Chester County Medicine Fall 2018 - 18

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Rationale for Promoting
HPV Vaccination in
Healthcare Settings
BY VICTOR ALOS, DMD, MPH, MS

T

he Human Papilloma Virus (HPV) is DNA, 8-gene,
ancient virus that has evolved over millions of years in
different species including humans. HPV is exclusively
an intraepithelial parasite. Experts estimate that there are close
to 200+ types of HPV.1 There are approximately 15 cancercausing HPV types from which HPV16 and 18 causes 70% of all
cervical cancers.2 HPV avoids detection of our immune system for
months. In approximately 10-20% of cases our immune system
cannot clear the HPV virus, leading to a persistent infection and
eventually to cancer. HPV evading-immune system mechanisms
include no viremia, having very low viral particles, preserving host
cells and replicating in epithelial cells in the process of cell death.2

Oropharyngeal squamous cell carcinoma (SCC) is now the
most common HPV-associated cancer in the United States.3
White men have higher rates of HPV related oropharyngeal
SCC than other racial and ethnic group.4 African American and
Hispanic women experience highest rates of HPV related cervical
cancer.5 The 2010-2014 incidence rate for oral and pharyngeal
cancer (all races, ages, both genders) showed an increasing trend
in Chester County. The county oral and pharyngeal age-adjusted
incidence rate for females ages 40+ in early stage cancer was
statistically significantly higher when compared to Pennsylvania
(2011-2015 data).6
Oral cancer screening includes
review of medical and dental
histories, signs and symptoms
such as long-lasting sore throat,
earaches, hoarseness, swollen lymph
nodes, pain when swallowing, and
unexplained weight loss. Providers
also examine lumps or irregular
tissue changes in the patient's neck,
head, cheeks, eyes, nose, scalp,
face, lips, and oral cavity including
irregularities, sores
or discolored tissues (red and white
lesions), facial asymmetry, masses, skin lesions, facial paralysis,
swelling or temporal wasting.7
1 8 C H E S T E R C O U N T Y M e d i c i n e | FA L L 2 0 1 8

Physicians' and dentists'
professional associations encourage
providers to educate themselves and
their patients about HPV and
associated diseases, HPV vaccination, as well as routine cervical
and oral cancer screening. Persistent HPV infection is the most
important risk factor for cervical cancer precursors and cervical
cancer, independent of other risk factors such as smoking. The
longer high-risk HPV infection is present, the greater the risk of
high-grade squamous intraepithelial lesions (HSIL). The peak age
for HPV infection is in the early 20s, leading to a peak prevalence
of HSIL around age 30, with the highest cancer risk at ages 45 to
60.8
Barriers to HPV vaccination discussion with patients among
physicians include parents needing more information before
vaccinating their children, concerns and the cost of HPV
vaccination, perception that there is no need to vaccinate boys,
parents forgetting dose schedules. A doctor recommendation
was key in children getting vaccinated.9 Dentists' barriers include
providers' lack of education about HPV infection and prevention
methods, level of comfort about counseling on safe sex practices,
especially adolescent patients and different cultural groups, belief
of risk that adolescents might initiate sexual behavior earlier, fear
that HPV discussion is taken as a judgment of patients' behaviors,
need for better communication skills and trusted informational
sources, and lack of privacy - physical structure / open dental
operatories/chairs.10
Experts recommend routine HPV vaccination at age 11 or
12 years for boys and girls and starting vaccines at 9 years of age.
Also recommend vaccination for females through age 26 years
and for males through age 21 years who were not adequately
vaccinated previously. Males aged 22 through 26 years may
be also be vaccinated.11 Suggested strategies to promote HPV
vaccination consist of recommending the HPV vaccine the same
way as other adolescent vaccines, e.g., Now that your child is 11,
he/she needs three vaccines to help protect against meningitis,
HPV cancers, and whooping cough, creating a culture of
immunization in your office, implementing systems to ensure


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Chester County Medicine Fall 2018

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