Pediatric Annals

Healthy Baby/Healthy Child 

Human Papillomavirus and the HPV Vaccine: Where Are We Today?

Leah Khan, MD

Abstract

Vaccine discussions are an important part of the general pediatrician's day. The human papillomavirus (HPV) vaccine, in particular, has been slow to gain acceptance by the general public. It has recently gained momentum (both positive and negative) on social media, which has led to an increase in questions and concerns from families. It is important that providers are equipped to address these concerns, answer questions, and provide quality information for families to help guide them in their vaccination decisions. Not only is it crucial to be knowledgeable about the vaccines themselves, but providers should also be informed about HPV and its potential disease burden. The HPV vaccine recommendations are also evolving, so it is important to stay abreast with current data to provide the best care for all patients. [Pediatr Ann. 2017;46(1):e2–e5.]

Abstract

Vaccine discussions are an important part of the general pediatrician's day. The human papillomavirus (HPV) vaccine, in particular, has been slow to gain acceptance by the general public. It has recently gained momentum (both positive and negative) on social media, which has led to an increase in questions and concerns from families. It is important that providers are equipped to address these concerns, answer questions, and provide quality information for families to help guide them in their vaccination decisions. Not only is it crucial to be knowledgeable about the vaccines themselves, but providers should also be informed about HPV and its potential disease burden. The HPV vaccine recommendations are also evolving, so it is important to stay abreast with current data to provide the best care for all patients. [Pediatr Ann. 2017;46(1):e2–e5.]

Vaccines are an important topic in pediatric medicine and providers in primary care spend a great deal of time discussing immunization with families. Recently, the human papillomavirus (HPV) vaccine has become a popular topic in social media, resulting in increased attention and questions from families. This article reviews the most up-to-date information about the burden of HPV in our communities, the safety and efficacy of the vaccine itself, and the most recent recommendations for its use.

Human Papillomavirus

From the common childhood wart to cervical cancer, most people are affected by HPV at some point in their lives. It is the most common sexually transmitted infection (STI) in the United States.1 There are over 100 different types of HPV and although many of these infections are asymptomatic and resolve on their own, a small subset of these virus types account for many poor outcomes; this allows for more targeted prevention strategies.1

Each year in the US, 14 million people are infected with HPV2 and 27,000 people are diagnosed with cancer attributed to HPV.3,4 This leads to more than 4,000 US deaths each year.2 In addition to genital warts and cancer, HPV can cause other medical problems, including adenocarcinoma in situ, cervical intraepithelial neoplasia (precancerous lesions), and juvenile respiratory papillomatosis.4 These diseases can lead to procedures, hospitalizations, and chronic health problems, causing a burden on patients, their families, and the health care system. A 2012 study estimated a yearly direct medical cost burden of $1 billion for HPV-related cancers in the US. This does not include screening or treatment of other HPV-related diseases, which brings the total cost close to $8 billion per year.5

The HPV Vaccine

A vaccine for HPV was approved by the US Food and Drug Administration in 2006.1 The first form of the vaccine (HPV4) was initially approved for females only and covers HPV types 6, 11, 16, and 18.1,6 In 2009, HPV2 was approved for use in females, covering HPV types 16 and 18.1 HPV4 was then approved for use in males in 2009.1 Most recently, in December 2014, HPV9—with additional coverage of HPV types 31, 33, 45, 52, and 58—was approved for use in both males and females.1 HPV9 will act as a replacement for the HPV4 vaccine, which will be phased out. HPV types 6 and 11 account for 90% of genital warts, and types 16 and 18 account for 70% of all cervical cancer.1 In the most recent vaccine, the addition of another five HPV types broadens HPV coverage even further.1

The vaccine trials included more than 72,000 participants and researchers determined it to be safe and effective.7 Over 40 million doses of the HPV vaccines were given in the first 5 years of its use,3 and as of March 2016 more than 90 million doses have been distributed.8

Efficacy of the Vaccine

The HPV vaccine has been successful at reducing the number of cases of genital warts and cervical cancer.1,6 Recent data show that just 42% of females and 28% of males have received all three vaccine doses.9 Despite these low vaccine rates, a significant decrease in disease was seen. In fact, the prevalence of the HPV types covered by the vaccine decreased by 64% among cervical samples between prevaccine and postvaccine data.1,9 With increasing vaccine rates, even better results are expected in the future. Although more data are still needed to obtain conclusive results about other types of HPV-related illness (anal and oral cancer), it could be inferred that decreased rates of HPV overall would lead to decreased rates of these diseases as well.

