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HPV Vaccine: A Coed Approach

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Now that HPV vaccine has been recommended as part of routine vaccination in boys, will uptake rates improve, or will parental objections continue to limit its use, as has happened in girls?


 

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.”

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

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