from vaccination, but they may get less benefit. This is because they may have already been exposed to one or more of the HPV types targeted by the vaccines. However, few sexually active young women are infected with all HPV types prevented by the vaccines, so most young women could still get protection by getting vaccinated.

Can pregnant women get the vaccine?

The vaccines are not recommended for pregnant women. Studies show that HPV vaccines do not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of either HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should do two things:

  • Wait until after her pregnancy to finish the remaining HPV vaccine doses.
  • Call the pregnancy registry [877-888-4231 for Gardasil, 800-986-8999 for Gardasil 9, or  888-825-5249 for Cervarix].

Should girls and women be screened for cervical cancer before getting vaccinated?

Girls and women do not need to get an HPV test or Pap test to find out if they should get the vaccine. However it is important that women continue to be screened for cervical cancer, even after getting all 3 shots of either HPV vaccine. This is because neither vaccine protects against ALL types of cervical cancer.

How effective are the HPV Vaccines?

All HPV vaccines target the HPV types that most commonly cause cervical cancer and can cause some cancers of the vulva, vagina, anus, and oropharynx. Two of the vaccines also protect against the HPV types that cause most genital warts. HPV vaccines are highly effective in preventing the targeted HPV types, as well as the most common health problems caused by them.

The vaccines are less effective in preventing HPV-related disease in young women who have already been exposed to one or more HPV types. That is because the vaccines prevent HPV before a person is exposed to it. HPV vaccines do not treat existing HPV infections or HPV-associated diseases.

How long does vaccine protection last?

Research suggests that vaccine protection is long-lasting. Current studies have followed vaccinated individuals for ten years, and show that there is no evidence of weakened protection over time.

What does the vaccine not protect against?

The vaccines do not protect against all HPV types— so they will not prevent all cases of cervical cancer. Since some cervical cancers will not be prevented by the vaccines, it will be important for women to continue getting screened for cervical cancer. Also, the vaccines do not prevent other sexually transmitted infections (STIs). So it will still be important for sexually active persons to lower their risk for other STIs.

Will girls and women be protected against HPV and related diseases, even if they don’t get all 3 doses?

It is not yet known how much protection girls and women get from receiving only one or two doses of an HPV vaccine. So it is important that girls and women get all 3 doses.

How safe are the HPV vaccines?

All three HPV vaccines have been licensed by the Food and Drug Administration (FDA). The CDC has approved these vaccines as safe and effective. The vaccines were studied in thousands of people around the world, and these studies showed no serious safety concerns. Side effects reported in these studies were mild, including pain where the shot was given, fever, dizziness, and nausea. Vaccine safety continues to be monitored by CDC and the FDA. More than 60 million doses of HPV vaccine have been distributed in the United States as of March 2014.

Fainting, which can occur after any medical procedure, has also been noted after HPV vaccination. Fainting after any vaccination is more common in adolescents. Because fainting can cause falls and injuries, adolescents and adults should be seated or lying down during HPV vaccination. Sitting or lying down for about 15 minutes after a vaccination can help prevent fainting and injuries.

Why is HPV vaccination only recommended for women through age 26?

HPV vaccination is not currently recommended for women over age 26 years. Clinical trials showed that, overall, HPV vaccination offered women limited or no protection against HPV-related diseases. For women over age 26 years, the best way to prevent cervical cancer is to get routine cervical cancer screening, as recommended.

What about vaccinating boys and men?

Gardasil and Gardasil 9 are licensed for use in boys and men. Both vaccines were found to be safe and effective for males 9 -26 years. ACIP recommends routine vaccination of boys aged 11 or 12 years with 3-doses of Gardasil or Gardasil 9. The vaccination series can be started beginning at age 9 years. Vaccination is recommended for males aged 13 through 21 years who have not already been vaccinated or who have not received all 3 doses. The vaccine is most effective when given at younger ages; males aged 22 through 26 years may be vaccinated.

Is HPV vaccine covered by insurance plans?

Health insurance plans cover the cost of HPV vaccines. If you don’t have insurance, the Vaccines for Children (VFC) program may be able to help.

How can I get help paying for HPV vaccine?

The Vaccines for Children (VFC) program helps families of eligible children who might not otherwise have access to vaccines. The program provides vaccines at no cost to doctors who serve eligible children. Children younger than 19 years of age are eligible for VFC vaccines if they are Medicaid-eligible, American Indian, or Alaska Native or have no health insurance. “Underinsured” children who have health insurance that does not cover vaccination can receive VFC vaccines through Federally Qualified Health Centers or Rural Health Centers. Parents of uninsured or underinsured children who receive vaccines at no cost through the VFC Program should check with their healthcare providers about possible administration fees that might apply. These fees help providers cover the costs that result from important services like storing the vaccines and paying staff members to give vaccines to patients. However, VFC vaccines cannot be denied to an eligible child if a family can’t afford the fee.

What vaccinated girls/women need to know: will girls/women who have been vaccinated still need cervical cancer screening?

Yes, vaccinated women will still need regular cervical cancer screening because the vaccines protect against most but not all HPV types that cause cervical cancer. Also, women who got the vaccine after becoming sexually active may not get the full benefit of the vaccine if they had already been exposed to HPV.

Are there other ways to prevent cervical cancer?

Regular cervical cancer screening (Pap and HPV tests) and follow-up can prevent most cases of cervical cancer. The Pap test can detect cell changes in the cervix before they turn into cancer. The HPV test looks for the virus that can cause these cell changes. Screening can detect most, but not all, cervical cancers at an early, treatable stage. Most women diagnosed with cervical cancer in the U.S. have either never been screened, or have not been screened in the last 5 years.

Are there other ways to prevent HPV?

For those who are sexually active, condoms may lower the chances of getting HPV, if used with every sex act, from start to finish. Condoms may also lower the risk of developing HPV-related diseases (genital warts and cervical cancer). But HPV can infect areas that are not covered by a condom—so condoms may not fully protect against HPV.

People can also lower their chances of getting HPV by being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That’s why the only sure way to prevent HPV is to avoid all sexual activity.


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