News Sexual Health

New Study Suggests Male Foreskin is a Reservoir for HPV; May Have Implications for Vaccinations and Circumcisions

Martha Kempner

A new stdy found that male foreskin is a reservior for HPV.  The authors suggest that this shows we should be vaccinating boys as well. Others question its implications for circumcision. 

A new study presented at the annual meeting of the American Urological Association suggests that male foreskin is a reservoir for HPV, the human papillomavirus.  Researchers in Australia examined the foreskin of 133 males between 7 months and 82 years who had undergone circumcision to treat phimosis, a condition in which the foreskin cannot be pulled back from the head of the penis. They found that nearly one third of them contained HPV, the virus that causes genital warts. The researchers cautioned, however, that just because HPV was present does not mean it was transmissible. 

HPV is one of the most common sexually transmitted diseases (STDs); the U.S. Centers for Disease Control and Prevention (CDC) estimates that half of sexually active people in the United States will have HPV at some point in their lives.  Most cases resolve themselves without any long term health consequences; however, some strains of HPV can lead to cervical cancer in women and, in rare cases, penile cancer in men. 

In the United Sates, there are two vaccines available to protect women from the strains of HPV that cause cervical cancer. The CDC recommends that girls be vaccinated at 11 or 12, though this has caused some controversy (in large part because of the sexual nature of transmission and the early age of vaccination).  One of the vaccines, Gardasil, has also been approved for use in boys, though the CDC does not recommend that all boys be vaccinated. 

The authors of this study say that this new evidence suggests that it is important to vaccinate boys as well.

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Our study revealed the occurrence of subclinical genital low- and high-risk HPV infections in boys and men, which could be a reservoir for HPV-associated diseases.  Since it is proven that viral transfer results from sexual contact, it is advisable to vaccinate not only girls but also boys before adolescence.”

The study also raises the issue of whether male circumcision should be promoted as a method of STD prevention. In recent years, studies have shown that male circumcision can reduce the risk of transmission of HIV, HPV, and herpes. While there are public health efforts to increase the practice among men in some areas, most notably in Africa, the American Academy of Pediatrics says the medical benefits are insufficient to recommend the procedure for all infant males in the United States. Opponents of circumcision suggest that it is unnecessary and can reduce sexual sensitivity in adults. In fact, circumcision rates have been dropping dramatically in this country. While over 90 percent of infant males in the United States were circumcised in the 1970s this was down to 64 percent in 1995 and just 33 percent in 2009.

Some public health experts say that this new study will likely not change circumcision practices.  Dr. Jonathan L. Temte, professor of family medicine at the University of Wisconsin School of Medicine and Public Health, explained to USA Today, “What this doesn’t tell us is anything regarding the relative risk of having a partner who’s circumcised vs. uncircumcised.” He went on to say: “I don’t think this changes the argument very much regarding pros vs. cons on circumcision.”

News Sexual Health

Study: Doctors May Be Discouraging HPV Vaccination

Martha Kempner

A study found that doctors don’t strongly recommend the vaccine, don’t discuss it in a timely manner, and tend to suggest it for young people they perceive to be at risk rather than for all girls and boys.

The HPV vaccination rate lags behind that of other vaccines, and a new study suggests that doctors may be a key part of the problem.

The study found that doctors don’t strongly recommend the vaccine, don’t discuss it in a timely manner, and tend to suggest it for young people they perceive to be at risk, rather than for all girls and boys. This study is a reminder of the confusion and controversy that has surrounded the HPV vaccine since it was approved for use almost a decade ago and suggests that these pervasive misunderstandings extend to the very people who should be promoting it the most.

The HPV vaccine protects against certain strains of the human papillomavirus, which can be sexually transmitted. The CDC estimates that 79 million people in the United States are infected with the HPV virus and 14 million new infections occur annually. Though most people won’t suffer long-term health consequences and may never know they have the virus, others may develop cervical cancer or cancers of the head, neck, throat, penis, or anus.

About 12,000 women in the United States develop cervical cancer each year and 4,000 women die from the disease.

