tag:theconversation.com,2011:/africa/topics/human-papillomavirus-3966/articlesHuman papillomavirus – The Conversation2022-05-31T12:12:43Ztag:theconversation.com,2011:article/1699132022-05-31T12:12:43Z2022-05-31T12:12:43ZWhat are HeLa cells? A cancer biologist explains<figure><img src="https://images.theconversation.com/files/465571/original/file-20220526-14-aez4rh.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1022%2C771&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cancer-causing viruses like HPV can cause cells to divide indefinitely and, in the case of Henrietta Lacks, become immortal.</span> <span class="attribution"><a class="source" href="https://flic.kr/p/A5Q7L1">Tom Deerinck/NIH via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>In an amazing twist of fate, the aggressive cervical cancer tumor that killed <a href="https://www.npr.org/2010/02/02/123232331/henrietta-lacks-a-donors-immortal-legacy">Henrietta Lacks</a>, a 31-year old African American mother, became an <a href="https://osp.od.nih.gov/scientific-sharing/hela-cells-timeline/">essential tool</a> that helped the biomedical field flourish in the 20th century. As a <a href="https://www.researchgate.net/scientific-contributions/Ivan-Martinez-2109620653">cancer researcher</a> who uses HeLa cells in my everyday work, even I sometimes find it hard to believe. </p>
<p>On Aug. 1, 2023, over 70 years after doctors took Lacks’ cells without her consent or knowledge, her family <a href="https://apnews.com/article/henrietta-lacks-hela-cells-thermo-fisher-scientific-bfba4a6c10396efa34c9b79a544f0729">reached a settlement</a> with biotech company Thermo Fisher. Lacks’ descendants had sued the company in 2021 for making billions of dollars off her cells. The family has not been previously been compensated.</p>
<p>Lacks’ cervical cancer cells, called “HeLa” after the first two letters of her first and last name, <a href="https://www.science.org/content/article/art-culture-developing-cell-lines">are immortal</a>, continuing to divide when most cells would die. This ability to survive through endless generations of cells is what makes them invaluable for scientists conducting experiments on human cells.</p>
<h2>Why HeLa cells matter</h2>
<p>Before HeLa cells, scientists wanted a way to grow and study human cells in the lab to conduct studies that are impossible to do in a living person. When Lacks’ cervical cancer cells were <a href="https://osp.od.nih.gov/scientific-sharing/hela-cells-landing/">successfully grown in a petri dish in 1951</a>, scientists now had a source of cost-effective and easy-to-use cells that expanded their ability to conduct research. From <a href="https://doi.org/10.1084/jem.97.5.695">polio</a> and <a href="https://doi.org/10.1016/j.cell.2020.07.024">COVID-19 vaccines</a> to <a href="https://doi.org/10.1002/jcp.22917">cancer research</a> and <a href="https://doi.org/10.1534/g3.113.005777">sequencing the human genome</a>, HeLa cells have played an enormous role in many scientific discoveries and advancements.</p>
<p>Henrietta Lacks’ story is also an <a href="https://www.wgbh.org/news/local-news/2022/05/17/thermo-fisher-seeks-dismissal-of-henrietta-lacks-familys-lawsuit-regarding-sale-of-her-cells">ongoing bioethics case</a>, because these cells were taken from her during a routine cervical cancer biopsy and were then given to researchers without her consent, as was <a href="https://doi.org/10.1146%2Fannurev-genom-083115-022536">common practice</a> at the time. The Lacks family has <a href="https://www.washingtonpost.com/local/legal-issues/henrietta-lacks-family-sues-company/2021/10/04/810ffa6c-2531-11ec-8831-a31e7b3de188_story.html">long attempted legal action</a> against companies they say have unfairly benefited from Henrietta’s cells. A <a href="https://www.npr.org/2010/02/02/123232331/henrietta-lacks-a-donors-immortal-legacy">2010 book</a> by journalist Rebecca Skloot details how HeLa cells affected both science and the Lacks family.</p>
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<figcaption><span class="caption">The Lacks family wasn’t aware that Henrietta’s cells had been harvested until Rolling Stone magazine journalist Michael Rogers contacted them two decades after her death.</span></figcaption>
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<p>But how did Lacks’ cells become immortal?</p>
<p>Lacks didn’t know that cells in her cervix were infected with a virus that causes one of the most common sexually transmitted diseases: <a href="https://www.cdc.gov/std/hpv/default.htm">human papillomavirus</a>, or HPV. There are more than 150 different types of HPVs, but only a small group are known to cause <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer">cervical cancer</a>. In fact, <a href="https://doi.org/10.1002/(SICI)1096-9896(199909)189:1%3C12::AID-PATH431%3E3.0.CO;2-F">99.7% of cervical cancers</a> are HPV positive. Fortunately, most people infected with high-risk HPVs are able to clear out the virus before it becomes cancerous. <a href="https://www.cdc.gov/vaccines/vpd/hpv/public/index.html">HPV vaccinations</a> can prevent over 90% of HPV-related cancers. But <a href="https://www.cdc.gov/cancer/hpv/basic_info/index.htm">10% of people</a> with HPV infections on their cervix develop cancer. Sadly, Henrietta was one of the unlucky ones.</p>
<p>Her misfortune has helped elucidate how HPV works. Since the <a href="https://www.nobelprize.org/prizes/medicine/2008/hausen/facts/">Nobel Prize-winning</a> 1976 discovery of <a href="http://www.ncbi.nlm.nih.gov/pubmed/175942">HPV’s essential role</a> in cervical cancer, many scientists, including me, have been investigating how HPV <a href="https://www.ncbi.nlm.nih.gov/books/NBK9929/">causes cancer</a>.</p>
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<figcaption><span class="caption">While some types of HPV cause warts on the skin, certain high-risk ones can cause cancer.</span></figcaption>
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<h2>Two proteins</h2>
<p>It turns out that the virus’ cancer-causing ability is linked to two proteins it produces. These viral proteins can <a href="https://pubmed.ncbi.nlm.nih.gov/1322242/">target and destroy</a> two major human proteins that protect against cancer, <a href="https://doi.org/10.1038/s41598-019-40094-8">p53 and retinoblastoma (Rb)</a>. P53 and Rb act as sentinels making sure cells don’t accumulate harmful genetic mutations and stop dividing after a set number of cycles. My research has focused on how HPV proteins interact with <a href="https://doi.org/10.1038/s41598-019-40094-8">tumor-suppressing</a> <a href="https://doi.org/10.1073/pnas.1017346108">proteins</a> in different types of human cells, including HeLa.</p>
<p>Most cells divide around <a href="https://doi.org/10.1016/0014-4827(65)90211-9">40 to 60 times</a> before they become too old to function properly and are naturally killed off. But HPV can allow cells to divide forever, because they attack the sentinels keeping uncontrolled division in check. After Lacks was infected with <a href="https://doi.org/10.1128/JVI.01747-15">HPV 18</a>, the second-most-common high-risk type of the virus, her cervical cells lost the ability to produce these sentinels. Without growth checks in place, her cells were able to divide indefinitely and became “immortal” – living on to this day both in test tubes and the <a href="https://www.immunology.org/hela-cells-1951">70,000 studies</a> they’ve made possible.</p>
<p><em>This article was updated to note the Lacks family’s settlement with Thermo Fisher on Aug. 1, 2023.</em></p><img src="https://counter.theconversation.com/content/169913/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ivan Martinez receives funding from the National Institute of Health (NIH), the American Cancer Society (ACS), and the National Science Foundation (NSF).</span></em></p>The immortal cancer cells of Henrietta Lacks revolutionized the fields of science, medicine and bioethics. And they still survive today, more than 70 years after her death.Ivan Martinez, Associate Professor of Microbiology, Immunology and Cell Biology, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1715402022-02-01T20:19:01Z2022-02-01T20:19:01ZSome cancers are preventable with a vaccine – a virologist explains<figure><img src="https://images.theconversation.com/files/432047/original/file-20211115-27-1mi04az.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5825%2C2973&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some strains of the human papilloma virus (HPV) have been associated with cancers, especially cervical cancer.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/human-papilloma-virus-illustration-royalty-free-illustration/713780957?adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p>One-fifth. Nearly <a href="https://doi.org/10.1128/CMR.00124-13">20% of cancers worldwide</a> are caused by a virus. </p>
<p>These viruses don’t cause cancer until long after they initially infect a person. Rather, the viruses teach the cells they take over how to escape the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117903/">natural biological process of cell death</a>. This strategy sets these altered cells on a path for other genetic changes that <a href="https://doi.org/10.1016/0014-4827(90)90027-8">can cause full-blown cancer</a> years down the road. </p>
