Discussion

Can you provide more information on the durability of the HPV vaccine?

Stan L. Block, MD, FAAP: We know from HPV4 vaccine studies that protection lasts at least 5 years. We expect data over the next few years to support that it lasts longer. With the hepatitis B vaccine, 3 doses are given during infancy and permanent protection is assumed. Similar to the hepatitis B vaccine, the HPV vaccine is a virus-like particle. I assume the HPV vaccine will provide long-term protection as well.

How critical is it to get the second shot?

Block: I tell all sexually mature adolescent patients that it is imperative to get the second shot. With 2 shots, data show adequate antibody response to provide antiviral protection for at least 1 year and possibly longer. Practitioners should emphasize to the adolescents that they must come back in 1 to 2 months to get their second dose. But to have long-term immunity, completing the series of 3 shots is essential.

How should practitioners talk to families who, for religious or other reasons, may believe their children do not need the HPV vaccine because it does not pertain to their community or lifestyle?

Rachel N. Caskey, MD, MaPP: This issue should be approached as you would anything else; that is, assess the family’s comfort level and understand their perspective and beliefs. If not getting the vaccine is something they believe strongly about, vaccination could wait for this family. The main caveat to this approach is the risk that the child will not remain within that lifestyle and community, or will partner with someone who had previous exposure, or may have an involuntary sexual exposure. Although it is important to be sensitive to the parent’s beliefs, practitioners should share with them the potential risks if the child’s lifestyle or community may change in the future.

In head and neck cancer, how is an HPV etiology distinguished from the effects of tobacco use, and what are some other risk factors for head and neck cancer?

Kenneth A. Alexander, MD, PhD: Head and neck malignancies are from 1 of 2 groups. Those that are HPV-associated are typically in younger adults (eg, people in their late 30s and 40s). The classic squamous cell carcinoma typically occurs in older men, in their 60s and 70s, and includes those who are smokers and/or have alcoholism. There has been no change in the incidence rate of the latter, but we are seeing a steady increase in the rate of HPV-associated malignancies, and these occur in nonsmoking and non-drinking younger men. Not surprisingly, as the number of sexual partners increases, so does the rate of HPV-associated head and neck malignancies. This correlation probably relates to the number of partners where there is orogenital contact. However, a lack of clarity currently exists because there appear to be nonsexual means by which HPV can be transmitted as well.

If numbness and pain occur after the first HPV shot, should the second be given?

Block: In the clinical trials, if this occurred following the first shot, we gave the next shot with the subject’s permission, and did not observe an increase in adverse reactions. An exception was made for subjects who had a major local reaction (eg, an Arthus reaction). In those cases we did not continue with the vaccine series.

What about patients who faint after the HPV4 vaccine?

Block: The key to this issue is to ensure that the patient sits and waits 15 minutes after the vaccine before moving. If they are permitted to leave early, they may have a vasovagal reaction, collapse, and even experience a seizure or deadly injury.