A 9-year-old male came to clinic for his health maintenance examination. He was overall healthy and there were no parental concerns. The past medical history found him to be fully immunized including seasonal vaccines.
The pertinent physical exam revealed him to have normal vital signs and growth parameters that were 10-50%. His examination was normal.
The diagnosis of a healthy male was made. His mother consented to all vaccines but asked why the HPV vaccine was being done at this age as her older daughter had it at 11-12 years. “In our community the vaccine rate was relatively poor. Not in our clinic but in the community. So we as a practice are following the recommendation to start vaccinating at age 9 years. We had a good rate before but now our rates are even higher so we are happy with the results. For some families who might be hesitant it also gives them a little bit more time to learn about the cancers it prevents and become more comfortable with getting the vaccine. Families like it that we can give it with other vaccines too like flu shots,” he responded.
Discussion
Human papilloma virus (HPV) is a circular, double-stranded DNA-virus that is the most common sexually-transmitted infection in the US and in many places world-wide. Diseases range from genital warts to respiratory papillomatosis to cancer. Cancer locations include skin, oropharyngeal, vulvar, vaginal, cervical, anal and penile cancers. It is estimated that HPV infection is associated with ~125,000 cases of cancer annually in the US.
HPV vaccine was initially approved in 2006 in the US with a quadrivalent vaccine. In 2016 a nonavalent vaccine was approved and is the only HPV vaccine currently approved in the US. The vaccine is recommended for ages to be given at 9-14 years with catchup vaccination routinely done up to 26 years, and potentially as late as 45 years of age with shared decision making between patients and health care providers.
Serotypes included are 6 and 11 (rarely carcinogenic but associated with 90% of anogenital warts and recurrent respiratory papillomatosis), 16 and 18 (associated with 70% of cervical cancers, 16 is associated with 95% of HPV-related oropharyngeal cancers), and 31, 33, 45 and 52 (associated with an additional 20% of cervical cancers). HPV prophylactic vaccines work by blocking entry of the virus into cells, presumably by antibody neutralization.
Learning Point
HPV vaccines are highly efficacious with mild side effects. It is estimated that up to 90% of HPV-related cancers are prevented especially cervical cancer. “Studies have […] demonstrated that earlier administration of the vaccines results in greater immunogenicity and long-lasting protection.” Greater effectiveness “”[…] is likely due to administration of these prophylactic vaccines prior to natural exposure to HPV from sexual activity rather than a biological mechanism independent of natural exposure.” It is estimated that up to 60% of adolescents have their sexual debut by age 18 years. It is also estimated that that “most sexually active women and men will become infected with HPV at least once in their lifetime.” Administration at early ages can lead to greater completion of the vaccine series as well.
Older adolescents and adults do have robust antibody responses that are higher than natural infection which likely gives substantial protection against HPV.
Some studies have also reported herd immunity protection effects as well. As the HPV vaccine has been efficacious, especially against cervical cancer, oropharyngeal cancers still are increasing and are now the main type of HPV-related immunity.
HPV vaccines for treatment (as opposed to prophylaxis) are also being developed designed to induce cellular immunity against established infections and potentially prevent continuation to cancer.
Questions for Further Discussion
1. What are treatments for respiratory papillomatosis? A review can be found here
2. What are treatments for genital warts? A review can be found here
3. What are some methods for counseling families who may be vaccine hesitant? A review can be found here
Related Cases
- Disease: HPV | Sexually Transmitted Diseases | Childhood Immunization
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: General Pediatrics | Infectious Diseases
- Age: School Ager
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: HPV and Vaccines.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Ellingson MK, Sheikha H, Nyhan K, Oliveira CR, Niccolai LM. Human papillomavirus vaccine effectiveness by age at vaccination: A systematic review. Hum Vaccin Immunother. 19(2):2239085. doi:10.1080/21645515.2023.2239085
Skolnik JM, Morrow MP. Vaccines for HPV-associated diseases. Molecular Aspects of Medicine. 2023;94:101224. doi:10.1016/j.mam.2023.101224
Escoffery C, Petagna C, Agnone C, et al. A systematic review of interventions to promote HPV vaccination globally. BMC Public Health. 2023;23(1):1262. doi:10.1186/s12889-023-15876-5
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa