HPV Vaccine for Boys Reduces Incidence of Genital Warts and Cancer

A couple taking a funny picture with their car. (iStockphoto)

In 2008, in one of my columns, I wrote about the importance of vaccination against human papillomavirus (HPV) infection. It is beneficial to young teens before they have had sexual contact. The vaccine has demonstrated high level of antibody response amongst teens who have not been exposed to the virus. Initially the target group was young girls. By preventing HPV infection, we can prevent deaths from cervical cancer.

The vaccine is almost 100 per cent effective against four types of HPV, two of which are responsible for 70 per cent of all cervical cancers. The vaccine may have cross-protection against some other HPV viruses. Unfortunately, HPV infection can occur with the first sexual intercourse, and half of Canada’s young women become sexually active by age 16.

In 2007, Australia became one of the first countries to implement a nationally funded HPV vaccination programme for girls and young women. An editorial in the British Medical Journal published on April 18, 2013 titled, “HPV vaccination – reaping the rewards of the appliance of science,” lauds the Australian effort and its success. The analysis of data on 85,770 new patients from six Australian sexual health clinics showed a remarkable reduction in the proportion of women under 21 years of age presenting with genital warts – from 11.5 per cent in 2007 to 0.85 per cent in 2011.

The near eradication of genital warts in young Australian women will probably have a major impact on the costs of sexual healthcare. Now it is time for the boys to do something about sexually transmitted infection. Many young boys are sexually active. They show up with venereal warts from HPV infection. Kudos to Prince Edward Island (PEI). It has become the first Canadian province to extend publicly funded school-based HPV vaccination to boys, as reported by the Canadian Press on April 19, 2013.

In 2007, the National Advisory Committee on Immunization (NACI) recommended that girls and women aged nine to 26 be vaccinated for HPV. In 2012, NACI included males of the same age in that recommendation to prevent genital warts and anal-genital cancers.

On April 25, 2013 the Canadian Press (CP) reported a policy statement released by the Society of Obstetricians and Gynecologists of Canada asking provincial and territorial governments to extend HPV vaccination programs to cover boys as done by PEI. Common sense would say that it is difficult to justify not offering boys the same protection as girls get.

CP report says provinces and territories have been slow to follow the advice, given the high cost of the vaccines, which are administered in three doses. A full course of HPV vaccine costs between $400 and $500 if purchased outside the provincial programs, where the shots are provided for free. But the experts say health care cost savings from reduction of genital warts and its consequence over months and years should take care of the cost of the vaccine.

It is time boys get the same protection as girls.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Preventing Cervical Cancer – New Guidelines Published in 2013

Pap smear micrograph showing a high-grade squamous intraepithelial lesion (HSIL). (Copyright 2010 Nephron. Permission is granted to copy, distribute and/or modify this image under the terms of the GNU Free Documentation License Version 1.2 or any later version published by the Free Software Foundation.)
Pap smear micrograph showing a high-grade squamous intraepithelial lesion (HSIL). (Copyright 2010 Nephron. Permission is granted to copy, distribute and/or modify this image under the terms of the GNU Free Documentation License Version 1.2 or any later version published by the Free Software Foundation.)

Every woman should know it is important to have regular Pap smear test. Since World War II, the test has been the most widely used and successful cancer screening technique in history. It is named after the Greek doctor who invented it – Dr. George Nicholas Papanicolaou.

An article in the Canadian Medical Association Journal (CMAJ January 8, 2013) says, “The incidence of and mortality due to cervical cancer in Canada have decreased substantially in the past 50 years, and long-term survival rates after treatment are high. Lifetime incidence was 1.5 per cent in 1972, and is now 0.7 per cent; risk of death from cervical cancer is now 0.2 per cent. Most advanced cervical cancer (and associated mortality) occurs among women who have never undergone screening or who have had a long interval between Papanicolaou (Pap) tests.”

For example, in 2011, an estimated 1300 new cases of cervical cancer were diagnosed in Canada, with about 350 deaths. The risk increases after age 25 years and older, peaking during the fifth decade of life.

Pap smear test helps pick early lesions before they become cancerous. This means less invasive treatment is required and the prognosis is better. In the same issue of the CMAJ, the Canadian Task Force on Preventive Health Care has published new guidelines for Pap smear test. These guidelines, which are based on the current scientific evidence, are as follows:

-For women aged less than 20 years, no routine screening for cervical cancer. (Strong recommendation; high-quality evidence)

-For women aged 20-24 years, no routine screening for cervical cancer. (Weak recommendation; moderate-quality evidence)

-For women aged 25-29 years, routine screening for cervical cancer every three years. (Weak recommendation; moderate-quality evidence)

-For women aged 30-69 years, routine screening for cervical cancer every three years. (Strong recommendation; high-quality evidence)

-For women 70 years of age or older who have undergone adequate screening (i.e., three successive negative Pap test results in the last 10 yr), routine screening may stop. For all other women 70 years of age or older, should continue screening until three negative test results have been obtained. (Weak recommendation; low-quality evidence)

Where the recommendations are weak, the decision to undergo Pap smear test depends if the health care provider and the patient think that there is an indication to do one. If the woman is sexually active, she has multiple partners or she has sexually transmitted infection then there would be an indication to do one. One drawback with these updated recommendations is they do not address screening with tests for human papilloma virus (HPV), because there is not yet sufficient data on its effect on mortality and incidence of invasive cancer, says the article.

In a commentary related to the guidelines, Dr. Janet Dollin says, “When Dr. Georgios Papanicolaou developed his famous test in the 1940s, we did not know that cervical cancer is a preventable sexually transmitted infection.” The role of cancer causing virus like HPV was not known. We now know infection with specific strains of HPV is a necessary precursor to cervical cancer. Some of these viruses cause genital warts – another sexually transmitted infection.

