Adolescent Immunizations Bill Cosgrove, MD FAAP Tri-county Immunization CoalitionApril 23, 2114
Adolescent Immunizations Credentials: Chair of Immunization Committee, UTAAP (since 1987) Chair, Utah Every Child By Two Immunization Coalition (in abeyance) Member, Steering Committee USIIS Member, Utah Scientific Immunization Advisory Committee President-elect of Utah Chapter AAP Conflict of interest: None
Adolescent Immunizations While we do a pretty good job of immunizing our infants/toddlers: 4:3:1:3:3:1 USA 71.9% 4:3:1:3:3:1 Utah 74.9% 4:3:1:3:3:1 TriCounty 63.9%
Adolescent Immunizations • We don’t do as well protecting our teens: • Tdap: • USA 84.6% • Utah 81.5%
Pertussis • Utah outbreak: • 1544 cases in 2012 • 1219 cases in 2013 • Highest incidence age 12-16
Adolescent Immunizations • Meningococcal: • USA 74.0% • Utah 56.5% • TriCounty 32.7% • Rates of invasive meningococcal disease are estimated as about 1:100,000. However, each case has sudden devastating effects on an entire community.
Adolescent Immunizations • HPV 3 doses, Girls 13-17: • USA 33.4% • Utah 24.1% • TriCounty 5.5% • Boys ?
Human Papillomavirus • HPV is a cancer-causing virus. • We have an excellent, safe, effective vaccine. • We don’t use it to protect our teens. • Why?
HPV Infection • Almost all females and males will be infected with at least one type of HPV at some point in their lives • Estimated 79 million Americans currently infected • 14 million new infections/year in the US • HPV infection is most common in people in their teens and early 20s • Most people will never know that they have been infected Jemal A et al. J Natl Cancer Inst2013;105:175-201
HPV Infection • 80% of us have been (or will be) infected with HPV. • 2-5% of adults remain virgins. • Most will be exposed to HPV.
HPV Transmission • HPV exposure can occur with any type of intimate sexual contact • Intercourse is not necessary to become infected • Nearly 50% of high school students have already engaged in sexual (vaginal-penile) intercourse • 1/3 of 9th graders and 2/3 of 12th graders have engaged in sexual intercourse • 24% of high school seniors have had sexual intercourse with 4 or more partners Jemal A et al. J Natl Cancer Inst2013;105:175-201
HPV is found in virgins • Study examined the frequency of vaginal HPV and the association with non-coital sexual behavior in longitudinally followed cohort of adolescent women without prior vaginal intercourse • HPV was detected in 46% of women prior to first vaginal sex • 70% of these women reported non-coital behaviors that may in part explain genital transmission Shew, J Infect Dis. 2012
Rapid acquisition of HPV in following sexual debut Study of 18-23 year-old males (n=240)
Average Number of New HPV-Associated Cancers by Sex, in the United States, 2005-2009 n=1003 n=2317 n=3039 n=694 n=1687 n=3084 Oropharynx n=9312 n=11279 • Jemal A et al. J Natl Cancer Inst 2013;105:175-201
HPV-Associated Oropharyngeal Cancers • Prevalence increased from 16.3% (1984-89) to 71.7% (2000-04) • Population-level incidence of HPV-positive cancers increased by 225% while HPV-negative cancers declined by 50% If trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020 Chaturvedi, 2011, J Clin Oncol- data from SEER
Why We Need to Do Better in HPV Vaccination of 12 year olds For each year we stay at 30% coverage instead of achieving 80%, 4,400 future cervical cancer cases and 1400 cervical cancer deaths will occur. • Currently 26 million girls <13 yo in the US; If none of these girls are vaccinated then: • 168,400 will develop cervical cancer and • 54,100 will die from it • Vaccinating 30% would prevent 45,500 of these cases and 14,600 deaths • Vaccinating 80% would prevent 98,800 cases and 31,700 deaths
Vaccines save lives (and anguish) • Most infected with HPV will have no symptoms. • Some feel shamed and disfigured by genital warts. • Some feel the fear and anguish of waiting for results of abnormal PAP smears or biopsies. • Some will experience cancer, hysterectomy, chemo, etc. • Some will die.
Guilt • All will have to deal with the burden of responsibility that they in turn also gave this virus to those they loved.
Alternatives to Vaccinating? • We can wait until the adolescent can safely make adult decisions…… • The pre-frontal cortex, responsible for emotional control and cognitive processing finally is fully formed by age 24-25. • We can hope that they “just say no”.
Sexual activity of teens • By age 12: 2% • By age 15 16% • By age 17 48% • By age 19 71% • http://www.guttmacher.org/pubs/FB-ATSRH.html
HPV Prophylactic Vaccines • Recombinant L1 capsid proteins that form “virus like” particles (VLP) • Non-infectious and non-oncogenic • Produce higher levels of neutralizing antibody than natural infection HPV VLP
HPV Vaccines • Gardisil covers HPV types 16, 18, and 6, 11 • Cervarix covers HPV types 16, 18 • Licenced for girls in 2006, for boys 2009
HPV Vaccine safety • 57 Million doses in the US • Safety similar to MCV4 and Tdap • Small risk of fainting
What can we do? • We cannot wait. • We must get our children protected while we can. The risk of exposure gets higher as months go by. • We, their health providers, must seize every opportunity to immunize our teens. A missed opportunity may well be our last (or only) chance.
Every teen • Identify needed vaccines for every teen that enters your office. • Teens have infrequent “well child” visits. • Sports exams, Scout exams. • Injury or illness visits. • Print vaccine forecast sheet for every teen (best for every child visit).
Delivery • This is a cancer vaccine. The conversation doesn’t have to be about sex. • We don’t spend a lot of time talking about the fecal-oral route, when we provide rotovirus vaccines. • Talking about modes of transmission just scares people off.
Delivery • If the parent asks about whether this vaccine is a license to take sexual risks, then site a study showing no increase in sexual activity after the vaccine. • http://pediatrics.aappublications.org/content/early/2012/10/10/peds.2012-1516
Delivery • HPV vaccine is no more a license to have sex, than the Tdap is license to go barefoot in the backyard and stomp around looking for nails.
Delivery • The strongest influence on whether a child gets the vaccines, is a strong recommendation from their doctor.
Delivery • After matter-of-factly announcing that of course their teen will get Tdap and Menactra, we (voice quavering) meekly suggest that we “need to talk” about HPV. Our delivery sends a louder message than our words. And our delivery is scaring some away.
Delivery • The message is: We can prevent these genital cancers….but only if we start now. Before exposure. • So, don’t be tentative. Deliver the message like somebody’s life depended on it.
HPV • The cancers are 20 years away. So why worry? • A time bomb, ticking down. And we don’t have a way to cut that red, no blue, wire. • But, we can prevent.
Teens • Teens, just like the toddlers they so recently were, are energetic, creative, and yet often obnoxious, • And they are worth saving.
Challenge • Go back to your office, and convince one family to immunize their teen. • Then, having saved a life (either this teen or one of their contacts)… • take the rest of the day off.