Towards the end of a routine office visit last year, my daughter’s pediatrician said he’d like to start talking about vaccinating her against human papillomavirus (HPV), the virus that causes genital warts and can lead to cervical and other cancers. His comment brought me to a full stop. She’s received all the routine childhood vaccinations and gets a flu shot once a year. But HPV vaccine? Why were we talking about vaccinating her against a sexually transmitted infection? She was only eight years old at the time, still protesting that “boys stink” and wrestling them to the ground in her karate class. Yes, I knew that someday she would grow up and become a sexually active adult… but why was her doctor recommending that she get vaccinated against the virus by the time she was 11 years old?

I’m not the only parent who has that gut reaction to the HPV vaccine. It feels almost perverse to think of your child and an STD in the same moment. Yet that parental reluctance is a barrier to protecting our children from cancer, genital warts, and a lot of pain and misery.

Among the many barriers to achieving the Healthy People 2020 goal of an 80% HPV vaccination rate, parental refusal is the most common. Despite the effectiveness and safety record of the HPV vaccine, parents decline it 56.4% of the time. Most often, the reasons they give are based on myths. Here’s the information you need to dispel the myths — and protect your kids.

What is HPV?

Human papillomaviruses (HPV) are a group of more than 200 related viruses. Some HPV types cause warts on the skin, while others cause warts on the genitals. Many types cause no symptoms.

More than 40 types of the virus spread through sexual contact, including vaginal, anal, and oral sex. Sexually-transmitted HPVs are categorized as low-risk and high-risk:

Low-risk (non-oncogenic) HPVs cause skin warts (called condylomata acuminate) on or around the genitals or anus, but do not cause cancer. Nine out of 10 cases of genital warts are caused by HPV types 6 and 11. HPV types 6 and 11 can also cause tumors to grow in the respiratory tract, a condition called recurrent respiratory papillomatosis. While the tumors are benign, in 3-5% of patients, tumors may undergo malignant degeneration to squamous cell carcinoma.
High-risk (oncogenic) HPVs cause cancer. More than a dozen high-risk HPV types have been identified. HPV types 16 and 18 are responsible for 70% of all HPV-related cancers in the United States. Types 31, 33, 45, 52, and 58 lead to 17% of HPV-related cancers in females and 4% in males.

High-risk HPV types cause about 5% of all cancer cases around the globe. In the United States, they lead to about 3% of cancer cases in women and 2% in men, a total of 26,000 new cancer cases per year. The nine types of HPV cause several types of cancer:

90% of cervical cancer cases
90% of anal cancer cases
70% of oropharyngeal cancer cases
65% of vaginal cancer cases
50% of vulvar cancer cases
35% of penile cancer cases

How Common is HPV?

HPV is the most common sexually transmitted infection in the United States. More than 80% of people in the United States will become infected with HPV at some time during their lives. An estimated 79 million people in the United States are currently infected with HPV.

Each year, 14 million new infections occur, approximately half in 15-24 year olds. In one study, more than 20 percent of girls (ages 14-19 years) were found to be colonized with high-risk HPV types (cite).

Data published by the Centers for Disease Control and Prevention (CDC) on April 17, 2017, show that rates of HPV infection remain disturbingly high in the United States:

Oral: During 2011-2014, among adults aged 18-59 years, the prevalence of prevalence of any oral HPV was 7.3%. High-risk HPV affected 4.0% of the population. Rates were highest among Blacks, white and Hispanic adults. Prevalence of any and high-risk oral HPV was higher in men than women.
Genital: During 2013–2014, among adults aged 18–59, the prevalence of any genital HPV was 45.2% and in men and 39.9% in women. High-risk genital HPV affected 25.1% of men and 20.4% of women. Prevalence was highest among Blacks, followed closely by whites and Hispanics.

The upshot: If you ever expect your daughter or son to become sexually active, then get them vaccinated. The risk of infection is very, very high, and the consequences of infection could be very, very bad.

How Does HPV Spread?

HPV is transmitted through skin-to-skin contact, including kissing, oral sex, and sexual intercourse. HPV can be transmitted with any genital-mucosal contact. Consistent, correct use of condoms can reduce transmission of HPV, but condoms do not fully protect against HPV. Areas of skin not covered by the condom may still come into contact. HPV can also be passed from a woman to her child during labor.

What about the HPV Vaccine?

As of Jan 2017, Gardasil-9 (9vHPV), produced by Merck & Co, Inc. Whitehouse Station, NJ, is the only HPV vaccine available in the United States. The vaccine protects against all nine HPV types that most frequently cause cancers or genital warts.

Immunization has been shown to be the most effective way to prevent for HPV infection. Since the introduction of the first HPV vaccine in 2006, rates of infection with HPV have dropped more than 65% in girls ages 19 and 35% in their older peers.

