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develop cancers. Indeed, one cancer is male
only. The cancers include the cervix, vagina
and vulva specifically in biologic females and
penis in the male. Both sexes have increased
risks for anal, head and neck tumors, and
esophageal cancers which typically occur in
the fourth decade or later. Another distressing
but nonmalignant condition caused by HPV
type 6 is recurrent respiratory papillomatosis
(RRP) where the upper airway and particularly
the vocal cords are covered by growths that
interfere with speaking and breathing and
cause hoarseness. RRP can lead to respiratory
failure due to obstruction by polyps. There are
2 varieties: the more usual is in infants who
acquire the infection by passage through an
HPV infected vagina and the other with same
presenting symptomatology in young (20s or
younger) sexually active adults.
The virus infects through small breaks in
the skin or mucosa when there is close contact.
The World Health Organization (WHO) has
designated HPV vaccine as an essential vaccine
in 2014; some countries have adopted access
for all those eligible. In the USA, insurers
have resisted covering the costs of vaccine
administration but have gradually yielded to
public health pressure and legislative fiats. The
younger the patient is, the higher the antibody
(protection) is and there is a higher antibody
protection if the vaccine is given before any
exposure to HPV by typical means. Indeed,
the recommendation is to give only 2 doses
of HPV vaccine if started before age 15 and
given at 6-month interval to complete series.
The female or male child can be vaccinated as
early as age 9 but a 6- to 12-month interval
is needed between doses. If for some reason
the second dose is given before 5 months, a
total of 3 doses will need to be administered
at least 4 months later. For both female and
male patients between ages 15 and 26, vaccine
intervals are at 0, 2, and 6 months. The Advisory Committee on Immunization Practices
(ACIP) of the Centers for Disease Control
and Prevention (CDC) has recommended
a three-dose vaccination schedule of 0, 2,
and 6 month intervals for women between
27 and 45 at risk for HPV infection as well
as immunocompromised individuals and
men who have sex with men. Boosters are
not recommended and if there is a delay in

recommended schedule, there is no additional
doses needed other than completing the two
or three doses recommended based on age.
Infection occurs frequently but does not
always lead to disease. The immune system
clears the virus in most individuals by age
30. That is why the American Society for
Colposcopy and Cervical Pathology (ASCCP)
recommends no testing for HPV virus before
age 30 except for those ladies who have an
abnormal Pap smear between ages 21 and 29.
Pap tests are not recommended under the age
of 21. Tobacco usage inhibits HPV clearance,
as there is 40-fold increased concentration
of cancer promoting compounds in cervical
mucus. Combined with a cancer-supporting
HPV type, the smoker has a higher risk for
cervical cancer.
The vaccine was first commercially available
in 2006 and was effective against HPV 16
and 18, the two types responsible for 70%
of cervical cancers. This vaccine is no longer
available in the United States; nor is the
quadrivalent vaccine which is active against
HPV types 6 and 11 which cause genital warts,

as well as the two cancer promoting subtypes
in the bivalent preparation. Currently, only
the nonavalent (9 types) vaccine is available
in USA. This preparation is active against
nine types: 6, 11, 16, 18, 31, 33, 45, 52, and
58 giving protection against another 20%
of cancers. We are still short of protection
from all cancer promoting types, but 90%
protection is better than no protection.
Interestingly, males with the proscribed
schedule of immunization show evidence
of seroversion (protection) in 99-100% of
cases, while females serovert at a 93-100%
rate. Protection is not dependent on a cellular
immune response, making this acceptable for
those with HIV and other infections.
Dr. Harald zur Hausen, who linked HPV
to cervical cancer, won a Nobel prize in
medicine in 2006 for his twenty-plus years
of study in Austria and Germany. The HPV
virus is a small (55 nm), nonencapsulated
DNA virus composed of 72 capsomeres. This
double-stranded circular virus has major and
minor protein antigens with 7904 DNA base
Continued on page 18
Central PA Medicine Fall 2019 17


CPM Fall 2019

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