[MUSIC] Welcome to Module IV Prevention, Vaccination, and the Horizon. This module explains HPV infection and the techniques for preventing infection. The nature of HPV vaccine and its effectiveness are also described. And the module reviews some of the indications for vaccination. The way I have set this module ip is through a series of questions. Questions that we as healthcare professionals typically field from patients with HPV and questions that we see from patients' family members as well. How, when, or from whom did I get HPV? That's a common question that we hear. HPV's a sexually transmitted virus and most sexually active people will get HPV in their lifetime. It really is impossible to know with any certainty from whom or when you acquired the HPV because most people don't know that they have it. Remember, this is a disease that largely is asymptomatic in 90% of people. Another question we see is how can we avoid or how can I avoid transmitting HPV to others. Well, lifetime mutual monogamy or abstinence are really the best ways to prevent transmission of the virus, although this is probably not realistic. Condom use and fewer sexual partners are considered the mainstay of prevention. Experts are still determining what risks, if any, sexual partners of patients with oropharyngeal cancer have in developing cancer. We do know that patients who have HPV associated oropharyngeal cancer are shedding the virus. That means they are transmissible but likely though virus that's transmitted has already been shared with your sexual partner and so it's difficult to know if there's any clinical significance of this. One of the questions we reserved quiet frankly is, if I become infected will I always be infected? A healthy immune response suppresses the virus in most infected people. And experts are still determining whether HPV remains in the body, when HPV is no longer contagious, and how long it takes between HPV infection and the development of oropharyngeal cancer. We do have a fairly good idea that from the time of transmission of the virus to the development of oropharyngeal cancer it can be between 10 and 20 years. Does HPV vaccination help? It absolutely does. HPV vaccine is important because it protects women against cervical cancer. The data is not clear on whether it protects our boys and young men from developing oropharyngeal throat cancer. However HPV is a very common virus. In nearly 80 million people about one in four are infected in the United States. As a result vaccination, because it's a extremely low risk with a very low toxicity profile, is strongly recommended for boys and girls. About 14 million people including teens become infected with HPV every year. Herd immunity requires that we try to achieve an 80% vaccination rate to significantly impact the transmission of this virus through the general population. What is HPV vaccine? Well, this is a common question because although most people hear about vaccinations, they don't understand them completely. In 2006 when vaccination was approved, it was approved by two different companies. The Merck product which was the tetravalent vaccine, this covered 6, 11 the low risk types, as well as 16 and 18 the high risk type. Another product was produced, the bivalent vaccine, covering just 16 and 18. More recently, the food and drug administration has approved Gardasil 9. This is a recombinant vaccine that covers nine different types of the precancerous or cancer causing HPV infections. In addition to 16 and 18, it covers 31, type 33, 45, 52, and type 58. It also covers the low risk types 11 and 6, but it's believed that the new types that are covered will hopefully cover 20% of currently uncovered cervical cancers in women. What's the impact of this 9-valent vaccine on throat cancer in young men? Again, this remains to be determined, because it's very early, and it'll take several years before the data comes out. Who is appropriate for HPV vaccination? A common question among pediatricians, obstetricians, and parents. HPV vaccine is recommended for all preteen boys and preteen girls, typically in the age range of 11 or 12. So that they're protected before ever being exposed to the virus. The idea is to vaccinate these kids before sexual debut. The HPV vaccine produces a more robust immune system response in these young patients. And so the younger they are, at least within this age range, the better you're going to get coverage in the future. HPV vaccine is given in three shots. The first shot is given followed by a second shot one to two months thereafter. And a third injection is given within six months of the initial shot. The CDC strongly recommends that all three injections are given to achieve the most robust immune response and protection which is ideal for the vaccine. Is there a way to detect HPV associated cancer such as a Pap smear? Well, there's no current method for detecting cancer in the precancerous stage. The Pap smear used for cervical cancer would be ideal if we could find an approach for throat cancer in young men and young women. However, this doesn't quite yet exist. Its the subject of significant research at the current time. There is no recommendation for screening. However, patients that present with an oral papilloma, which is a warty like lesion that is a result of the HPV infection. We typically perform an excisional biopsy removing the wart and then testing that. In those cases where it's low risk type, 6 and 11, we'll follow those patients, typically, once a year. In the higher risk types, such as 16, 18, and some of the others we discussed. Those patients we typically follow a little bit more closely because of the precancerous nature of that type. We see those patients and follow them with a head and neck examination every three to four months. Although, there's no consensus on this and that must recognized. There's no evidence that patients with a history of cervical HPV are at higher risk for HPV associated throat cancer. So women with cervical cancer as a result of HPV don't demonstrate a higher risk of throat cancer. And the data is still being collected to determine if there's an association with men who develop throat cancer transmitting this type of virus and the precancerous virus to women. What should I tell my partner about my HPV status? Well, most infected people do not have any signs or symptoms. However, if you decide to talk with your partner about your HPV status we recommend that you talk openly and very honestly. It's important to recognize that partners who have been together any length of time typically share HPV. Although it's important also to recognize that it's impossible to understand the direction of transmission. HPV is a very common virus and it does not imply infidelity nor does it imply promiscuity. So there should be no blame, no shame associated with the HPV diagnosis. There is a psychosocial impact of HPV, and there's a significant emotional distress in women recently diagnosed with HPV associated cervical cancer. They express feelings of guilt, depression, confusion and even lowered self-esteem. And it's these findings that warrant a very careful and serious counseling program. Which we spend a great deal of time with our patients reviewing and discussing so that there aren't those feelings of guilt and depression. And they understand the nature of the disease and the nature of the infection that caused the disease. Summary of Module IV. Lifetime mutual monogamy is probably the best way to prevent transmission of HPV, however this is not likely realistic. Although HPV may integrate into the host DNA, our healthy immune system typically will suppress the virus in most infected people. HPV is a sexually transmitted virus, as we discussed, and most sexually active people will get HPV in their lifetime. That doesn't mean that they're necessarily going to develop HPV associated cancers. And finally, HPV vaccine is critically important both for women and for men. And they should be administered in three shots, given at one to two months after the initial injection, and within six months of the initial injection. And the course should be completed. I appreciate you spending the time with me on Module IV and as typical, there will be a series of questions that follow this module. If you're interested in achieving the course for CME credits, you can find the course on the Coursera online website. Thank you. [MUSIC]