Studies also find importance in the timing of vaccine delivery. Those who receive the vaccine earlier (between ages 11 and 15 years) produce a better immune response than patients who receive the vaccine when they are older (between ages 16 to 23 years).3 In fact, the younger age group has double the antibody response of their older counterparts.3 This information should be shared with families who are hesitant about vaccinating at the recommended age of 11 or 12 years. This difference in response to the vaccine has also contributed to new dosing guidelines that are discussed below. No waning protection is shown 8 to 10 years postvaccination.4

Safety and Vaccine Side Effects

More than 90 million HPV vaccines have been distributed, and the vaccine has been found to be safe and few significant side effects have been reported.8 The most common side effects seen are pain or redness at the injection site (63%–90%), headache (9%–10%), and fever (4%–10%).2 On rare occasions (<3%), other side effects have been reported such as dizziness, syncope, fatigue, nausea, abdominal pain, mouth pain, and induration or nodule at the injection site.7 Because these side effects are generally mild and self-limited, the benefits of the vaccination far outweigh the risks.

There are two groups in which the vaccine is contraindicated: (1) people who have had a significant reaction to a previous dose of the HPV vaccine or one of its components or have a severe allergic reaction to yeast; and (2) pregnant women as there are not enough data to support administering the vaccine during pregnancy.2,3

Recommendations for Vaccination

The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) recommend HPV vaccines for both male and female adolescents at age 11 or 12 years as part of the regular vaccine schedule.3 HPV2 and HPV4 are given as a three-dose series at 0, 1 to 2, and 6-month intervals.HPV2 is approved only for females and HPV4 is approved for both males and females. In October 2016, the ACIP released new recommendations for HPV9 dosing, which is approved for males and females.10 The ACIP now recommends that HPV9 be given as a two-dose series (at 0 and 6 months) in patients who receive the vaccine at age 9 to 14 years and as a three-dose series (at 0, 1 to 2, and 6 months) in patients who do not begin the series until age ≥15 years10 (Table 1). This new recommendation may improve vaccine rates and encourage families to begin the vaccine series at the recommended age of 11 or 12 years.

�A;Dosing Recommendations for HPV Vaccines

Table 1.

Dosing Recommendations for HPV Vaccines

Barriers to Vaccination

HPV is a widespread disease in the US and it can lead to devastating outcomes. Since the development and subsequent approval of the HPV vaccine in 2006, there has been a slow response to the vaccine in the community.1 As a result, vaccine rates are far below initial goals. This may be, in part, due to the novelty of the vaccine. Many families feel that the vaccine is “too new” and choose to wait for more information before vaccinating. The original three-vaccine recommendation has also proved challenging as repeat visits are required to complete the series. In addition, the Internet and social media have allowed misinformation to spread quickly and widely, increasing anxiety for families. Another barrier to vaccination is the association of this vaccine to a STI and how parents perceive that in relation to their children

Conclusion

The HPV vaccine shows great promise as a cancer-preventing vaccine.6 Despite low immunization rates, disease rates are falling and results are expected to continue to improve in the future.1 Healthy People 202012 set a goal of 80% of eligible males and females for complete vaccination with the HPV vaccine. There are many ways that providers can encourage more widespread acceptance of the vaccine to improve current vaccination rates.

Practitioners must be prepared to answer questions that families might have regarding vaccine safety and efficacy. With an ever-increasing pool of information on the Internet, it becomes the provider's role to highlight for patients and their families what is factual and what is misinformation. Another way to encourage vaccination is to present the HPV vaccine along with the other vaccines (often required for school) that are given at the recommended age. Finally, focusing the discussion on cancer prevention instead of STI prevention can help families feel more comfortable with having the vaccine administered to their younger children.

