MedicalMonday #2: HPV vaccination - danger or protection?

Attention men: if you are just about to skip this post, thinking HPV vaccination is a women's issue, rethink, keeping in mind that 64 to 70 % of the partners of HPV-infected women, are affected themselves.

In total, 2/3 of the human population gets infected by HPV once in their lifetime.

What is HPV?

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HPV is the short form for human papilloma virus, a DNA virus, of which over 170 types are known and about 40 types are transmitted through sexual contact.
It is the most common sexually transmitted infection worldwide.
The human papilloma virus is passed through skin-to-skin-contact of the genitals or sexual intercourse. Risk factors include multiple sexual partners, an early age of first sexual intercourse, having damaged skin area and smoking.
The virus can also be transmitted from a mother to her child during the birth, which can cause respiratory, as well as genital infection.

Most infections with the Human papilloma virus don't cause any symptoms and resolve spontaneously.
Nevertheless, depending on the type of virus, HPV can cause warts on hands, feet and genitals, but also is responsible for 5% of the global cancer burden.
Especially cervical cancer, concerning the female, and oropharyngeal cancer, concerning the male sex go hand in hand with persistent HPV infections.
Cervical cancer is unique in human cancers, as the etiologic agent, HPV, is fully established and proven that persistent infections of oncogenic HPV-types in the cervical epithelium lead to invasive carcinoma. HPV-16 and -18 are responsible for 70% of cervical cancer in the US.
Though anal, penile and vaginal cancer are much rarer, also a significant relation to HPV could be detected.

Number of human papillomavirus –associated cancers overall, and by sex

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Evaluation of HPV or HPV-related cervical cellular changes include a Pap smear, which should be done as routine during a gynecological examination, a DNA test and the use of acetic acid.
The DNA test is an evaluation method for the high-risk types of HPV and is recommended for woman 30 and older.
Also a biopsy of abnormal area can be necessary.
At the moment, there is no test available for men to check for HPV. Therefor diagnosis is based on visual inspection.

There is no cure or treatment for the HPV infection, but in the last few years HPV prevention, meaning vaccination, has been a big issue. The controversy of this sensitive topic leads us to the next point - HPV vaccination.

The history of HPV vaccination

After the first HPV vaccine had been released in 2006, the following years were marked by many terrifying stories and warnings on media concerning adverse effects and injuries or even death by HPV vaccination.
Till now, also here on Steemit I have already read horrifying warnings and stories, people are sceptic.

It is true, that the first version of HPV vaccine was worse tolerated in comparison to most other vaccines nowadays. Allergic reactions, pain or swelling and syncopes were reported. Even a few cases of seizures and paraesthesia have been seen.
Especially the story of a 13 years old girl, who wasn't able to handle life alone anymore after a seizure which occurred a view days after HPV vaccination attracted my attention and was, next to the importance of this topic concerning myself and many friends of mine, a reason for me to start research.
After reading through lots of studies, meta-analysis and articles, I haven't found any proof that the seizures were caused by the HPV vaccine, but I also have to admit that it also couldn't be proofen that it wasn't. Of course, this dilemma is an often discussed problem in the vaccination-topic.
So what can we do if we can't proof a question neither in the one, nor the other way?
We lean on statistics.

That's what I did and found out that at the beginning of the HPV vaccination series, indeed, seizures and anaphylaxis occurred in really rare cases.
Though the clinical approval process for medicines is really strict by now, many deficiencies come up when the substance is already distributed. What made the whole research process even more difficult concerning HPV, is that, as the name indicates, the human papilloma virus affects only human, which made it hard to perform experimentation on animals.

Nevertheless, the the blessing of medicine and science in general, is that it is constantly developing. As history shows, imperfection and failure is needed for improvement.
Therefor, the HPV vaccine industry has made great progress in the last view years and current studies encourage to rethink one's (when sceptic) opinion.

HPV vaccination nowadays

In May 2017, the HPV vaccine was included in national immunisation programmes for females in 71 countries and for males in 11 countries. Does this mean HPV vaccination is better tolerated by now?

First of all, it has to be said, that the current used vaccine is a 9-valent virus like particle vaccine, which means that it protects from 9 different HPY types in comparison to before used quadrivalent and before this, bivalent vaccines.
While the 4vHPV vaccine prevents cervical cancer in 70%, the 9vHPV does in about 90% of cases.

