Transcript Slide 1

HPV and STI
 Palm Beach State College
 Lunch and Learn Lecture Series
 March 20, 2013
 Dudley Brown, Jr., MD, MBA
Background
 AA Pre-Med--Broward Community College (1993)
 BS in Psychology--University of Miami (1995)
 MD--University of Florida College of Medicine (1999)
 MBA--Northern Illinois University (2011)
 Residency in Obstetrics and Gynecology--Cook County Hospital,
Chicago, IL (Chief Resident)
 Private Practice for 10 yrs (8+ yrs in IL)
 Office locations: West Palm Beach and Jupiter
 Surgeries and Deliveries at Good Samaritan and St Mary’s Medical
Centers in WPB
 Accepting New Patients
 (561)357-6277
 www.tenetfloridaphysicianservices.com
Human Papilloma Virus
 Most common newly acquired sexually transmitted disease
in the United States
 An estimated 6.2 million new HPV infections occur each
year
 Currently 20 million people in the US are infected
 Worldwide 630 million people are infected
Epidemiology of HPV
 Double stranded DNA virus
 Only infects humans
 More than 100 types of HPV
 Cutaneous and Mucous membranes
Human Papilloma Virus
 75% percent of sexually active Americans will be
infected with HPV at some point in their lives
 74% percent of new cases occurs in individuals 1524 years of age
 Highest incidence consistently found in sexually
active women younger than 25
Sexual Behaviors of High School Students
 Survey of high school students reveal that
7.4% of students who responded reported
having initiated sexual intercourse before 13
years of age
 22% of 9th graders
 49% of 12th graders
HPV Studies
 Studies of adolescent and college-age women
revealed that as many as 90% have tested positive
for HPV at least 1 time
 For males studies have revealed 30%. This lower
number reflects the difficulty of detecting the
virus in males
HPV Facts
 Most individuals infected with HPV do not know
that they are infected because they have no
detectable HPV associated disease
 Among adolescents the average HPV infection
lasts a median of 5 to 6 months
 Approximately 70% to 91% of HPV infections will
regress within 2 years although the high risk types
are more persistent
Prevalence of Cervical HPV
Prevalence decreases sharply in women after age of 30
Those with persistent infection are at the highest risk for
the development of high-grade precancerous lesions of
invasive cervical cancer
HPV testing in women 30 and older has been approved
done along with a Pap smear
Diseases Caused by HPV
 Cervical Cancer and Pre-cancerous cells
 Vulva Cancer and Vaginal Cancer
 Anal Cancer and Penile Cancer
 Genital Warts( condyloma acuminatum)
 Head and Neck Cancers
 Recurrent Respiratory Papillomatosis
Transmission of HPV
 HPV is spread primarily by sexual contact
 Spread from mother to child at childbirth
 Transmitted by non-penetrative sexual contact
 Non-penetrative sexual contact includes fingervulva, penile-vulva, oral-penile.
 One study revealed that 10% of virgins had HPV
infections
Risk Factors for HPV
 High number of sexual partners
 Previous infection with herpes simplex virus and
other sexually transmitted diseases
 Young age at initiation of sexual activity
 HIV
 Depressed immune system
 Post-organ transplant such as kidney transplant
Types of HPV
 There are over 100 types of HPV viruses
 Of the 100 types only approximately 35 have been
shown to infect the genital tract
 Classified as high risk and low risk types
 Risk of cancer is higher in the high risk types and
lowest in the low risk types
Genotypes of HPV
Low risks : 6 and 11, others 40,42,43,53,54,61,72,73 and 81
High risks: 16 and 18, others 31,33,35,39,45,51,52,58,59,
and 68
Based on oncogenic (cancer) potential
Low Risk HPV
 Genital Warts
 Recurrent respiratory papillomatosis
(mother to child)
 Squamous intraepithelial lesions/ Abnormal Pap
Low Risk HPV
 Types 6 and 11
 These types cause 90% of genital warts
High Risk HPV
 Cervical Cancer & Pre-cancerous cells (Abn Pap)
 Vulva Cancer
 Vaginal Cancer
 Anal Cancer
 Penile Cancer
 Head and Neck Cancers
High Risk HPV
 Types 16 and 18
 These types cause 70% of cervical cancers
 HPV 16 causes 60% of cervical cancers and HPV 18
causes 10% of cervical cancers
Lancet Oncology 2010; 11:1048
High risk HPV
 Persistent viral infection with high-risk HPV
genotypes causes virtually all cancers of the cervix.