Providers can greatly influence patients' decisions to immunize by providing quality information and reliable resources to families so they can make an informed decision for their children (Table 2).

�A;Take-Home Points

Table 2.

Take-Home Points

References

  1. Centers for Disease Control and Prevention. Other sexually transmitted diseases. https://www.cdc.gov/std/stats15/other.htm#hpv. Accessed December 20, 2016.
  2. Centers for Disease Control and Prevention. Vaccine Information Statements. HPV (human papillomavirus) vaccine—Gardasil-9. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv-gardasil.html. Accessed December 20, 2016.
  3. Committee on Infectious Diseases. HPV vaccine recommendations. Pediatrics. 2012;129(3):602–605. doi:10.1542/peds.2011-3865 [CrossRef]
  4. Human papillomaviruses. In: Kimberlin DW, Long SS, Brady MT, Jackson MA, eds: Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015: 576–583.
  5. Chesson HW, Ekwueme DU, Watson M, Low DR, Markowitz LE. Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine. 2012;30(42):6016–6019. doi:10.1016/j.vaccine.2012.07.056 [CrossRef]
  6. Petrosky E, Bocchini JA Jr, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee of Immunization Practices. MMWR Morb Mortal Wkly Rep. 2015;64(11):300–304.
  7. American Academy of Pediatrics. The AAP and HPV vaccine safety: frequently asked questions. https://www.aap.org/en-us/Documents/hpv_vaccine_safety_faq.pdf. Accessed December 16, 2016.
  8. Centers for Disease Control and Prevention. Frequently asked questions about HPV vaccine safety. http://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html. Accessed December 16, 2016.
  9. Jenco M. ACIP updates recommendations on HPV, HepB, MenB vaccines. http://www.aappublications.org/news/aapnewsmag/2016/10/20/acip102016.full.pdf. Accessed December 16, 2016.
  10. Palefsky JM. Epidemiology of human papillomavirus infections. http://www.uptodate.com/contents/epidemiology-of-human-papillomavirus-infections. Accessed December 16, 2016.
  11. Centers for Disease Control and Prevention. Immunization schedules: for health care professionals. https://www.cdc.gov/vaccines/schedules/hcp/. Accessed December 16, 2016.
  12. HealthyPeople.gov. Healthy People 2020. Immunization and infectious diseases. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives. Accessed December 20, 2016.
  13. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/nhanes.htm. Accessed December 20, 2016.

Dosing Recommendations for HPV Vaccines

Vaccine Type Population Dose 1a Dose 2 Dose 3
HPV2 Females Age 11 or 12 yearsb 1–2 months after first dose 6 months after first dose
HPV4 Females Males Age 11 or 12 yearsb 1–2 months after first dose 6 months after first dose
HPV9 Females Males Age 11 or 12 yearsb If given at age <15 years, 6 months after first dose If given at age ≥15 years, 1–2 months after first dose Not applicable 6 months after first dose

Take-Home Points

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HPV is widespread and nearly everyone will have some form of it in their lifetime1

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Three vaccines are available1,6 <list-item>

HPV2 (covering types 16 and 18)

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HPV4 (covering types 16, 18, 6, and 11)

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HPV9 (covering types 16, 18, 6, 11, 31, 33, 45, 52, and 58)

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Types 6 and 11 account for 90% of genital warts and types 16 and 18 account for 70% of cervical cancer1,3

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The National Health and Nutrition Examination Survey13 showed a significant drop in HPV in cervical samples between prevaccine and postvaccine years. This was despite low vaccine rates

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All three vaccines are given at 0, 1–2, and 6-month intervals except for HPV9, which if given between ages 9 and 14 only requires two doses at 0 and 6 months2,9

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Common side effects are pain and redness at the injection site, headache, and fever2

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It is increasingly important for providers to stay informed about HPV and the vaccine itself to help patients make informed decisions based on quality information

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Authors

Leah Khan, MD

 

Leah Khan, MD, is a Pediatrician, Park Nicollet Clinics.

Address correspondence to Leah Khan, MD, 300 Lake Drive East, Chanhassen, MN 55317; email: leahdkhan@gmail.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20161216-01

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