<p>As a <a href="https://scholar.google.com/citations?user=LyV-cJVvSncC">microbiologist and researcher of viruses</a>, I seek to understand how viruses affect living cells and the health of the people who are infected. These particular viruses are unique and interesting, both for their effects on patients and because of the potential ways they might be treated or prevented.</p>
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<h2>The viral landscape</h2>
<p>All known viruses can be categorized into one of 22 distinct families. Five of these families are called “<a href="https://doi.org/10.1016/S1470-2045(12)70137-7">persisting</a>,” because once a person is infected, the virus remains in their body for life. One example is the herpes virus that <a href="https://theconversation.com/the-chickenpox-virus-has-a-fascinating-evolutionary-history-that-continues-to-affect-peoples-health-today-168636">causes chickenpox in children</a> and can reappear later in life as shingles. This ability to survive over the long term helps the virus spread from person to person.</p>
<p>There are seven known viruses that can cause cancer. <a href="https://doi.org/10.1007/978-3-030-57362-1_2">Five of them</a> are members of persistent virus families. The <a href="https://www.cdc.gov/std/hpv/stdfact-hpv.htm">human papillomavirus</a>, commonly known as HPV and known to cause cervical cancer, is in the papilloma family. The <a href="https://www.cdc.gov/epstein-barr/about-ebv.html">Epstein-Barr virus</a>, which causes Hodgkin lymphomas, and the <a href="https://www.cancer.org/cancer/kaposi-sarcoma/causes-risks-prevention/what-causes.html">Kaposi’s sarcoma-associated virus</a>, are both in the herpes family. The <a href="https://www.who.int/news-room/fact-sheets/detail/human-t-lymphotropic-virus-type-1">human T-lymphotropic virus</a>, which can cause a type of leukemia, is what’s known as a retrovirus. And <a href="https://dx.doi.org/10.1098%2Frstb.2016.0276">Merkel cell polyoma virus</a>, which causes Merkel cell carcinoma, is in the polyoma family.</p>
<p>All five of these viruses contain genetic code for one or more proteins that teach cells how to avoid cell death, effectively immortalizing them and promoting cell growth. The cancer cells that develop from these oncogenic viruses all contain their original viruses’ genetic information, even when they appear years after the initial infection. But only a small percentage of people who are infected with one of these five oncogenic viruses ultimately develop the full-blown cancer associated with it.</p>
<p>The other two viruses, <a href="https://www.cdc.gov/hepatitis/hbv/index.htm#">hepatitis B</a>, in <a href="https://doi.org/10.1007/978-3-642-69159-1_2">the hepadna family</a>, and <a href="https://www.cdc.gov/hepatitis/hcv/index.htm#">hepatitis C</a>, in the <a href="https://www.ncbi.nlm.nih.gov/books/NBK1630/">flavi family</a>, are somewhat different. Most people infected with <a href="https://doi.org/10.1098/rstb.2016.0274">those viruses</a> are able to fight the infection through their own immunity and <a href="https://doi.org/10.1002/cld.576">eliminate the virus</a>. </p>
<p>However, in people who are not able to fight off the infection, long-term infections of these viruses often cause extensive liver damage. These people are at risk of developing a type of liver cancer called hepatocellular carcinoma, because the body’s attempts to repair the damaged liver tissue increase the chance of a cancer-related mutation. The viruses themselves do not teach the liver cells to become immortal or transform themselves, the way the other five oncogenic viruses do to the cells they target.</p>
<p>These viral-induced cancers are serious health threats. <a href="https://www.mayoclinic.org/diseases-conditions/hepatocellular-carcinoma/cdc-20354552#">Hepatocellular carcinoma</a>, for instance, <a href="https://doi.org/10.3389/fonc.2021.686962">kills approximately 800,000 people a year</a>, making it the third-deadliest cancer globally. About three-quarters of those killed have had hepatitis virus infections in the past.</p>
<p>HPV is similarly dangerous. The cervical cancer it causes <a href="https://doi.org/10.1016/S2214-109X(19)30482-6">kills some 311,000 people a year</a> worldwide, making it the deadliest cancer in women until recently. That number includes <a href="https://www.cdc.gov/cancer/hpv/statistics/index.htm">36,000 women in the U.S.</a> But HPV doesn’t just put women at risk. A similar number of people in the U.S. die each year from anal and throat cancers linked to HPV.</p>
<figure class="align-center ">
