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Vexing vaccination issues for adolescents
Vaccinating adolescents demands a unique approach for patients and parents.
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As I try to fit another vaccination into the already crowded immunization schedule (and this time for adolescents!), I feel obligated to try to explain why I need to give this mother’s pre-adolescent or teenage daughter three or four shots at the present visit.
The tears usually tend to inundate the young daughter’s cheeks. How am I going to reassure her and find the time for this mother (or father) and daughter that these vaccines are worthwhile, and that they are safe?
Realize, I have raised four teenaged daughters. I thus empathize with facing the trepidation of teenage-needle phobia. I have experienced the exasperation of attempting to rationalize to the daughter the necessity of protecting our family members from strange and rare and distant “exotic” diseases. After all, who is going to ever personally see pertussis, meningococcal invasive disease or even cervical cancers or precancers? (Not my angels.) Unfortunately, these dangerous diseases are still continuously floating just beneath the surface.
Why give pertussis vaccines?
Pertussis is the new component of the combined tetanus, diphtheria and pertussis (TDaP) vaccine. The tetanus component has been mandated for middle school entry for tetanus prevention anyway. So discussion about the necessity of this vaccine is rather easy. Every family knows that a tetanus booster is needed each 10 years or so once a child starts school. We are just adding coverage for “whooping cough” with TDaP.
We have two different versions of TDaP available (Boostrix, GlaxoSmithKline; and Adacel, Sanofi Pasteur), beginning at age 10 or 11 years, respectively. Adverse events to the new formulation of TDaP are similar to the previous version of dT. It may even be given to pregnant or breast-feeding females.
Meningococcal vaccine
The protein conjugate meningococcal vaccine will soon be recommended for all teenagers between 11 and 18 years old, and not strictly targeted to age groups — thank goodness! (We had to ignore this loopy scheduling.) Most families have heard about some person in their community recently dying or being devastated by this dastard bacteria. Most are also aware of the hysteria which accommodates the discovery of a meningococcal case nearby their family.
Please note that the vaccine does not contain serotype B, which means the vaccine optimally will be about 70% protective in this population as well.
The only thorny issue for this otherwise rosy vaccine has been recent reports in the Vaccine Adverse Event Reporting System (VAERS) of some alleged temporal association of the vaccine with Guillain Barré syndrome. The reported cases barely exceed an added risk of 0.5 cases per million patients in a similarly-aged cohort, whereas the well-documented risk for invasive meningococcal disease approaches about 10 to 15 per million. Furthermore, based upon VAERS data, there appears to be no increased risk for those age 11 to 14. The slight increase risk over baseline only appears to be just in those aged 15 to 19.
For most families the word “meningitis” conjures up such dire and ominous thoughts that a protective vaccine usually needs little further explanation.
Why vaccinate for HPV?
The new quadrivalent human papillomavirus vaccine (HPV4, Gardasil, Merck) is recommended for all girls aged 11 to 12 with catch-up vaccination for those aged 13 to 25 years old. (9- and 10-year-olds are also included).
Two critical explanations should always be stated up front to families:
First, there is an available vaccine that can prevent a huge number of cases of a common female cancer/precancers, venereal warts, abnormal pap smears, colposcopies, cervical and vaginal surgeries and tremendous associated anxiety.
Second, most insurance companies or Vaccines For Children (VFC) funds cover most or all of its expensive cost.
Serotypes 16 and 18 account for 70% of all cervical precancers/cancers, and serotypes 6 and 11 account for 90% of all venereal warts.
Several further explanations generally arise with this vaccine and these follow.
The primary reason for giving this vaccine is efficacy. Yes, the vaccine is nearly 100% effective in preventing oncogenic invasion caused by the four type-specific strains. This would translate for the serotype naïve (most 9- to 15-year-olds and at least about 85% of 16- to 25-year-olds) to a 70% reduction for all cervical precancers/cancers; and a reduction in lifetime risk for venereal warts from 10% to 1%.
However, the published data so far suggests that for all 16- to 25-year-old women, a 17%-20% reduction of cervical precancer/cancers would occur in three years and a reduction in venereal warts from 1.0% to about 0.7% in three years.
