News Sexual Health

The HPV Vaccine Is Working: Rates Have Dropped Over 50 Percent Since Introduced

Martha Kempner

Though only half of teen girls have gotten one dose of the vaccine and fewer than a third have gotten the recommended three doses, new research has found that the proportion of teen girls infected with the strains of HPV that the vaccine addresses has dropped by 56 percent.

New research published in the Journal of Infectious Diseases shows that the human papillomavirus (HPV) vaccine, which has been controversial since even before Gardasil was approved by the Food and Drug Administration in 2006, is working. Despite the fact that only one half of teen girls have gotten one dose of the vaccine and fewer than one-third have gotten the recommended three doses, the proportion of teen girls infected with the strains of HPV that the vaccine addresses has dropped by 56 percent.

HPV is a highly contagious sexually transmitted disease (STD) that is spread from infected skin to uninfected skin. Transmission of HPV can be prevented by condoms, but only if the infected skin is in an area covered by the condom. If it is on an area such as a man’s scrotum, condoms cannot help reduce transmission.

Approximately 79 million Americans are currently infected with HPV, and about 14 million people become newly infected each year. HPV is so common that nearly all sexually active men and women will get at least one type of HPV at some point in their lives. Most of them will have no symptoms or health problems. In fact, the body can often clear itself of the infection without intervention. Some people, however, will get genital warts, which may go away on their own or may need to be removed by a health-care provider. Of greater concern is that certain strains of the virus, if left untreated, can lead to cervical cancer. Approximately 12,000 women in the United States are diagnosed with cervical cancer each year, and about 4,000 die. HPV can also cause cancer of the penis and anus, and is responsible for a recent increase in cases of head and neck cancers.

Gardasil was designed to provide protection against four common strains of the virus—the two that account for 70 percent of cervical cancers and the two that account for 90 percent of genital warts. (A second vaccine, called Cervarix, which only protects against the two strains that cause cervical cancer, was approved in 2009, but the authors of the study say that based on the timing of their data the effect is mainly a result of Gardasil.)

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The vaccine is given as a series of three shots and is approved for young people—both men and women—between the ages of nine and 26. The Centers for Disease Control and Prevention (CDC) recommends that HPV vaccines become part of the routine vaccinations for girls who are 11 or 12 years old because in order to ensure that it works, it has to be given before they become sexually active. Though not recommended as part of the routine vaccinations for boys, health-care providers suggest that they receive the vaccine at the same age.

The current study was conducted by the CDC and compared infection rates in girls ages 14 to 19, before the vaccine was introduced and after. It looked specifically at those strains of HPV targeted by Gardasil. The proportion of girls infected with these dropped from about 12 percent before the vaccine was available to 5 percent (again, a drop of 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 unvaccinated as well. Among girls who had gotten the vaccine, however, the drop in HPV infections was even higher, at 88 percent.

The study did not look at rates of cervical cancer, but since that disease develops so slowly, it is unlikely that the vaccines have had an impact on rates yet.

The study also found that the proportion of teens who had ever had sex did not go up, nor did the proportion of those who had had multiple sex partners. This should not be surprising, as other studies have also found that access to the vaccine does not give young people license to engage in unsafe sexual behavior, as opponents of the vaccines have argued. (See this Rewire article for further discussion on this argument). The study did find that a higher percentage of vaccinated teens said they’d had three or more sex partners. Dr. Lauri Markowitz, the study’s lead author, told the Washington Post this suggested that those teens most in need of the vaccine’s protection were getting it, and that by preventing the virus in them, their peers were protected as well.

One interesting result of this study is that the protection seems to have set in even though so few teens have had the recommended three doses of the vaccine. Markowitz said this warranted further study and discussion about whether all three shots are necessary.

Commentary Science

HPV Vaccines Are Working, So It’s Time to Stop Arguing About Them

Martha Kempner

A new study finds that HPV rates have plummeted in the last six years. Yet HPV vaccination rates continue to lag behind those of other vaccines, in part because of the stigma surrounding sexually transmitted infections.

According to a new study, human papilloma virus (HPV) rates have plummeted in the first six years vaccines against the virus have been available. Unfortunately, HPV vaccination rates lag behind those of other recommended inoculations, in part because of the stigma that stifles conversations around sexually transmitted infections.

Perhaps these new success rates—coupled with additional new research that reminds us of the possibility of non-sexual HPV transmission—will convince more parents to take advantage of this potentially life-saving vaccine.

HPV is actually a group of more than 150 related viruses, 40 of which are known to be sexually transmitted. Most types of the virus are thought of as low-risk, because they are unlikely to cause health problems. Nine types, however, have been identified as high-risk and are thought to be responsible for 99 percent of cervical cancers and a large portion of vulvar, vaginal, penile, anal, and oropharyngeal (a part of the throat) cancers.

Since 2006, there have been three vaccines against HPV developed and released on the market. The most recent, made available last year, was the most wide-ranging; it protects against the nine high-risk types of the virus.

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The vaccine is given as a series of three shots over eight months. The Centers for Disease Control and Prevention (CDC) recommends that boys and girls begin the series at age 11 or 12 in order to be sure that they are fully vaccinated before they become sexually active, but those who do not get the shots at that time can get them at any point before age 26. Experts estimate that widespread vaccination could prevent up to 90 percent of cases of cervical, anal, and genital cancer.

Though the research released last month uses data collected before the latest vaccine was available, the success of the original vaccine supports an optimistic outlook for the future prevention of HPV.

For the new study, which was published in the journal Pediatrics, researchers used data from the CDC’s National Health and Nutrition Examinations Survey (NHANES). They compared cervical and vaginal specimens from individuals ages 14-to-34 collected between 2003 and 2006—before the vaccine was available—with samples collected between 2009 and 2012, after the first vaccine was in use. They also used vaccination records from the latter group.

They found that 11.5 percent of young women ages 14-to-19 in the pre-vaccine group had one of the four types of HPV covered by the original vaccine. This dropped to about 4 percent in the group examined after the vaccine was available. Among those ages 20-to-24, the prevalence rate dropped from 18.5 percent to roughly 12 percent. There was no change among the oldest age group.

Overall, the study concludes, within six years of the vaccine’s introduction, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s.

Dr. Laurie E. Markowitz, lead author of the study, told the Guardian that results were better than expected.“The fact that we are seeing a larger decrease overall than what we expect given our coverage rates does suggest there may be some herd protection,” which occurs when a large enough portion of the population is vaccinated to slow the spread of the virus, she said. “There also may be effectiveness from less than a complete three dose series,” Markowitz continued.

Researchers anticipate that more people will continue to benefit from the vaccines. Markowitz told the Guardian, “As women who got the vaccine when they were younger age move into these older age groups, we should continue to see a continued decrease,” because they will not transmit the strains to anyone else as they become sexually active.

In addition, vaccination rates have improved since this data was collected. In 2009, only about 44 percent of girls had received one dose of the vaccine and only about 27 percent had received all three. By 2014, two-thirds of teenage girls ages 17 and under had received at least one of the three recommended doses of the HPV vaccine, and about 40 percent had received all three doses.

The CDC recommends that boys get the HPV vaccine as well, but vaccinations rates among boys have always been lower than those among young women—perhaps because when the vaccine was originally introduced, it was only suggested for girls, or perhaps because it is best known for preventing cervical cancer. But vaccination rates for boys have been on the rise as well. In 2014, roughly 42 percent of teenage boys ages 17 and under had received at least one dose of the vaccine: about 8 percentage points higher than the year prior.

Unfortunately, HPV vaccination rates still lag behind those of other recommended vaccines. For comparison, in 2014, about eight in ten teens ages 17 and under had received the quadrivalent meningococcal conjugate vaccines and roughly 87 percent had received the Tdap vaccine, which covers tetanus, diphtheria, and pertussis.

There are a number of reasons that HPV vaccination rates might be lower than others, including the fact that only two states and Washington, D.C. require the vaccine for school-aged children. By contrast, the Tdap vaccine is required in most states; meningitis vaccines are required in about half. Additionally, some parents may not have the resources or time to take their children to get a series of three vaccinations.

Not surprisingly, there still exists a discomfort with the sexually transmitted nature of HPV. Since, the HPV vaccine was introduced, there have been those who argue that vaccination will be seen by teenage recipients as permission to have sex, thereby increasing their risky behavior. This faction also argues that it is not necessary to inoculate young people against HPV because they can easily avoid it by just not having sex.

Numerous studies have found that HPV vaccines do not, in fact, turn young people into sex machines. A study last year from the United Kingdom, for example, found girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not. An earlier study in the United States found that teen girls who had been vaccinated were more likely to use condoms than their non-vaccinated peers. Other studies have found that young people’s perception of sexual risk and risk behaviors do not change after vaccination.

Perhaps a new article will take the wind out of the sails of the argument that teens should “just say no” to prevent HPV. The paper, cleverly titled “Penises Not Required,” reviewed 51 studies that found evidence of transmission through means other than penile-vaginal or penile-anal intercourse. Some of the studies reviewed found HPV DNA in the genital tract of female “virgins”—though the definitions of “virgin” varied widely among studies, and were based on respondents’ self-reported sexual activity. Other studies found HPV DNA in children who had not been sexually abused. Some studies focused on evidence of HPV DNA on medical equipment, toilet seats, and sex toys, and questioned whether this would be sufficient to transmit the virus. And others suggested the possibility of finger-to-genital transmission either from a partner or even from one’s own hands.

The researchers told Rewire in an email that their results have to be interpreted cautiously, as they do not provide proof of non-penetrative or non-sexual transmission. Nonetheless, the possibility that this virus can be transmitted without sex should help us rid the HPV vaccine debate of moralizing. As the researcher concludes in the article, “The distribution of HPV vaccines has been hindered, in part, by societal discomfort with the role of HPV in human sexuality. A fuller appreciation of the potential for non-sexual HPV transmission could help increase vaccine acceptance.”

The facts are simple. We have a vaccine that prevents cancer, it’s working, and that’s a major public health victory. It’s time to stop arguing about whether vaccinating kids against an STD is a good idea and start protecting everyone.

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.”