<img alt="A schoolgirl receives the HPV vaccination." src="https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The HPV vaccine is recommended for all children and adolescents, starting at age 11.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/schoolgirl-getting-vaccinated-royalty-free-image/871552754?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<h2>Reasons for optimism</h2>
<p>The <a href="https://www.elsevier.com/connect/the-hpv-vaccine-10-years-on">first viral vaccine to protect against HPV infection</a> and its <a href="https://www.kff.org/womens-health-policy/fact-sheet/the-hpv-vaccine-access-and-use-in-the-u-s/">associated cancers</a> was approved for use in the U.S. in 2006. It has proved to be <a href="https://www.theguardian.com/society/2021/nov/04/its-incredible-hpv-vaccine-saves-thousands-of-women-from-cervical-cancer-uk-study-shows">highly effective at preventing both HPV infection</a> and the <a href="https://www.cancer.gov/news-events/cancer-currents-blog/2020/hpv-vaccine-prevents-cervical-cancer-sweden-study">subsequent development of cervical carcinoma</a>. </p>
<p>HPV vaccines are now widely available around the globe. The HPV vaccine is <a href="https://www.mayoclinic.org/diseases-conditions/hpv-infection/in-depth/hpv-vaccine/art-20047292">safe, with very mild side effects</a>. It is recommended for children starting <a href="https://www.cdc.gov/vaccines/parents/diseases/hpv.html#">at ages 11 to 12</a>, since different individuals become sexually active at different ages. The <a href="https://www.cdc.gov/vaccines/vpd/hpv/hcp/vaccines.html">protective effects</a> of the vaccine <a href="https://www.cdc.gov/vaccines/vpd/hpv/hcp/safety-effectiveness.html">last beyond</a> <a href="https://kidshealth.org/en/teens/hpv-vaccine.html">10 years</a>, and booster shots are available. </p>
<p>Older people – typically up to 26 years of age – can also receive the HPV vaccine. By preventing infection in the first place, the vaccine also prevents the subsequent cancers that may result from a viral infection. </p>
<p>The vaccine for hepatitis B virus has been similarly successful over a longer time period. Introduced in 1986, it was recognized as <a href="https://www.hepb.org/prevention-and-diagnosis/vaccination/history-of-hepatitis-b-vaccine/">the first anti-cancer vaccine</a>. Since then, <a href="https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/facts-and-figures/">more than a billion people</a> worldwide have received it. The vaccine <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">has been shown</a> to be <a href="https://www.hepb.org/prevention-and-diagnosis/vaccination/">extremely safe and effective</a>. </p>
<h2>Vaccines save lives</h2>
<p>The numbers of cancers prevented and lives <a href="https://canceratlas.cancer.org/taking-action/vaccines/">saved by the vaccines</a> against the hepatitis B virus and human papillomavirus are enormous and indisputable. Yet, as with the resistance to COVID-19 vaccines, vaccine hesitancy is an ongoing problem. In 2019, 46% of adolescents ages 13 to 17 in the U.S. had not received their <a href="https://www.cdc.gov/hpv/partners/outreach-hcp/hpv-coverage.html">recommended HPV vaccines</a>. In 2020 in Mississippi, <a href="https://www.americashealthrankings.org/explore/annual/measure/Immunize_HPV/state/MS">HPV vaccine coverage in adolescents</a> reached a meager 32%.</p>
<p>But the U.S. is better off than some other industrialized nations. In Japan, the current rate of HPV vaccine coverage in adolescents is less than 1% because of false reports of adverse events in 2013. Despite <a href="https://dx.doi.org/10.1186%2Fs12889-019-7097-2">repeated, definitive discrediting of these claims</a>, vaccine uptake in Japan has not rebounded.</p>
<p>Vaccination campaigns have eradicated <a href="https://www.cdc.gov/smallpox/index.html">smallpox</a> and effectively eliminated <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, <a href="https://www.cdc.gov/measles/about/history.html">measles</a> and certain other infectious diseases. Let’s hope that ongoing vaccine efforts can make HPV-induced cancers and hepatitis B virus-induced cancers a thing of the past as well.</p><img src="https://counter.theconversation.com/content/171540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald C. Desrosiers receives funding from the National Institutes of Health. </span></em></p>Some cancers are actually caused by viruses that linger for long periods in the body, or cause physical damage that later turns cancerous.Ronald C. Desrosiers, Professor of Pathology, Vice-chair for Research, University of MiamiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1754882022-01-27T13:28:22Z2022-01-27T13:28:22ZYouth largely underestimate the risks of contracting STIs through oral sex, a new study finds<figure><img src="https://images.theconversation.com/files/442650/original/file-20220125-21-17v99to.jpeg?ixlib=rb-1.1.0&rect=184%2C76%2C1932%2C1301&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young people say they don't use protection during oral sex.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/couple-kissing-while-walking-in-the-street-royalty-free-image/1159056063">F.G. Trade/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Young people are largely unaware of the risk of contracting sexually transmitted infections, or STIs, through oral sex. That’s the finding of <a href="https://doi.org/10.1370/afm.2761">our recent study</a>, published in Annals of Family Medicine. </p>
