HPV Vaccines, for Everyone.

Human Papilloma Virus (HPV) is the virus that causes more than 90% of cervical cancers, roughly 70% of vulvar and vaginal cancers, most anal cancers, and more than 60% of penile cancers. While oropharyngeal cancers (those affecting the mouth, throat and neck) have traditionally been caused by tobacco and alcohol, the CDC reports that 70% of cancers of the oropharynx may be linked to HPV.


Prevalence of HPV Infection in Adults


Eighty-five percent of adults will have had HPV at some point in their lives. The highest incidence of new HPV infections has been seen in women under 20 years of age. People commonly think that older adults or people in monogamous relationships are not at risk of acquiring HPV infections and HPV-related disease such as genital warts, and cancers. While the risk of HPV is higher in the teenage years and in the early 20s, research shows that risk is not limited to young people or those who are dating, and HPV infections continue to increase as patients get older.


For women over the age of 30, if they do not have an HPV infection, their risk of acquiring HPV over five years is more than 20%. For women over the age of 45, the 5-year risk of acquiring HPV is still more than 10%. The risk is not zero, regardless of age.


A study from the National Health and Nutrition Examination Survey 2007-2010 (including American women ages 18-59 years) showed that the prevalence or chance any of those women had an HPV infection was 42% across the group, and as high as 59% in non-Hispanic black women. While the prevalence of HPV in women declines with age, the prevalence of HPV in adult women over 50 is still quite high, at 35%.


The prevalence of HPV is even higher in men, about 63%, and studies show it does not decline with age.


In Ontario, we immunize girls and boys in grade 7 against HPV because the immune response to the vaccine is highest from age 9-15, and we hope to protect them before they become sexually active. There is still a need to immunize adults: sexual behaviour patterns are changing with high rates of online dating, divorce, and infidelity, so risk of exposure may persist or recur. But new exposure is not the only reason to vaccinate...


Clearance Rates of HPV


Persistence of HPV infections increases with age, so if you do acquire HPV, the chance you will be able to clear it decreases the older you get. And the forms of HPV most linked to cancer (such as type 16 and 18) are more aggressive and harder to clear.


Some patients may have latent (inactive) HPV infections that only surface as they get older; this may explain why some women in monogamous relationships or who are no longer sexually active develop HPV-related disease: they had an earlier exposure to HPV, but only as they age does this infection become active and cause illness.


What About Natural Immunity from Previous Infection?


Many women (and men) do not develop any natural antibodies to HPV infection, and infection with one strain of HPV does not appear to protect us from infection with other types of HPV. Even if you do develop antibodies, these natural antibodies do not seem to protect against subsequent infection, even with the same type of HPV! HPV antibodies from a natural infection basically only tell us that you have had an exposure - they do not protect you from future HPV infection.


Universal Vaccination: Regardless of Age


The wonderful news is that HPV immunization produces high levels of antibodies that are protective against subsequent infection. The antibodies produced from vaccination are long-lasting and do not require booster dosing once you have completed the full series of HPV vaccines. HPV vaccination reduces recurrence of disease in those who have previously been exposed and treated for disease, and has reduced recurrence of disease in the cervix, vulva, and anal precancerous cells, and for external genital warts.


The Society of Gyn-Oncologists of Canada (GOC) recommend universal HPV vaccination, regardless of age. The National Advisory Committee on Immunization (NACI) recommends vaccination in all individuals, female and male, from age 9, with no upper age limit.


It is never too late to be immunized against HPV. It's a vaccine that PREVENTS CANCER.


Book an appointment for a pap smear, HPV testing, and to get your HPV (Gardasil9) vaccine.


REFERENCES

  1. Muñoz N, Méndez F, Posso H, et al. Incidence, duration, and determinants of cervical human papillomavirus infection in a cohort of Colombian women with normal cytological results. J Infect Dis. 2004;190:2077-2087.

  2. Shi R, Devarakonda S, Liu L, et al. Factors associated with genital human papillomavirus infection among adult females in the United States, NHANES 2007-2010. BMC Res Notes. 2014;7:544.

  3. Giuliano AR, Lazcano-Ponce E, Villa LL, et al. The human papillomavirus infection in men study: human papillomavirus prevalence and type distribution among men residing in Brazil, Mexico, and the United States. Cancer Epidemiol Biomarkers Prev. 2008;17:2036-2043.

  4. Winer RL, Hughes JP, Feng Q, et al. Prevalence and risk factors for oncogenic human papillomavirus infections in high-risk mid-adult women. Sex Transm Dis. 2012;39:848-856.

  5. Nyitray AG, Carvalho da Silva RJ, Baggio ML, et al. Six-month incidence, persistence, and factors associated with persistence of anal human papillomavirus in men: the HPV in men study. J Infect Dis. 2011;204:1711-1722.

  6. Castle PE, Schiffman M, Herrero R, et al. A prospective study of age trends in cervical human papillomavirus acquisition and persistence in Guanacaste, Costa Rica. J Infect Dis. 2005;191:1808-1816.

  7. Bulkmans NW, Berkhof J, Bulk S, et al. High-risk HPV type-specific clearance rates in cervical screening. Br J Cancer. 2007;96:1419-1424.