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To verify the safety of the HPV vaccination, I was looking for a study, as big and reliable as possible, as I know about the controversy and bipolar reliability of scientifically studies (you can find a study supporting nearly any opinion, if you look for it hard enough).
I came upon a review, including 109 studies, forty-one publications reported on a total of 81 clinical trials and twenty-nine studies of surveillance systems, as well as twenty-three case reports and 16 population-based studies across six countries.
The results concerning adverse effects of especially the 9vHPV vaccine (compared to the 4vHPV vaccine) are summarized as follows: Safety of Human Papillomavirus Vaccines: (Link)

Data report a similar safety profile in 9vHPV and 4vHPV vaccine, though injection-site reactions were slightly more frequent with the 9vHPV vaccine. It is assumed that this is related to the greater amount of the adjutant aluminium.
Frequencies of systemic adverse effects were similar, including headache the most common (11-14%). Also fatigue, muscle pain and nausea were reported, as they are known as adverse effects of nearly all vaccinations.
Anaphylaxis rate was detected 0.223 per 100,000 doses.
No significantly increased risk among venous thromboembolism as well as for autoimmune event could be found.
Further, no increased risk of multiple sclerosis or other demyelinating diseases, seizures or convulsion and even a reduced risk of epilepsy was reported.
These studies refer to HPV vaccination of females. Nevertheless, a lower proportion of adverse affects among men than woman was detected.

The study finishes with the following key points:

• There is a large volume of evidence on the safety of the human papillomavirus (HPV) vaccine.
• Our review has identified robust scientific evidence that supports the safety of the HPV vaccine.

The official recommendation by the Who is the following:
"WHO recognizes the importance of cervical cancer and other HPV-related diseases as global public health prob- lems and reiterates the recommendation that HPV vaccines should be included in national immunization programmes. Cervical cancer, which comprises 84% of all HPV-related cancers, should remain the priority for HPV immunization. Prevention of cervical cancer is best achieved through the immunization of girls, prior to sexual debut. All 3 licensed HPV vaccines – bivalent, quadrivalent and nonavalent – have excellent safety, ef cacy and effectiveness pro les."

Personal opinion

I come from a family, which is very sceptic against all forms of vaccination and had no vaccination during my childhood at all. As I am studying medicine now, I was not only committed to catch up on vaccination needed by hospital workers, but also was forced to deal with this topic as I suddenly found myself surrounded by complete contrary opinions than I was used to at home. I know that many doctors react pretty strict and harsh when it comes down to the vaccination discussion and I have to say that I also had a friable feeling when I went to get my first vaccination, because I was just used to see it as a dangerous thing from my childhood on.
Nevertheless, I have learned to inform myself adequately and then decide after scientifically proof what is best for me. Though I can understand fear and unsureness against vaccination, I would just recommend to inform oneself as good as possible and most important without prejudice.
Concerning the HPV vaccination, I don't want to give any recommendations. If you are interested and still not convinced what to do, please read through the given sources or talk to a gynecologist you trust.

Disclaimer: This is not a reliable scientifically article or recommendation. It is a summary of my knowledge and researches, tried to simplify to a level one without medical prior knowledge can understand easily. If you are informed better, please correct me.

Sources:

• Anastasia Philips, Cyra Patel, Alexis Pillsbury, Julia Brotherton, Kristine McCartney; Safety of Human Papillomavirus Vaccines: An Updated Review, Springer 2017
  https://link-springer-com.ez.srv.meduniwien.ac.at/article/10.1007%2Fs40264-017-0625-z
• Mia R Schmiedeskamp and Denise R Kockler; Human Papillomavirus Vaccines, The Annals Of Pharmacotherapy, 2006
  http://journals.sagepub.com.ez.srv.meduniwien.ac.at/doi/pdf/10.1345/aph.1G723
• Xianfang C.LiuaChristopher A.BellbKimberley A.SimmondsbLawrence W.SvensonabcMargaret L.Russella; Adverse events following HPV vaccination, Elsevier, Alberta 2006–2014
  https://ac-els-cdn-com.ez.srv.meduniwien.ac.at/S0264410X16002036/1-s2.0-S0264410X16002036-main.pdf?_tid=55c9ad4c-f972-11e7-8185-00000aab0f6c&acdnat=1515965692_c3ee243adf4cf916604dc12da8b06c01
• http://apps.who.int/iris/bitstream/10665/255353/1/WER9219.pdf?ua=1
• https://de.wikipedia.org/wiki/Humane_Papillomviren#Männer_und_HPV
• https://www.krebshilfe.net/information/krebs-risiko/infektionen-hpv/