A pediatrician weighs in on human papillomavirus vaccination.
If you have sex now, had sex in the past or will have sex in the future, there's an excellent chance you've had, have or will someday have human papillomavirus (HPV), the sexually transmitted infection that is linked to several cancers. The Centers for Disease Control (CDC) estimates that as many as 80 percent of people in this country — women and men — will contract HPV during their lifetimes.
Fortunately, the approval in 2006 of two HPV vaccines, Gardasil and Cevarix, by the Food and Drug Administration has helped reduce infections with the strains of HPV that can cause cervical, anal, vulvar and vaginal cancers, as well as cervical dysplasia (abnormal changes in the cells on the surface of the cervix that can lead to cancer) and genital warts. For instance, the Journal of Infectious Diseases recently published data that in girls and women ages 14 to 19, infection rates for the strains of HPV targeted by the vaccine went from 11.5 percent between 2003 and 2006 to just 5.1 percent between 2007 and 2010.
But due to controversy about vaccinating young people against a sexually transmitted infection and parental concerns about possible long-term effects of these relatively new vaccines, many children, teens and young adults aren't getting vaccinated, leaving them vulnerable to future HPV infection. Discover Rush Online recently sat down with Karen Lui, MD, a pediatrician at Rush University Medical Center, to discuss this prevalent infection — and to clear up some common misconceptions about HPV vaccination.
Q: Why is it necessary to protect against HPV infection?
A: Let me start by explaining that about 99 percent of the time, HPV infections will clear up on their own within two years; the immune system will simply rid the body of the infection. So the vast majority of the time, people don't know they even have HPV and there are no long-term consequences. That's the good news. Unfortunately, when the body doesn't banish the infection on its own, you're at risk for some potentially serious problems. Of the more than 40 strains of HPV, there are four specific strains — 6, 11, 16 and 18 — that the vaccines are designed to prevent. These are the strains that cause genital warts and are linked to cervical cancer, vulvar cancer and vaginal cancer in women as well as anal, penile and oropharyngeal cancers in men. (The oropharynx is the middle part of the throat, including the base of the tongue, tonsils, soft palate and the walls of the pharynx.)
One of the concerns about HPV is that unless you have visible symptoms like genital warts, or unless a PAP test reveals an abnormality in the cervical cells, you won't realize you are infected. And if you are sexually active after you become infected, there's a good chance you will infect your partner or partners. It's a stealthy infection, and there's no cure for it. That's why prevention is so important.
Q: Is the vaccine the best way to keep from getting HPV?
A: I look at HPV prevention as having multiple components. The first is definitely the vaccine. If possible, get vaccinated before you become sexually active because the vaccine can't treat HPV if you already have it. In addition, I recommend using condoms during sex. As with other sexually transmitted infections, all it takes is one time and one partner to get HPV, and condoms are a good protective step for preventing not only HPV, but many other STIs as well, including HIV, gonorrhea and chlamydia. They're also obviously a good way to prevent unwanted pregnancies.
Q: So can't you just use condoms? Why take the extra step of getting the vaccine?
A: You should protect yourself as many ways as possible. The vaccine and condoms should go hand in hand, because both are excellent ways to prevent the spread of HPV, but neither one is 100 percent. While studies have shown that using a condom properly and consistently — meaning every single time you have sex — can reduce HPV transmission, any area of the penis not covered by the condom can be infected by the virus. Plus, while the infection is most commonly passed by vaginal or anal sex, you can also transmit it during oral sex and skin-to-skin contact, and in those cases a condom isn't going to protect you at all. That's where the vaccine can help safeguard you.
It's also important for women, even after you've been vaccinated, to get your annual PAP tests starting when you're 21 to check for any cervical abnormalities resulting from HPV infection, including precancerous lesions. There are about 19,000 HPV-related cancers in women in the U.S. each year, and screening is the best way to catch these cancers early.
Q: At what age should you vaccinate for HPV?
A: The vaccination is a series of three shots over about a six-month span. We can start the series as early as nine, but we usually start around age 11. Fortunately, the vaccine is covered by most health insurance plans up to age 26, so if you missed getting it as a child, you do have some time to go as an adult. But as I mentioned earlier, it's most effective to vaccinate before a person has sex for the first time. Some kids will start to be sexually active in their early teens, so 11 is usually a good time to vaccinate. I have definitely given the vaccine to some 9-year-olds, and that's usually when there's some kind of family history of cervical cancer — typically an aunt or grandmother — and the parents come to me and ask me for the vaccine. I'm more than happy to give it early. You should talk with your pediatrician or primary care doctor; if there's a history of cervical cancer, you may decide to protect your kids as early as you can.
Q: The recommendations recently changed so boys can now start getting the HPV vaccine at 11. Why should boys be vaccinated at all?
A: Well, in addition to preventing genital warts, studies have shown that the HPV vaccine can help prevent anal cancer in men. If you can do something to reduce your chances of getting cancer, why wouldn't you? Research may ultimately show that the HPV vaccine also protects against penile and oropharyngeal cancers. If it does, that would be a huge finding because according to the National Cancer Institute, more than half of all oropharyngeal cancers are linked to HPV, and by 2020 HPV is projected to cause more oropharyngeal cancers than cervical cancers in the U.S. However, we just don't know yet whether the vaccine will safeguard against these two specific cancers. Only time — and further research — will tell.
