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A Word from Dr. Pfenninger: Updated guidelines for HPV vaccination

I understand that the majority of readers of this column are not teenagers. Teenagers are rather oblivious to their need for preventive health practices. After all, they are going to live forever!
Parents of teenagers are in their 30s and 40s. They don’t often read the paper, either. So, grandparents, I’m relying on you to help spread the word that vaccines to prevent cancers from the human papillomavirus (HPV) are essential. The Center for Disease Control and the American Cancer Society have made it easier to comply, since recommendations have been reduced from three shots to two.


The first human papillomavirus vaccine (Gardasil 4) was introduced in 2006. It was also the first vaccine specifically created to prevent cancers. It is estimated that 30,700 cancers are attributable to the HPV (wart) virus every year in the United States. It is not required that cancer specimens be tested for HPV. However, a study showed that 91 percent of cervical cancers, 69 percent of vulvar cancers, 75 percent of vaginal cancers, 63 percent of penile cancers, 89 percent of anal cancers in males, 93 percent of anal cancers in females, and 72 percent of oral pharyngeal (mouth and throat) cancers in males (63 percent in females) are from the HPV virus. HPV is sexually transmitted and society’s more casual attitude toward sex has promoted the spread of HPV and the subsequent cancers. The majority of these cancers are preventable if youth are vaccinated before their first sexual exposures.


The CDC estimates that 14 million people become infected with HPV annually. Luckily, the majority of time, the virus is cleared by the immune system. Some HPV infections lead to genital warts (condyloma), while others cause cancer. In some estimates, 70 to 80 percent of adults have had exposure to the genital types of the HPV virus. There are over 100 types of HPV and only a small portion cause cancer. Most, like those that cause warts on the hands and feet, are not associated with any type of cancer.
When Gardasil 4 was introduced, it provided an unprecedented opportunity. It prevented 75 percent of anal/genital cancers and 95 percent of genital warts. Now, Gardasil 9 has been approved, which prevents infection from nine different HPV types. Approximately 95 percent of all genital warts and 95 percent of all sexually-transmitted cancers are able to be prevented.


The vaccines have been studied extensively since their introduction. There are no significant short-term complications (just the pain at the injection site), nor any long-term complications. They do not increase sexual promiscuity or earlier introduction to sex. One preliminary study in Europe has shown that the girls/women who first received the vaccine have now experienced a 28 percent decrease in auto-immune disease incidence.
With the recent research, and the fact that Gardasil 9 is the only HPV vaccine being made in the U.S. now, the Advisory Committee on Immunization Practices of the CDC has updated the guidelines for the vaccine. Children nine to 14 years old should receive HPV vaccine on a two-dose schedule, rather than a three-dose one, which was previously recommended. After receiving the first dose, the second dose is administered six to 12 months later. The protection achieved is as good with the two-dose regimen as with the three-dose regimen, as long as the vaccines are given before 15 years of age. Younger recipients have a more robust antibody response. So, the optimal time to receive it is at ages 11 to 12 for both sexes. However, vaccination as young as age nine is recommended if a child has been sexually abused or assaulted. For those who do not receive the vaccine by age 15, catch-up vaccinations are recommended through age 26. However, these people need three doses.


People who are in any way immune-suppressed should also obtain the three-dose regimen.
Receiving this vaccine can prevent most cervical, vulvar, vaginal, penile, and oral/pharyngeal cancers, as well as genital warts.
Ninety-eight percent of those receiving the two-dose regimen became protected against all HPV types in the vaccine within four weeks after receiving the vaccine. People who have started a vaccine series with either the Gardasil 4 or the Gardasil 9 can complete the series with the Gardasil 9. For those who received the Gardasil 4 recommended series, there is no need to receive the Gardasil 9. Age of receipt of the first dose determines whether two or three doses are needed. It is especially important that men 26 and under who have sex with men undergo routine HPV vaccination. Transgender persons should be routinely vaccinated against HPV, following the regimen for all adolescents.
The HPV vaccine is not used for any treatment. It only works for prevention of infection.
Parents and grandparents, you need to be sure that your children/grandchildren are receiving the HPV vaccine. The two-dose vaccine, with expanded coverage, makes it much easier to comply with recommendations and is more cost-effective.


In 1986, one of my main interests became the evaluation of abnormal Pap smears (which are the result of HPV) with colposcopy and I was fascinated by the developing story of the connection between the human papillomavirus and cancer. I remember speaking to many physician audiences saying, “In the future, we will have a vaccine against this virus and these cancers.” I am blessed to be living in the future. What I do not understand is how some will not take advantage of the amazing advances we’ve seen in medical care and the protection HPV vaccine can provide.


Dr. John L. Pfenninger’s column appears on Sundays. His office, Medical Procedures Center, is located in Midland.

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