 The same HPV types that cause cancer of the cervix
also cause most cases of anal cancer.
Hoots BE et al. Int J Cancer 2009;124:2375
Abnormal Paps
 Low risk type will tend to resolve spontaneously
without treatment
 Approximately 10% - 13% will progress to higher
grade lesions
 High grade lesions have been shown to develop
into cancer within 3 years if not treated
Cervical Cancer
 Is the second most common cancer in women
worldwide
 Estimated 400,000 – 500,000 cases occur each year
with 80% occurring in developing countries
 In 2006 the American Cancer society estimated
9710 new cases with 3700 deaths in the United
States
Medical Costs
 In 2000 the direct medical costs of HPV infections
among persons age 15 – 24 were estimated to total
$2.9 billion dollars
 False positive paps cost $350 million
 Annual cervical screening cost $2.3 billion
 Direct medical costs of abnormal paps with
treatment is approximately $ 4.6 billion per year
Prevention of HPV
 Abstinence
 Condoms by 70%
 Vaccine
HPV Vaccine
June 8, 2006 the US Food and Drug
Administration ( FDA )approved the HPV vaccine
for use among females 9 to 26 years of age
Available HPV Vaccines
 Gardasil, a quadrivalent vaccine, targets HPV types
6,11,16, and 18
 Cervarix, a bivalent vaccine, targets HPV types 16 and
18
HPV Vaccine Trials
 Randomized double-blinded clinical trials of both
vaccines were designed to determine if HPV
immunization could prevent the development of
cervical intraepithelial neoplasia (CIN2/3),
adenocarinoma in situ,or cervical cancer related to
HPV 16 and 18
Gardasil Vaccine Trials
 17,000 adolescents and young women
 Among HPV negative, the efficacy of this quadrivalent
vaccine for preventing CIN 2 or more severe disease
due to HPV types included in the vaccine was 97 to 100
percent.
 Among all trial participants ( with or without prior
HPV infection), the efficacy was 44 percent. This
reduction of efficacy in this group reflects the fact that
the vast majority of enrollees in this trial were already
sexually active and many had been previously infected
with HPV
Cervarix Vaccine Trials
 Trial enrolled 18,000 adolescents and young women
 HPV negative group overall efficacy was 93%
 Overall population of study participant efficacy was
30%
 These data are consistent with those seen with the
Gardisil vaccine trials and emphasize the need to
vaccinate individuals before the onset of sexual activity
to gain the greatest benefits
N Engl J Med 2007; 356: 1928
HPV Vaccines
 Vaccines are widely available in the Australia,
Canada, Europe, and the United States for the
prevention of cervical intraepithelial neoplasia and
cervical cancer in women: in 2010, the FDA also
approved this vaccine for the prevention of anal
intraepithelial neoplasia and anal cancer in women
based on the clinical trial results in men
Timing of immunization
 Immunization with HPV is most effective among
individuals who have not been infected with HPV
 Approved for ages 9 to 26
 Optimal timing is before sexual activity
 Females who are sexually active should be vaccinated
up to target age of 26
 A history of abnormal Pap test, genital warts, or HPV
infection is not a contraindication for the vaccine
 However immunization is less beneficial for females
who have already been infected with one or more of
the HPV vaccines types
Serologic testing
 Serologic testing or HPV DNA is not required
prior to immunization
Recommendation for women
 Advisory Committee on Immunization Practices
(ACIP) has recommended that HPV vaccination be
routinely offered to females between the ages of 11 and
12 years. Vaccine can be administered as early as age 9.
Catch up vaccination is recommended for females
aged 13 to 26 years who have not been previously
vaccinated or who have not completed their vaccine
series.