Vaccination rates in Australia approach 80%. Yet in the United States, HPV vaccination rates remain low. In 2015, 6 out of 10 females and 5 out of 10 males aged 13 to 17 years had started the HPV vaccination series.

Who Should Get Vaccinated, and When?

In October 2016, the ACIP revised its recommendations for administration of HPV vaccine, reducing the number of doses to two (2) for youth (female and male) ages 9-14 years at initiation of vaccine. Doses should be given at 0 and 6-12 months. If the first dose given at 14 years, then only one more dose after 6 months is needed. This recommendation was based on findings that antibody levels after 2 doses are similar to three-dose regiment (0, 1-2, and 6 months), both initially and after 36 months.

Youth and young adults ages 15-26 years should still receive the three (3) doses, at 0, 1-2, and 6-12 months. The three-dose series is also recommended for those who are immunocompromised.

Experts recommend the vaccine be administered the 11-12 year old visit, for two reasons:

Prevention works best. The vaccine works best if given before the adolescent becomes sexually active. YRRS data show that 24% of adolescent boys and girls report sexual intercourse by 9th grade, and 58.1% do by 12th grade.
Younger immune systems respond best. Antibody response (the amount of disease-fighting substances produced by the body) is stronger for youth ages 9-15 years than for those 16-26 years.

Dispelling Common Myths about HPV and the Vaccine

Common myths about HPV vaccine include:

Myth: My child is too young to get the vaccine.
- Truth: The vaccine is safe for children as young as nine years old.
Myth: My child won’t get HPV.
- Truth: No, your child won’t get HPV – until he or she becomes sexually active. Even if your child abstains from sexual activity until marriage, there’s a chance she or he will contract HPV. More than 80% of people in the United States will become infected with HPV at some point in their lives. HPV is the most common sexually transmitted virus, and it can be transmitted without sexual intercourse, just through skin-to-skin contact.
Myth: HPV won’t cause any problems if my child does get it as an adult.
- Truth: Most people are able to fight off HPV with no ill effects. But in many people, HPV causes cancer. It also causes unsightly and uncomfortable warts, which can cause problems themselves. HPV can complicate pregnancy, labor, and delivery, causing women to have a cesarean section if genital warts are present. Women who develop cervical cancer may not be able to carry a fetus to term.
Myth: The vaccine is not safe.
- Truth: The vaccine was tested on more than 20,000 women ages 16-26 years before was approved for widespread use in 2006. Side effects of the HPV vaccine are short-lived and include fainting, dizziness, nausea, headache, and pain, redness, or swelling at the injection site. Studies have probed potential associations between the vaccine and autoimmune disorders, blood clots, stroke, the brain, multiple sclerosis, allergic reactions, Guillain-Barre Syndrome, appendicitis, and seizures. No associations have been found.
Myth: The vaccine is not required, only recommended, so it’s not important that my child get it now.
- Truth: HPV vaccine is not required for school, camp, or other settings, because the reason for requiring vaccines in those settings is to prevent the spread of disease in ways that we interact every day. Required vaccines focus on diseases that are spread by coughing, casual touching (e.g. handshakes, doorknobs, or clothing). Recommended vaccines are still important for your child’s health, even if the virus isn’t transmitted in casual settings.
Myth: The vaccine will encourage my child to become sexually active at an early age.
- Truth: There is no evidence that early vaccination with HPV vaccine encourages early sexual activity. Nor do youth who received the vaccine have more partners once they become sexually active.

Our story? I looked at my daughter, took a deep breath, then turned to her pediatrician and said, “You betcha. When is it best for her to start?”

Additional Resources

https://www.cdc.gov/hpv/hcp/answering-questions.html

Sources

Bernstein HH, Bocchini JA Jr; COMMITTEE ON INFECTIOUS DISEASES. Practical Approaches to Optimize Adolescent Immunization. Pediatrics. 2017 Mar;139(3). pii:e20164187. doi: 10.1542/peds.2016-4187. Epub 2017 Feb 6.

Bernstein HH, Bocchini JA Jr; COMMITTEE ON INFECTIOUS DISEASES. The Need to Optimize Adolescent Immunization. Pediatrics. 2017 Mar;139(3). pii: e20164186.doi: 10.1542/peds.2016-4186. Epub 2017 Feb 6.

Centers for Disease Control and Prevention. Human papillomavirus (HPV) vaccination coverage among adolescents 13-17 years by State, HHS Region, and the United States, National Immunization Survey-Teen (NIS-Teen), 2015. Teen Vax View. https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/dashboard/2015.html

McQuillan G, Kruszon-Moran D, Markowitz LE, Unger ER., Paulose-Ram R. Prevalence of HPV in adults aged 18–69: United States, 2011–2014. NCHS data brief, no 280. Hyattsville, MD: National Center for Health Statistics. 2017.

Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MC, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Transm Dis 40(3):187–93. 2013