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Am Fam Physician. 2007;75(1):28-30

See related article on page 117.

A medical intervention that is a true preventive tool and a good reason for anticipatory guidance and education does not come along often; the new human papillomavirus (HPV) vaccine is both. In June 2006, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommended universal administration of three doses of the quadrivalent HPV vaccine (Gardasil) in girls 11 or 12 years of age.1 The recommendation also allows physicians, at their discretion, to immunize girls as young as nine years and to vaccinate women up to 26 years of age.1

HPV is ubiquitous in human populations. Of the more than 40 serotypes of HPV known to cause genital infections, four (types 6, 11, 16, and 18) are responsible for approximately 70 percent of cervical cancer cases and 90 percent of genital wart cases in the United States.2 HPV acquisition occurs rapidly after the initiation of sexual activity. Fifty-four percent of females have been shown to have HPV infection within four years of first sexual intercourse.3 Moreover, sexual activity commences early in the United States: 29.3 percent of ninth-grade girls report prior sexual activity, a number that increases to 62.4 percent by 12th grade.4 Consequently, HPV infection is the most common sexually transmitted disease (STD) in American youth.5

HPV infection has significant consequences. In 2002, there were approximately 14,000 new cases of cervical cancer and 4,000 deaths from the disease, making it the 11th most common cancer in U.S. women.6 In addition, an estimated 300,000 high-grade and 1 million low-grade squamous intraepithelial lesions are detected each year, leading to multiple follow-up visits and invasive procedures (e.g., colposcopies, cervical biopsies). HPV infection accounts for expenditures of more than $2 billion per year and significantly affects patient privacy and comfort.6

The HPV vaccine is extremely effective, especially when it is provided before acquisition of the targeted serotypes. The vaccine prevents over 95 percent of HPV infections caused by serotypes 6, 11, 16, and 18, thus blocking the initial pathogenic step that leads to 70 percent of cervical cancers.2 Therefore, immunization before the initiation of sexual activity is of paramount importance. Later immunization can still provide protection, depending on the patient's history of HPV exposure. Although the vaccine can significantly reduce the incidence of cervical pathology, screening with Papanicolaou smears should continue because of the potential effects of HPV serotypes not covered by the vaccine.

The ACIP recommendation capitalizes on the extremely low likelihood of prior sexual activity in early-adolescent girls and facilitates the delivery of two other recommended vaccines (i.e., tetravalent meningococcal conjugate vaccine [MCV4; Menactra] and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis booster [Tdap; Boostrix, Adacel]). Together, these three vaccines provide the opportunity for important anticipatory guidance during early adolescence.

The onset of adolescence often is a time when patients generally are in relatively good health and do not visit their physicians; the majority of adolescent visits are for acute illness and injury. Nevertheless, patients need anticipatory behavioral guidance during adolescence. There is good evidence that educational interventions effectively reduce STD risk.7 Although there is no recommendation for a routine early adolescence visit, the American Academy of Family Physicians endorses discussing substance use (e.g., tobacco, alcohol), obesity, physical activity, and STDs with adolescent patients.8 The new HPV vaccination recommendation is an excellent starting point for enhancing these discussions. The potential benefit of this starting point is reduced, however, because the prevention and anticipatory guidance is targeted only at girls. Therefore, there is a need to further evaluate the effectiveness of this vaccine in males and to thoughtfully develop a routine early adolescence preventive health care visit for both sexes in family medicine settings.

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