 The American College of Obstetrics and Gynecologists
(ACOG) follows the same recommendations
Recommendation for Males
 Advisory Committee on Immunization Practices
(ACIP) recommends HPV vaccine in males age 11 and
12. It can be given as early as age 9. Catch-up
vaccination age 13 to 21 years
 Permissive use of the vaccine in male age 22 to 26
 Permissive use means that the vaccine is
recommended but not considered to be sufficient
priority to include on a routine vaccination schedules
 Vaccines recommended on a permissive basis is less
likely to be covered by patient’s health insurance
Vaccine in Pregnancy
 Although neither HPV vaccine contains no live virus,
use in pregnancy is not recommended because of
limited data on safety.
 In the vaccine trials pregnancy occurred in 1053
women who started the series and no obvious fetal
anomalies were observed.
 In women who start the series and become pregnant
before completion of all three shots, may resume the
series in the postpartum period
 Lactating women can receive the vaccine
HIV and Immunocompromised
 HPV is not specifically recommended for persons with
HIV infection, immunosuppression, or other chronic
medical diseases. However according to ACIP
guidelines its use can be considered since it is not a
live vaccine.
Gardasil and Cervarix
 Vaccination consists of a series of 3 shots
 Gardasil Injections will be given at 0 months, 2
months, and 6 months followup
 Cervarix injections will be given at 0 months, 1
months, and 6 months
 Cost $120.00 per shot
 Total of $360.00 for complete series
 Many teens are eligible for free vaccination under
the Vaccine for Children Program
 CDC recommends when the series is interrupted for
any length of time, it can resumed without restarting
the series
 Duration of protection- is unknown: to date women
have been protected during a mean follow-up for 42
months
Cancer Prev Res(Phila) 2009; 2;868
Side effects of Vaccine
 Minimal
 Most common: pain, swelling, and redness at
injection site 1-2 days
 Least common: fatique, headache, rash and upset
stomach and temperature elevation
Adverse Reactions
 In the United States, adverse events following immunizations are
collected and analyzed within the Vaccine Adverse Event Reporting
System (VAERS)
 This data was compiled following administration of of approximately
40 million doses of HPV vaccines
 From June 1, 2006 to September 2011, VAERS received 20,096 reports of
adverse events following HPV immunization, 19,075 reports among
females and 569 among males
 Majority were mild 92% and 8 % serious including 72 deaths, of which
34 were confirmed. There was no unusual pattern or clustering to the
deaths that would suggest that they were caused by the vaccine
CDC Vaccine Safety/Vaccines/HPV assessed on November, 15,2011
Vaccine Adverse Event Reporting System
 Most of the adverse reaction was not greater than those
reported with other vaccines, with the exception of
syncope and venous thromboembolic events, as detailed in
a 2008 report.
 Among 1896 syncopal reports , 15 % resulted in a fall or
injury
 Among the 31 with thromboembolism, 28(90%) had a
known risk factor( estogen-containing birth control pills or
a family history of clotting disorder). There were 4 deaths
among the pulmonary embolism cases
 Anaphylaxis has been reported. The over all risk rate of
anaphylaxis in the VAERS is .1 case per 100,000 doses.
Advisory Committee on Immunization
Practices
 ACIP recommends a routine 15 minutes waiting
period following vaccination so that the patient may
continue in a sitting or supine position as needed; this
may decease the risk of syncope with subsequent
injury.
 The rate of thrombotic events following HPV
vaccination was not increased among those without
prediposing risk factors
Cervical Cancer Screening
 Cervical cancer screening with Pap test has reduced
the incidence and mortality of cervical cancer by 70%
over the past six decades.
 Cervical cancer screening continues to be of great
importance since HPV immunization will not prevent
approximately 25-30% of cervical cancers in HPV
negative and does not protect women already infected
with carcinogenic HPV types against the development
of cancer.
Conclusion
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Vaccination against the most common types of
HPV causing disease is expected to dramatically
reduce the burden of illness associated with HPV.
Routine Pap smear screening is the best way to
detect pre-cancerous cells and prevent cervical
cancer
Dr Dudley Brown, Jr
Accepting New Patients (561)357-6277