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The newest version of the HPV vaccine protects against nine strains of the virus, some of which are known to cause most cases of cervical cancer. Researchers have suggested that if this vaccine were to be widely used, it has the potential to prevent 90 percent of all cervical, vulvar, vaginal, and anal cancer.

Despite this potential to save lives, HPV vaccination rates have been lower than that for other recommended vaccines. In 2014, 60 percent of girls ages 13-to-17 received at least one of the three recommended doses of the HPV vaccine, but only 39.7 percent had received all three, as Rewire reported.

Rates of the vaccination for boys are lower, with 41.7 percent of boys age 13-to-17 having received at least one dose of the vaccine and 21.6 percent receiving all three. In contrast, 79.3 percent of teens age 13-to-17 had received the quadrivalent meningococcal conjugate vaccines (which protects against meningitis), and 87.6 percent had received the Tdap vaccine (which covers tetanus, diphtheria, and pertussis).

The new study suggests that doctors may contribute to this imbalance because they are not strongly promoting HPV vaccination for their patients. For the study, which was published in Cancer Epidemiology, Biomarkers & Prevention, researchers surveyed 776 physicians and asked about five communications practices that national guidelines suggest are necessary for delivering the vaccine. The practices include timeliness (did they recommend the vaccine by ages 11 or 12 or wait until patients were older, and did they recommend it for both boys and girls and boys?); consistency (did they recommend the vaccine for all patients or just those whom they considered at risk?); urgency (did they recommend getting it at the current visit or suggest parents go home and think about it?); and strength of endorsement (did they describe the vaccine is “very” or “extremely” important or were they less emphatic?).

They found that 26 percent of physicians said they don’t provide timely recommendations for girls and 39 percent said they don’t do timely recommendations for boys. Consistency was also low, as 59 percent of physicians acknowledged that they recommended the vaccine more for patients they perceived at high risk rather than recommending it for all of their patients.

Physicians were about equally split on the concept of urgency (51 percent recommend same-day vaccinations). Twenty-seven percent of physicians across the country admitted that they do not strongly endorse HPV vaccination.

The researchers were discouraged by their findings. “We were surprised that physicians so often reported recommending HPV vaccination inconsistently, behind schedule, or without urgency,” Melissa Gilkey, one of the study’s authors, said in a press release. “We are currently missing many opportunities to protect today’s young people from future HPV-related cancers.”

These missed opportunities come alongside growing evidence that HPV vaccines are reliably effective. A 2013 report by the CDC, for example, looked at some of the strains targeted by the vaccine. It compared the infection rate in girls 14-to-19 before the vaccine was approved and another from after it received government approval. The proportion of girls infected with the strains dropped by 56 percent.

This applies to all teens, whether or not they were vaccinated, and may be a result of what public health experts refer to as “herd immunity”—if enough of the population is protected by a vaccine, that protection extends to the unvaccinated as well. Among girls who had gotten the vaccine, however, the drop in HPV infections was even higher, at 88 percent.

Another study found that cervical cancer rates were lower in states that had higher rates of HPV vaccination. For example, 66 percent of young women in Vermont have received at least one dose of the vaccine and 5.4 women out of 100,000 are diagnosed each year. In contrast, 41 percent of girls in Arkansas have received one dose of the vaccine and 10.2 out of 100,000 women are diagnosed with cervical cancer each year.

Forty percent of girls in Mississippi received one dose of the vaccine and the cervical cancer rate is 9.2 per 100,000 women.

Doctors may be the key to boosting these vaccination rates. The study’s authors wrote that prior research has shown that a health-care provider’s recommendation is the single biggest influence on whether parents decide to get the HPV vaccine for their daughter or son.

Gilkey said there are easy changes providers can make. “Physicians have a lot of influence on whether adolescents receive the HPV vaccine. Our findings suggest that physicians can improve their recommendations in three ways: by recommending HPV vaccination for all 11- to 12-year-olds and not just those who appear to be at risk; by saying the HPV vaccine is very important; and by suggesting vaccination on the day of the visit rather than at a later date.”

News Health Systems

Study: States With Low HPV Vaccination Rates See Higher Cervical Cancer Rates

Martha Kempner

A new study finds that cervical cancer rates and HPV vaccination rates tend to move up and down together, suggesting once again that if more young women get vaccinated there will be fewer cases of cervical cancer.