In the meantime, there's another compelling reason to give boys the HPV vaccine: A lot of girls still aren't getting the vaccine. Despite studies showing that the vaccine works well and is safe, only about one third of girls ages 13 to 17 in the U.S. have received all three shots. So if you can vaccinate boys, you can help prevent them from contracting HPV infection and, subsequently, from spreading it to their current and future sexual partners. When you protect the boys, you're also protecting girls.
Q: In your experience, what are the biggest concerns parents have about the vaccine?
A: One of the main concerns parents have brought up to me is that the vaccine will give their child HPV. They say, "You're injecting the virus into the body. Won't that give them HPV?" That's a common misconception. I explain to the parents that there is no viral DNA in an HPV vaccine, so there is no way for the vaccine to infect any of the cells and replicate the way a virus does; in other words, it can't cause a disease. Like a lot of other vaccines, when the HPV vaccine is injected into the body, your body will try to respond to it and make a bunch of antibodies to fight it. Those antibodies will safeguard you against HPV infections. So that's the concern I hear the most.
Another common concern is that it's one of the newest vaccines — for girls and women, it's been recommended since 2006, but in boys and men, although we were allowed to start using it in 2009, it was not officially recommended until 2011 — so parents are worried that we don't have any long-term studies to prove it's safe. They're worried that they'll vaccinate their kids now and something bad will happen later in life.
It's a valid concern. But I try to explain that the studies have been going on for years and years, so we're starting to get more data. And we wouldn't really put out a vaccine if we didn't think it was safe. So far, the main side effects are very similar to the other vaccines we give: the most common is pain at the injection site, like tetanus, where it can make your arm throb a little bit. And it can cause a little bit of fever and sometimes a headache, which a lot of the other vaccines can cause. And then there's been some fainting — that can be scary, but seems to be more from the needle than the vaccine. For all vaccines, but for this one especially, there are databases where you call in if there are any side effects so the CDC can keep track of how people are responding and so far, nothing truly concerning has come up.
Sometimes it helps to tell parents that I've had the HPV vaccine, and I wouldn't recommend something for their children that I wouldn't get myself.
Q: What advice do you give parents who want to discuss the HPV vaccine with their kids?
A: I tell parents that starting around 11 or 12, when boys and girls are entering adolescence, they should start talking to their kids about sex if they haven't already. The schools will start talking about sex around that time, and some kids will start to become sexually active. I tell parents they should try to have an open conversation about sex and everything that goes along with it, including the risks. I recommend telling your child that you don't think he or she should be having sex at such a young age, but that when they do start considering it, they need to know some of the potential consequences. It can be a very broad, general discussion, but HPV should be included, along with chlamydia and gonorrhea and pregnancy — and, of course, HIV/AIDS. Parents must stress to their kids that condoms are not just important, but absolutely essential. You can contract HPV during your first sexual encounter or your 20th, and you can get it even if you've been monogamous and had sex with only one person. It's so common. Of course, a large percentage of people will just get rid of the virus by themselves. But we don't know who will and who won't.
Q: You mentioned that the vaccine protects against genital warts. Why is it important to prevent them? Are they linked to cancer?
A: Fortunately, genital warts are unrelated to cancer, but they are bothersome, and they're extremely difficult to get rid of. Even if you remove them with surgery, ablation or different topical treatments, they can come right back. Like herpes, genital warts will come and go and may plague you for the rest of your life. Most people picture them to be like the warts you get on your fingers or toes. But usually all I have to do is show people pictures of genital warts and that’s enough to encourage them to at least consider the vaccine more seriously.
Q: What if a parent doesn't want their child to get the vaccine but the child wants it?
A: I've actually had that happen several times. I encouraged the kids to have an ongoing, open conversation with their parents about their wishes. But I told them once they turn 18 or when they get their own health insurance, go ahead and get vaccinated, because they can still get it up until they're 26. It's hard for some kids to admit to their parents that they're sexually active or are considering it. But it's important to be honest with your parents and tell them that you want to protect yourself. A couple of times, the parents changed their minds during the appointment and said, "OK, if you want it, we can do it."
Parents need to understand that just because their kids want the HPV vaccine, it doesn't mean they're promiscuous, or even that they plan to start having sex right away. They're talking about doing something now that can help keep them safe for the rest of their lives — and as parents, that's all we really want for our children.
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- Read an online Q&A with gynecologic oncologist Alfred Guirguis, DO , in which he answers questions about the HPV vaccine, cervical cancer, ovarian cancer, progesterone and minimally invasive hysterectomies.
- It doesn’t offer the HPV vaccine, but Rush’s Travel Medicine and Immunization clinic provides comprehensive services for international travelers of all ages, including a full range of pre-trip immunizations and after-trip care.Learn more about the clinic.
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Please note: All physicians featured in Discover Rush Online are on the medical faculty of Rush University Medical Center. Some of the physicians featured are in private practice and, as independent practitioners, are not agents or employees of Rush University Medical Center.
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