The key operative limitation to this thinking is the three-year study interval. Most cervical precancers/cancers take more than five to 30 years to develop. (For more on this, see my next column in an upcoming issue.) I am impressed that much difference showed up at all this early in the follow-up phase.
We are witnessing some similar ominous changes in our practice as well, with a notable number of older adolescent females developing grade-2 or even grade-3 cervical lesions.
But what would be the effect in over two or three decades in the entire vaccinated population of 15- to 25-year-olds who have already been sexually active? Although at least 25-30% of women will become infected with HPV16 or HPV18 in their lives, I would guess that we will see a reduction in lifetime risk of cervical precancers/cancers from 3.7% to nearly 1.5% (strictly those caused by HPV 16 and 18), instead of 1.1% in the sexually naive group. Researchers writing in the Garland study in the New England Journal of Medicine (2007; 356:1928-43), noted HPV4 vaccination will also reduce the rate of VIN/VaIN 2/3 precancers by at least 0.1% as well. In summary, HPV4 vaccination could reduce the lifetime risk of all genital tract cancers by 4.2% to 4.7%.
Another aspect to consider when discussing HPV4 vaccine is durability. Protection has been documented for five years in adult women so far by immunologic data, and studies are ongoing. Remember, in our articles in Pediatrics 2006 and in the Pediatric Infectious Disease Journal 2007, the antibody titers in the 10- to 15- year-old girls after three doses of vaccine are nearly double that of young adult women, a group in whom nearly 100% serotype specific protectiveness has been established. In the younger girls, one year after the three-dose series, titers still remain higher than natural immunity and seroconversion rates approach 100%.
So the issue remains, when giving the vaccine to a 10- or 12-year-old, we expect one of two things. The vaccine will show nearly lifetime longevity because of high antibody titers, or we expect a booster dose may be needed sometime in the future (10 to 30 years, your guess is as good as mine). Either way, because adolescents have such a higher frequency of cervical HPV acquisition after sexual debut (37% to 55%), higher susceptibility to infection, and higher frequency of severe cervical disease (seven-fold), then starting vaccination both at age 11 or so in addition to 15- to 25-year-olds (once the horse is out of the barn and gone, so to speak) seems like a prudent approach.
Another factor to consider with HPV4 vaccine is safety. With several million doses already administered across the world, no isolated major adverse events other than background noise or a 10% rate of post shot syncope, have been reported. Yet we should warn our patients that the rates of local reactions for each dose will approximate the following: sore arm 50%, redness 10%, swelling 10%, with severe local reactions of about one in 100. Please be sure that the ladies remain sitting at least 15 minutes after vaccination.
The final aspect to consider when discussing the HPV4 vaccine is morality.
I cannot really argue religious beliefs when it comes to giving a vaccine to prevent cancer for one’s daughter. My only three questions for those parents who ask about morality are:
Would I give this vaccine to my daughters? (So you believe me, the AAP and the CDC or not?) Me, yes.
Does giving the TDaP booster promote your daughter’s stepping on rusty nails? Me, no.
And finally, you know my daughters are perfect angels too. Isn’t it all those boys that you cannot trust (OUCH!)
She is likely going to marry one of “those boys” one day and may be exposed to HPV then. It hurts to use the girls are better than boys argument. But if it opens the door to vaccination with HPV4, then perpetuation of the partial myth may be worth it.
Dr. Block has received research grants in the past from each of the manufacturers’ products discussed.
For more information:
- Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.
- Block SL, Nolan T, Sattler C, et al. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, 18) L1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics. 2006;118:2135-2145.
- Goldie SJ, Grima D, Kohli M, et al. Comprehensive natural history model of HPV infection and cervical cancer to estimate the clinical impact of a prophylactic HPV-16/18 vaccine. Int J Cancer. 2003;106:896-904 (ISSN: 0020-7136).
- Reisinger K, Block S, Ponce-Lazcano E, et al. Safety and persistent immunogenicity of a quadrivalent human papillomavirus types 6, 11, 16, 18 L1 virus-like particle in preadolescents and adolescents: a randomized controlled trial. Pediatr Infect Dis J. 2007:26:201-209.