More proof that vaccinating young people against human papillomavirus (HPV) can prevent cervical cancer was presented this week at a health disparities conference, as a national study found that there are fewer cases of cervical cancer in states in which HPV vaccines are more common.

Distrust of vaccines—based largely on dubious information—and fear that the vaccine might encourage promiscuous sexual behavior among teenage girls could be factors in states with the lowest HPV vaccination rates and the highest cervical cancer occurrences. Numerous studies have shown that the vaccine does not encourage promiscuity.

The study, presented at a conference organized by the American Cancer Research Association, pointed to a number of states on opposite ends of the spectrum. In Massachusetts, for example, 69 percent of girls ages 13 to 17 receive at least one dose of the vaccine, which is given as a series of three shots six months apart, and only six out of 100,000 women are diagnosed with cervical cancer each year.

Sixty-six percent of young women in Vermont have received at least one dose of the vaccine and 5.4 women out of 100,000 are diagnosed each year.

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In contrast, 41 percent of girls in Arkansas have received one dose of the vaccine and 10.2 out of 100,000 women are diagnosed with cervical cancer each year. In Mississippi, only 40 percent of girls received one dose of the vaccine and the cervical cancer rate is 9.2 per 100,000 women.

Fifty-seven percent of girls nationally have received one does of the vaccine and the national cervical cancer rate is 8.2 per 100,000 women.

This new study confirms research showing that vaccine rates are much lower in the South than in other parts of the country.  A 2013 study of older women, ages 18 to 26, found that between 2008 and 2010, 37.2 percent of young women in the Northeast had received at least one shot compared to 28.7 percent the Midwest and West, and just 14 percent in the South.

The newest study shows that cervical cancer rates and HPV vaccination rates tend to move up and down together. Though the authors could not prove causality, their finding suggest that increasing the uptake of the vaccine in a state could have a direct impact on cervical cancer rates and could help even out existing disparities between states.

Cervical cancer affects about 12,000 women each year in the United States, and about 4,000 women die from the disease.

Worldwide, the numbers are much higher. The clear majority of cervical cancers (91 percent) are caused by HPV, a highly contagious sexually transmitted disease (STD) that is spread from infected skin to uninfected skin. Around 79 million Americans are currently infected with HPV, and about 14 million people become infected each year.

Though the HPV vaccine has been shown to be safe and effective, it has been a tough sell since it came onto the market in 2006. Low vaccination rates reflect a general distrust of vaccines that stems from disproven data released in the late 1990s linking vaccines to the rise in autism.

This explains only part of the problem, because other vaccines are more readily accepted. In fact, the Centers for Disease Control and Prevention estimated in August that if 13-year-old girls had been given the vaccine at the same time they were given the other vaccines recommended for that age, 91.3 percent of them would have received at least one dose.

Some parents seem worried that vaccinating against as sexually transmitted disease would encourage sexual behavior in young girls. Others have said that the recommended age of 11 is too young to even discuss sexual behavior, despite lack of evidence that the vaccine changes a teen’s sexual behavior.

There is a lack of understanding among parents about the HPV vaccine and many parents don’t realize that it can actually prevent cancer.

Perhaps the most important research on the vaccine thus far are studies that show it is working. Despite the low vaccination rates, the proportion of teen girls infected with the strains of HPV that the vaccine addresses has dropped by 56 percent.

This applies to all teens, whether or not they were vaccinated. This may be a result of what public health experts refer to as “herd immunity”—if enough of the population is protected by a vaccine, that protection extends to the un-vaccinated as well. Among girls who had gotten the vaccine, however, the drop in HPV infections was even higher, at 88 percent.

Jennifer Moss, a doctoral student at the University of North Carolina Gillings School of Global Public Health and the author of the new study, told TIME, “These states could really use some interventions to increase the rates of HPV vaccination now, and hopefully there will be big dividends in the coming decades in terms of cancer mortality.”

Moss added that pediatricians play a critically important role.

“The factor that’s most strongly associated with HPV vaccination is whether a child’s health care provider recommends it,” she said. “We really need strong recommendations from health care providers to adolescent patients and their parents to get the vaccine.”