HPV vaccine effective but grossly underutilized

Friends, this is a really great read. -- Dr. Dale

HPV vaccine effective but grossly underutilized

http://www.post-gazette.com/stories/news/health/hpv-vaccine-effective-but-grossly-underutilized-698118/

August 5, 2013 12:03 am

By Monica Disare / Pittsburgh Post-Gazette

When Kathy Hixenbaugh of South Fayette heard about the HPV vaccine from her son's pediatrician, she thought about it, talked to her 13-year-old son and together they decided to have him vaccinated.

But a recent report from the federal Centers for Disease Control and Prevention titled, "HPV vaccine: Safe, effective, and grossly underutilized" claims that not enough parents are making the same decision.

"There is no doubt in my mind that the vaccine is underutilized," said Jonathan Pletcher, clinical director for the division of adolescent medicine at Children's Hospital of Pittsburgh of UPMC, "I think there's generally a lack of understanding about HPV."

Human papillomavirus or HPV is one of the most common sexually transmitted diseases in the country. The vaccine, approved by the Food and Drug Administration in 2006 for females ages 9 to 26 and administered in three shots over six months, protects against four strains of HPV; two of these strains account for about 70 percent of all cervical cancers, as well as cancer to the vagina and vulva. The two others cause 90 percent of genital warts. HPV also is linked to anal cancer.

In 2009, the FDA recommended that males ages 9 to 26 also receive the three-shot vaccination. Men can develop genital warts or cancer of the penis, anus or oropharynx (the back of the throat) from HPV. Males also help spread HPV to their female partners

"Boys are at risk, boys are carriers, [so] it's a no-brainer," Dr. Pletcher said.

Children are encouraged to get the vaccine starting at ages 11 or 12 before they become sexually active to protect against infection.

According to the new study, HPV vaccination rates in girls ages 13-17 years failed to increase between 2011 and 2012, and three-dose coverage declined slightly from 2011 to 2012.

HPV is present in 79 million Americans, although not all cases develop into cancer. In 2009, the most recent year for which statistics are available, according to the CDC's website, 12,357 women in the United States were told they had cervical cancer, and 3,909 died from the disease.

According to the CDC, for each year that the three-dose HPV vaccine series coverage remains near the current level of 33 percent, an additional 4,400 women will be diagnosed with cervical cancer and 1,400 cervical cancer-attributable deaths will occur in the future.

Some experts believe that parents aren't receptive to the vaccine because they are just uncomfortable thinking about their young children becoming sexually active.

When Mrs. Hixenbaugh talked to another parent about the HPV vaccine, the parent said her son would not receive the shot because he was not going to have sex until he was married, she said.

"Parents don't want to talk about sex and their kids," she added. "Honestly, to think that kids aren't going to have sex is ridiculous."

Doctors also need to debunk the belief by some parents that the HPV vaccine encourages promiscuous sex while at the same time they explain the potential health benefits, said Thomas Krivak, director of the clinical research division of gynecological oncology at the Allegheny Health Network.

"HPV is associated with sex, and I think that that gets polarizing," Dr. Krivak said. "I don't think that anyone says after you finish her three-shot course it's OK for you to go have sex, [so] go have sex with 15 different people."

He added that while there are both benefits and risks to any type of medical procedure, vaccines play an important role in public health. According to the CDC's report, in the seven years that the HPV vaccine has gone through safety monitoring and evaluation, no serious safety concerns have been identified. The number of adverse events following the vaccine has decreased from 2008-12.

Others feel that a pediatrician's relationship with the family is the missing link in improving the HPV vaccination rate. The problem is that only about 60 percent of teenagers see their pediatrician annually, said Joseph Aradri, a doctor of osteopathic medicine and president of Pediatric Alliance in Green Tree.

While most pediatricians support the use of the HPV vaccine, some underplay the importance of the three-shot course, Dr. Pletcher said.

The CDC's 2012 National Immunization Survey-Teen data show that not receiving a health care provider's recommendation for HPV vaccine was one of the five main reasons parents reported they did not vaccinate their daughters.

Mrs. Hixenbaugh also pointed out that, from a practical standpoint, the vaccination requires three trips to the doctor's office, which makes it inconvenient.

The trend to have fewer HPV vaccinations has been observed in some, but not all, quarters of Pittsburgh. The number of people who received the HPV vaccination at the Allegheny County Health Department has decreased. In 2010, 758 vaccinations were administered, in 2011 that number increased to 923 and then in 2012 it dropped to 465, said Ronald Voorhees, acting director of the health department.

He added that this number does not necessarily reflect whether Allegheny County as a whole is getting fewer vaccines because residents may be vaccinated at private practices.

There also is a segment in the Pennsylvania population that is anti-vaccine, said Dr. Krivak, which may be driving some of these trends.

However, the number of people who were vaccinated at the Pediatrics Alliance Arcadia office in McCandless is on track to increase this year. The number of HPV vaccinations given in 2011 was 122. It shot up to 243 in 2012 and is currently at 159 in 2013 with five months left to go. This means that the office will likely give more HPV shots than in 2012, said Bill Coppula, a physician at the Arcadia office. Dr. Coppula added that he is encouraged by the progress in HPV vaccination but that he hopes the number of people receiving the vaccine will continue to increase.

As an additional boon, the shot is usually covered by insurance. According to the CDC report, because of the Affordable Care Act, most private health insurance plans must cover the full cost of HPV vaccine without a co-pay or deductible.

