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Pleading The Case For Boys To Receive The HPV Vaccine

A recent announcement is likely to generate a lot of controversy. The Advisory Committee on Immunization Practices of the CDC has recommended that boys and young men be vaccinated against human papillomavirus (HPV). Previously the guidelines said boys “could” be given the HPV vaccine. Now they have recommended that boys age 11 to 12 “should” be vaccinated, as well as boys age 13 to 21 who have not already had the full series of 3 shots. The vaccine can also be given to boys as young as 9 and to young men age 22 to 26.

The vaccine was originally promoted as a way to prevent cervical cancer. Boys don’t have a cervix, so why should they be subjected to a “girl’s” vaccine? There are some good science-based reasons:

  • Boys can transmit the virus to female sex partners later in life, leading to cervical cancer in women.
  • More importantly, boys themselves can also be directly harmed by the virus. It can cause genital warts, cancer of the head and neck (tongue, tonsils and throat), anal and penile cancer, respiratory papillomatosis, and giant condyloma of Buschke and Lowenstein. In rare cases, immunocompromised patients can develop epidermodysplasia verruciformis.
  • HPV has even been associated with cardiovascular disease.

Some of these conditions are not common, and the most common one, genital warts, may sound trivial. But “a picture is worth a thousand words,” so here is a link to a picture of a giant condyloma of Buschke and Lowenstein as an example of what HPV can do to the unvaccinated. The picture is not pleasant. If you are squeamish, you may not want to look at it. If you can’t even stand to look at it, imagine how devastating it would be to have it appear on your own body, and how nice it would be to be vaccinated against it.

The patient is a 45 year old man who had a 1-year history of discomfort when sitting. The picture shows a cauliflower-like verrucous mass around the anus, measuring 15cm in diameter. It required surgery. These lesions are rare, destructive tumors that mostly affect men under the age of 50. They are benign, but they destroy adjacent tissue, and malignant transformation can occur. They are caused by one of the types of HPV infection that can be prevented by the HPV vaccine, HPV type 6, which was confirmed by DNA analysis in this case.

Before anyone accuses me of relying on “anecdotal” evidence, that’s not what this is: this is an illustration of a rare but serious complication of HPV infection. If it appears alarmist, maybe that’s just what science needs to get its message across, to counteract all those emotionally laden stories of patients who were allegedly hurt (“Schoolgirl, 14, Dies After Being Given Cervical Cancer Jab”) and the lies that are continually published (“HPV Vaccine Kills At Least 21 Girls So Far”). Maybe science should fight back with headlines like “Failure to Get HPV Vaccine Causes Giant Flesh-Eating Wart!”

Gardasil is a quadrivalent vaccine that protects against HPV types 16 and 18, which are responsible for about 70 percent of cases of cervical cancer, and against types 6 and 11, which are responsible for 90 percent of genital warts. It also produces some degree of cross-immunity with other HPV strains. Overall prevalence of HPV in women in the US is 26.8%, although the prevalence of the types targeted by the vaccines is only 3.4%.  Most studies of HPV in men have reported a prevalence of least 20%, and some have reported much higher, up to 72.9%.  Prevalence data are misleading, because they do not reflect lifetime incidence or cancer risk: many infections resolve spontaneously, and it is the persistence of certain serotypes that leads to precancerous and cancerous lesions. By one estimate, between 75 percent and 80 percent of females and males in the United States will be infected at some point in their lives.  There is an alarmingly high incidence of new HPV infections in the teenage/young adult population, the group targeted for vaccines. Vaccines are most effective when given before initiation of sexual activity. These concerns have led to recommendations for legislation to facilitate vaccination.

The vaccine is very safe. Most reported side effects are mild, mainly local reactions with an occasional fainting episode. Deaths and serious adverse events after HPV vaccination have been reported to the Vaccine Adverse Event Reporting System, but none of these have been causally linked to the vaccine. The vaccine clearly works. Questions have been raised about its effectiveness, but epidemiologist Tara Smith has shown that those questions are misguided.   While it is too early to document its impact on cancers or mortality, there is clear evidence that the vaccine reduces the incidence of precursors for several types of cancer. A recent study in the NEJM confirmed its effectiveness in preventing anal intraepithelial neoplasia, a precursor of anal cancer, in men who have sex with men. The rate of anal cancer is increasing in both men and women, and it is hoped that the vaccine will reverse that trend. The rate of HPV-related head and neck cancer is increasing in young men, and can also be expected to decrease with vaccination.

I won’t get into ideology, cost-effectiveness, or the pros and cons of mandatory vaccination, but the science is clear: for both sexes, the benefits of this vaccine outweigh the risks. In The New York Times Dr. William Schaffner was quoted as saying

This is cancer, for Pete’s sake… A vaccine against cancer was the dream of our youth.

I made sure my daughters got the vaccine. If I had sons, I would vaccinate them too.

*This blog post was originally published at Science-Based Medicine*

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2 Responses to “Pleading The Case For Boys To Receive The HPV Vaccine”

  1. chloe says:

    Most people have herpes/hiv/hpv may feel lonely and shamed. But 70 million are afflicted with STD in the U.S. alone and an estimated over 400 million worldwide. There is an exclusive community PozSpaces,com for singles and friends with STD. If you just need to find someone to talk to or need help or advice, this is the best place. Never feel lonely again!

  2. akili says:

    Herpes is one of the most misunderstood std’s out there. The simple truth
    is that 90% of the adult population has it but doesn’t realize it. If you ever
    get a fever blister you have herpes. The only difference between mouth herpes
    and the other kind is simply where it’s located. It’s the same virus, resting at
    the back of your brain untill something triggers it and you get an outbreak.
    There is no difference in oral herpes and the other kind, just the location, and
    there is no cure for herpes, though drugs such as Valtrax can stop an ourbreak
    once you get one. Odds are these wrestlers already had the virus and why the big
    to do here is beyond me. You may know more about herpes on the dating and
    support site HerpesMate. Good luck to you all!

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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