June 28, 2013

HPV Vaccine Is a Clear Success

As we wrote a couple of years ago, adolescent vaccination rates for several diseases were up, and although the one for human papillomavirus (HPV) was among them, its rates lagged the others.

Being vaccinated against HPV before a person is sexually active protects girls from developing cervical cancer later in life and can protect boys from genital warts and penile and anal cancer. HPV is the most common sexually transmitted infection.

Despite the less than ideal vaccination numbers, there’s good news: The HPV vaccine is reducing the prevalence of the virus dramatically in teenage girls.

As reported by NPR, the Centers for Disease Control and Prevention (CDC) has released a study showing that in the first four years of immunization, infections from the four strains of the virus targeted by the vaccines fell by more than half among U.S. 14- to 19-year-olds.

The study, published in the Journal of Infectious Diseases, found no decrease in the HPV strains covered by the vaccine in other age groups, which supports the idea that the vaccine is responsible for the decrease among teenagers. Also supporting the association is the fact that researchers did not find that sexual activity among girls in the target population had decreased; still, the prevalence of HPV declined from nearly 12% to slightly more than 5%.

Despite the CDC’s vigorous promotion of getting kids vaccinated before they become sexually active, many parents resist, somehow thinking that being immunized is the same thing as giving permission to have sex. Others are wary in general of vaccines, an attitude we’ve addressed here, ( “More Proof that Vaccines Have Nothing to Do with Autism”) and here. (“Feds Say Childhood Vaccine Schedule Is Safe and Effective.”)

Federal health officials, according to NPR, were surprised at the significant decrease, considering that only about 1 in 3 girls in this age group has received the full three-dose course of the vaccine. About half have received a single dose.

The CDC recommends that girls get the HPV vaccine when they are 11 or 12, but females as old as 26 are urged to get the three-shot course if they have not received the vaccine earlier. The recommendation is the same for boys, except that the “catch-up” vaccination is recommended only until 21.

The cost, says NPR, runs $128 to $135 a dose, or around $400 for the full course, but it’s covered by many insurers, and Vaccines for Children, a federal program, provides it free for qualified patients.

The CDC’s goal is to get 80 percent of adolescents fully vaccinated. CDC Director Dr. Thomas Friedan told NPR, “Of girls alive today between the ages of zero and 13, there will be 50,000 more cases of cancer if we don't increase the rates to 80%. And for every single year we delay in getting to 80%, another 4,400 women are going to develop cervical cancer in their lifetimes — even with good screening programs."

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December 7, 2012

Pediatricians Support Routine Emergency Contraceptive Prescriptions for Teens

The American Academy of Pediatrics supports a policy that might discomfit some parents but that speaks to reality: Many teenagers regularly have sex, and they should be protected against unwanted pregnancy and the harms it can cause.

In a policy statement issued last month, the AAP said as part of routine care, pediatricians should counsel their adolescent patients about the use of emergency contraception (commonly known as Plan B, which is the brand name for one of the drugs used). Health-care providers should educate teens on the use and availability of these drugs, which interrupt the process of conception. Also, the AAP said, doctors should provide an advance prescription for one of three emergency contraceptive treatments, because they don’t work unless taken shortly after sexual intercourse, and because parental involvement might not be possible or advisable. Sometimes the risk of pregnancy is the result of sexual assault.

The goal of the policy statement is to:

(1) educate pediatricians and other physicians on available emergency contraceptive methods;
(2) provide current data on safety, efficacy and use of emergency contraception in teenagers; and
(3) encourage routine counseling and advance emergency-contraception prescription as part of a public health strategy to reduce teen pregnancy.

As the statement points out, in most states, kids younger than 17 must obtain a prescription from a physician to get emergency contraception. In all states, females 17 and older and males 18 and older can obtain emergency contraception without a prescription.

Providers should ensure the teens understand the possible side effects and adverse events that such drugs can cause, and make sure they also understand that these contraceptive measures do not offer protection against sexually transmitted infections.

The policy statement, written by the AAP’s Committee on Adolescence, was published in the journal Pediatrics.

The use of emergency contraception can reduce the chance of pregnancy as long as 120 hours after unprotected sex or in the event of contraceptive failure. Emergency contraceptive drugs, however, are most effective if taken within 24 hours after intercourse, which bolsters the need to have a prescription on hand.

Anything to do with contraception use can be fraught with spiritual, political and emotional pressure. Often referred to as the "morning after pill," emergency contraception is not the same drug regimen as that used to induce abortion after conception. Commonly called RU486, that drug is mifepristone (Mifeprex), which disrupts implantation of the fertilized egg. The emergency contraceptives supported for teens by the AAP elevate hormones that create additional uterine mucous, which prevents ovulation and fertilization if taken promptly after intercourse.

The incidence of pregnancy has decline among teenagers in the last two decades, but, as the Journal authors noted, U.S. birth rates remain “significantly higher than other industrialized nations.”

They also said teens are "more likely to use emergency contraception if it has been prescribed in advance of need."

As discussed on MedPageToday.com, each of the three methods the AAP supports for emergency contraception has distinct features:

Plan B requires patients to take two 0.75 mg levonorgestrel tablets 12 hours apart or a single 1.5 mg dose. Patients known to be pregnant should not take it. Also, it can cause nausea, vomiting and heavier menstrual bleeding. Patients should take a pregnancy test if they don’t have a normal period within 3 weeks of taking the drug.

Ulipristal is a single, 30 mg pill that should be taken within 120 hours after unprotected sex or contraception failure. Side effects can include headache, nausea and abdominal pain. Pregnant patients shouldn’t take it, as they risk loss of the fetus. Patients with severe abdominal pain three to five weeks after taking it should be evaluated for ectopic pregnancy.

The Yuzpe method requires patients to take two doses of at least 100 mcg of ethinyl estradiol and at least 500 mcg of levonorgestrel. It’s best for patients with no or limited access to an emergency contraception product. This use is off-label—meaning the patient takes it for a purpose other than what the FDA has approved it for—but the AAP says that this combination of oral contraceptives is safe and effective.

Side effects of the Yuzpe method include nausea and vomiting, fatigue, breast tenderness, headache, abdominal pain and dizziness. Patients who are not supposed to take estrogen should not use the Yuzpe method.

It’s always best when parents and teens can discuss the possible consequences of sexual activity and the provision of health care as appropriate. But it’s difficult, and just saying “no” is head-in-the-sand parenting. The medical establishment agrees that simply being young shouldn’t deprive people of getting the care they need to prevent unwanted, and often lifelong, consequences of accidents, immature behavior or victimization.

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