Dr. Dollin says, “Indeed, improving uptake and access to HPV vaccination and cervical screening would do more to lower the rates of cervical cancer than deciding at what age to start Pap testing and how frequently it should be done.” The National Advisory Committee on Immunization (NACI) recommends the vaccination of boys and girls to prevent the burden of HPV disease.

Dr. Dollin says that the US Preventive Services Task Force recommends screening for women aged 21-65 years with a Pap every three years or, for women aged 30-65 years who want to lengthen the screening interval, a combination of Pap and HPV testing every five years.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

What Women Should Know About HPV Vaccination?

Vaccination against human papillomavirus (HPV) infection is being promoted as beneficial to young teens before they have had sexual contact. The vaccine has demonstrated high level of antibody response especially in women who have not been exposed to the virus. Hence the target group is young girls. By preventing HPV infection, we can prevent deaths from cervical cancer.

The vaccine is almost 100 per cent effective against four types of HPV, two of which are responsible for 70 per cent of all cervical cancers. The vaccine may have cross-protection against some other HPV viruses.

Most common side-effect is pain at the injection site. Otherwise, it is a safe vaccine except recently, concern has been expressed as some cases of anaphylaxis have been reported. Usually, anaphylaxis due to any vaccination is rare, with an estimated incidence of 0.1–1 per 100,000 doses.

Anaphylaxis is a severe acute allergic reaction that is sudden in onset. The skin symptoms are the most common, followed by breathing difficulties and then trouble swallowing. The person goes into shock and by that time it may be too late to save life. Anybody who is in the business of providing vaccinations should be prepared to deal with anaphylaxis. An individual, after receiving any vaccination, should be observed at least for 15 minutes.

In the September 9 issue of Canadian Medical Association Journal (CMAJ), the subject of anaphylaxis after HPV vaccination has been discussed in detail.

A study done in Australia reported that from the 269,680 HPV vaccine doses administered in schools, seven cases of anaphylaxis were identified, which represents an incidence rate of 2.6 per 100,000 doses. They found this to be higher than comparable school-based delivery of other vaccines. The article says, “However, overall rates were very low and managed appropriately with no serious sequalae.” Identified cases of anaphylaxis following vaccination tend to occur less than one hour after vaccination.

The experts do not know why these girls had adverse reactions to the vaccine. The authors of the Australian study say that the estimated rate of anaphylaxis following quadrivalent HPV vaccine was significantly higher than identified in comparable school-based delivery of other vaccines. However, overall rates were very low and managed appropriately with no serious sequelae. None of the patients went into shock. That is good news.

According to CMAJ, in the United States, 15 cases of anaphylaxis or anaphylactoid reactions following HPV vaccination were reported to the Vaccine Adverse Events Reporting System in 2007. As of July 21, 2008, 11 cases have been reported in 2008. Over 13 million doses of this vaccine had been distributed as of the end of 2007. Although there may be underreporting, the rate of about one case per one million vaccinations is consistent with the rate of anaphylaxis following several other vaccines.

People opposed to this program would like to delay immunization until a young woman is sexually active. Unfortunately, HPV infection can occur with the first sexual intercourse, and half of Canada’s young women become sexually active by age 16.

What about the boys? Some young boys are sexually active as well. They show up with venereal warts from HPV infection. CMAJ says Canada and other industrialized countries (except for Australia) have only approved vaccination for females thus far, because studies involving males have not been completed. Hence, for now, only immunized women will be protected.

Finally, there is no doubt there is compelling evidence the HPV vaccine is remarkably safe. Preventing cervical cancer is very important. In Canada, an estimated 1300 women will be diagnosed with cervical cancer this year and 380 will die. In spite of years of Pap smears and regular screening, cervical cancer is still prevalent.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Lesbians and Cervical Cancer

Do lesbians get cervical cancer? Do they need Pap smear on regular basis?

This is a good question. Most people would think that lesbians do not get cervical cancer. That is not true.

This subject is discussed in an editorial in the British Medical Journal (BMJ) titled, “Health needs of women who have sex with women”. I will attempt to summarize it here.

The editorial starts by saying, “…..lesbian is a term that describes sexual identity. However, sexual identity does not necessarily predict sexual behavior—most lesbians have a history of sexual intercourse with men.”

We know that sexual intercourse with men is a powerful risk factor for cervical cancer. The virus responsible for developing changes in the cervix, which may eventually lead to cervical cancer, is called genital human papillomavirus. Studies have shown that one in five women who have never had heterosexual intercourse have human papillomavirus.

“Therefore regular testing of cervical (Pap) smears should be recommended to all women who have sex with women, regardless of their present or past sexual activities”, says the BMJ editorial.

Another condition is called “bacterial vaginosis”. This is more common in women who have sex with women than heterosexual women—it is found in up to half of women who have sex with women.

Sexually transmitted infections such as Chlamydia, gonorrhoea, and syphilis, are less common amongst women who have sex with women – but they are still at risk. The editorial says that overall more than 10 percent of women with exclusively female partners have a history of sexually transmitted infections.

Female to female sexual transmission of HIV has been reported. The editorial also briefly touches on other aspects of lesbian lifestyle which can affect lesbian’s mental and physical health.

Another article in the same issue of the BMJ provides online health information web links for lesbians. There are many sites. I will mention just two:

Health Canada site is: www.hcsc.gc.ca/english/women/facts_issues/lesbian_health.htm.

American Government site is: www.4woman.gov/faq/Lesbian.htm.

These sites offer guidance about the frequency with which lesbian women should have pap smears, screening for sexually transmitted infections, and mammograms.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!