  8. Berggrund, M., Gustavsson, I., Aarnio, R. et al. HPV viral load in self-collected vaginal fluid samples as predictor for presence of cervical intraepithelial neoplasia. Virol J. 2019;16:146.

  9. Wieland U, Kreuter A, Pfister H. Human papillomavirus and immunosuppression. Curr Probl Dermatol. 2014;45:154-165.

  10. Liu G, Sharma M, Tan N, Barnabas RV. HIV-positive women have higher risk of human papilloma virus infection, precancerous lesions, and cervical cancer. AIDS. 2018;32:795-808.

  11. Cistjakovs M, Sultanova A, Jermakova O, et al. Importance of high-risk human papillomavirus infection detection in female renal transplant recipients in the first year after transplantation. Infect Dis Obstet Gynecol. 2018:2018:9231031.

  12. Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases Ann Rheum Dis. 2020;79:39-52.

  13. Doorbar, J. Latent papillomavirus infections and their regulation. Curr Opin Virol. 2013;3:416-421.

  14. Giuliano AR, Viscidi R, Torres BN, et al. Seroconversion following anal and genital HPV infection in men: the HIM study. Papillomavirus Res. 2015;1:109-115

  15. Beachler DC, Jenkins G, Safaeian M, et al. Natural acquired immunity against subsequent genital human papillomavirus infection: a systematic review and meta-analysis. J Infect Dis. 2016;213:1444-1454.

  16. Pamnani SJ, Sudenga SL, Viscidi R, et al. Impact of serum antibodies to HPV serotypes 6, 11, 16, and 18 to risks of subsequent genital HPV infections in men: the HIM study. Cancer Res. 2016;76:6066-6075.

  17. Olsson SE, Kjaer SK, Sigurdsson K, et al. Evaluation of quadrivalent HPV 6/11/16/18 vaccine efficacy against cervical and anogenital disease in subjects with serological evidence of prior vaccine type HPV infection. Hum Vaccin. 2009;5:696-704.

  18. Castellsagué X, Muñoz N, Pitisuttithum P, et al. End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24-45 years of age. Br J Cancer. 2011;105:28-37.

  19. Government of Canada. Update on the recommended Human Papillomavirus (HPV) vaccine immunization schedule. Accessed August 3, 2021. https://www.canada.ca/en/public-health/services/publications/healthy-living/update-recommended-human-papillomavirus-vaccine-immunization-schedule.html

  20. Muñoz N, Manalastas R Jr, Pitisuttithum P, et al. Safety, immunogenicity, and efficacy of quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine in women aged 24-45 years: a randomised, double-blind trial. Lancet. 2009;373:1949-1957.

  21. CDC. Human papillomavirus (HPV): cancers caused by HPV. Accessed August 3, 2021. https://www.cdc.gov/hpv/parents/cancer.html

  22. Swedish KA, Factor SH, Goldstone SE. Prevention of recurrent high-grade anal neoplasia with quadrivalent human papillomavirus vaccination of men who have sex with men: a nonconcurrent cohort study. Clin Infect Dis. 2012;54:891-898.

  23. Swedish KA, Goldstone SE. Prevention of anal condyloma with quadrivalent human papillomavirus vaccination of older men who have sex with men. PLoS One. 2014;9:e93393.

  24. Kang WD, Choi HS, Kim SM. Is vaccination with quadrivalent HPV vaccine after loop electrosurgical excision procedure effective in preventing recurrence in patients with high-grade cervical intraepithelial neoplasia (CIN2-3)? Gynecol Oncol. 2013;130:264-268.

  25. Ghelardi A, Parazzini F, Martella F, et al. SPERANZA project: HPV vaccination after treatment for CIN2. Gynecol Oncol. 2018;151:229-234.

  26. Pieralli A, Bianchi C, Auzzi N, et al. Indication of prophylactic vaccines as a tool for secondary prevention in HPV-linked disease. Arch Gynecol Obstet. 2018;298:1205-1210.

  27. Ghelardi A, Marrai R, Bogani G, et al. Surgical treatment of vulvar HSIL: adjuvant HPV vaccine reduces recurrent disease. Vaccines (Basel). 2021;9:83.

  28. The Society of Gynecologic Oncology of Canada. Opportunistic HPV vaccination: an expanded vision. Accessed August 3, 2021. https://g-o-c.org/wp-content/uploads/2015/01/18_EEE_WhitePaper_FINAL_Jun18-1.pdf

  29. CERVARIX [monographie de produit]. Accessed August 3, 2021. https://ca.gsk.com/media/673224/cervarix.pdf

  30. CERVARIX [product monograph]. Accessed August 3, 2021. https://ca.gsk.com/media/589880/cervarix.pdf

  31. GARDASIL® 9 [product monograph]. Accessed August 3, 2021. https://www.merck.ca/static/pdf/GARDASIL_9-PM_E.pdf

  32. Fu TC, Carter JJ, Hughes JP, et al. Re-detection vs. new acquisition of high-risk human papillomavirus in mid-adult women. Int J Cancer. 2016;139:2201-2212.