But for those who have decided to vaccinate their children, the matter boils down to a simple calculation.

"If there's something out there that I can do to protect my child from the potential for cancer, I feel like I need to do that as a parent," said Paula Krivak of Ohio Township, who is Dr. Krivak's wife and decided to have both her son and daughter vaccinated.

Monica Disare: mdisare@post-gazette.com.

Study Ties Poor Oral Health to Cancer-Causing Virus

A couple weeks ago I blogged about Oral Health and its link to HPV.  Here it is again in the New York Times.  Such a great read.  -- Dr. Dale ----------

http://well.blogs.nytimes.com/2013/08/21/study-ties-poor-oral-hygiene-to-cancer-causing-virus/?ref=health&_r=0

AUGUST 21, 2013, 1:09 PM

Study Ties Poor Oral Health to Cancer-Causing Virus

By CATHERINE SAINT LOUIS

People with swollen gums, missing teeth and other signs of poor dental health are more likely to be infected orally with the human papillomavirus, researchers reported on Wednesday.

HPV, a sexually transmitted virus, causes cancers of the cervix, mouth and throat. The new study, published in Cancer Prevention Research, is the first to document a link between the infection and poor oral health, but other experts noted that the research found only an association and relied mostly on self-reported data about oral health. It is too early to say with confidence that brushing and flossing regularly can prevent oral HPV infection, they said.

The finding is a “modest association,” said Aimée R. Kreimer, an epidemiologist at the National Cancer Institute who was not involved in the study. “We don’t know if poor oral health causes HPV infection and would go on to cancer,” she said.

This finding suggests another potential downside to deficient hygiene “because of a possible association between poor to fair oral health and the presence of the human papillomavirus, which in itself is identified with several diseases,” said Dr. Sol Silverman, a professor of oral medicine at the University of California, San Francisco, and a spokesman for the American Dental Association.

Researchers at the University of Texas Health Science Center at Houston reviewed data on both high-risk and low-risk oral HPV infection and oral health in 3,439 adults, ages 30 to 69, participating in the nationally representative 2009-10 National Health and Nutrition Examination Survey, known as NHANES. The study found that being male, smoking cigarettes, and having multiple oral sex partners increased the likelihood of oral HPV infection, findings similar to those in an earlier analysis of NHANES data.

But after controlling for smoking and the number of oral sex partners, the new study found that self-rated poor oral health was an independent risk for oral HPV infection. The odds of having an oral HPV infection were 55 percent higher among those reporting poor to fair oral health.

Throat cancer caused by HPV is increasing, particularly along middle-aged white men. About 25,000 cases a year are diagnosed in the United States. Many experts believe oral infection with the virus has increased along with the frequency of oral sex.

“What we think might be happening is if you have poor oral health — ulcers, gum inflammation, sores or lesions, any openings in the mouth — that might provide entry for HPV,” said Christine Markham, the second author on the paper and an associate professor of health promotion and behavioral sciences at the University of Texas Health Science Center at Houston. “We don’t have sufficiently strong evidence to demonstrate that conclusively in the study, but that’s our thinking.”

Yet the increase in risk is modest, said Dr. Kreimer, “less than the two- to threefold elevations in risk that cause concern.” And three of the four measures used to assess the participants’ oral health, including the presence of gum disease, were self-reported, a limitation of the study. One measure — number of teeth lost — was reported by dental hygienists.

“It’s the first paper linking self-reported measures of poor oral hygiene and an oral HPV infection,” Dr. Maura L. Gillison, a professor of medicine at Ohio State University, who was not involved in the study. “It’s a strong paper because it’s a first, but does it have public health significance? Should people change their behavior? I would say no.”

Oral cancers caused by HPV are typically found near the tonsils or at the base of the tongue, she added, and it’s hard to see how those regions could be directly affected by periodontal inflammation.

Experts including Dr. Gillison nonetheless called the study an important first step. “Further study — even though it would be expensive and time-consuming — should be considered,” said Dr. Silverman.

If you’re gay and you know it clap your hands. AND THEN READ THIS!

Happy Cervical Health Awareness Month! Wait. What? January is Cervical Health Awareness Month.  As an M.D. specializing in HPV, how can I not spend some time honoring such an important health topic.

HPV, the virus underlying genital warts and anal cancer in men, is one of the most commonly treated areas in my office.  Even though much of the HPV talk in the news is concerned around women and cervical cancer, there are many concerns that affect men.

Are you gay?  Or bisexual?  According to the Center for Disease Control and Prevention, you are 17 times more likely to develop HPV-related anal cancer than heterosexual men.  Why?  Well, anal cancer is one hint.  Also, “men with weakened immune systems, including those who have HIV, are more likely than other men to develop anal cancer.  Men with HIV are also more likely to get severe cases of genital warts that are harder to treat.”

In a study from 2011, it was found that more than 50% of men over the age of 15 have been infected with HPV.  The study also stated that “each year roughly 6% of men will contract a new infection of the strain that is most associated with cervical cancer in women — HPV 16.”

It’s important to know that although the overall rates of cancers are declining, the National Cancer Institute states that HPV cancers are on the rise.

PLEASE come see me if you have any questions or concerns about HPV, or if you notice anything abnormal about your body.  You can ask me anything.

I’ve saved many lives and will continue to spread the word to educate my patients, friends, family and the internet.   Don’t be afraid.

I got you!

— Dr. Dale

l