<p>Research and education on oral sex are critical because it is a very common sexual practice. And many STIs are <a href="https://www.cdc.gov/std/healthcomm/stdfact-stdriskandoralsex.htm#">transmitted orally</a>, including herpes, gonorrhea, chlamydia, syphilis, HIV and human papillomavirus (HPV). </p>
<h2>Why it matters</h2>
<p>The Centers for Disease Control and Prevention reports that <a href="https://www.cdc.gov/std/healthcomm/stdfact-stdriskandoralsex.htm#">85% of sexually active people</a> ages 18 to 44 have engaged in oral sex at least once. A separate survey found that 41% of adolescents ages 15 to 19 reported having oral sex.</p>
<p>Historically, research on reducing STI transmission among young people has focused primarily on heterosexual vaginal intercourse rather than other forms of sexual activity, such as oral sex. </p>
<p>Increased <a href="https://www.cdc.gov/std/healthcomm/stdfact-stdriskandoralsex.htm">use of protection</a> like condoms or dental dams could lead to lower rates of STI transmission through oral sex. But many of the young people we surveyed indicated that they do not use protection.</p>
<p>An earlier study found that <a href="https://doi.org/10.1016/j.jadohealth.2017.08.022">fewer than 10%</a> of youth reported using protection during oral sex. </p>
<h2>How we do our work</h2>
<p>To conduct our study, we relied on a <a href="https://www.researchprotocols.org/2017/12/e247/">nationwide sample</a> of over 1,000 adolescents and young adults ages 14 to 24. We polled young people using <a href="https://hearmyvoicenow.org/">MyVoice</a>, a texting-based polling system. Our team developed a set of four open-ended questions for youth about their sexual behavior and practices. For instance, they included questions such as how risky participants perceived oral sex without protection to be, and what might help people use protection during oral sex. </p>
<p>For the most part, young people in the study knew that STIs could be transmitted through oral sex. What many didn’t fully understand, however, was exactly how risky it can be without protection. They often considered the act less risky than vaginal sex, with most ranking the risk associated with unprotected oral sex as “low” to “moderate.” “You can’t really get anything super harmful from it,” one respondent wrote.</p>
<p>But they can. And many have. </p>
<p>Oral sex can transmit HPV. Infection with HPV has no cure. It is also a major risk factor for head, neck and cervical cancer later in life. Over the past 20 years, the rate of HPV-related head and neck cancers in America <a href="https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm">has skyrocketed</a> – jumping from 20% to more than 70% of all diagnosed cases, outpacing even HPV-related <a href="https://www.cdc.gov/cancer/hpv/statistics/cases.htm">cervical cancer</a>. </p>
<p>An <a href="https://www.cdc.gov/hpv/parents/vaccine-for-hpv.html">existing vaccine against HPV</a> is effective <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-vaccine-fact-sheet#">against some strains of the virus</a>. But <a href="https://www.cdc.gov/hpv/partners/outreach-hcp/hpv-coverage.html">vaccination rates</a> <a href="https://www.cdc.gov/hpv/partners/outreach-hcp/hpv-coverage.html">against HPV are relatively low</a> both in the U.S. <a href="https://www.who.int/news-room/fact-sheets/detail/immunization-coverage">and globally</a>.</p>
<h2>What still isn’t known</h2>
<p>Many study respondents pointed to a lack of comprehensive and inclusive sexual education as the reason young people don’t use protection. Some were not hopeful about changing the behavior of young people. “I don’t think anything could help, as using protection for oral sex is a bizarre concept towards most people.” </p>
<p>Others suggested, however, that “normalizing the use of protection during oral sex in the media” would lead to more young people using dental dams and other barrier methods.</p>
<p>We don’t yet know what works best to convey to youth the risk of unprotected oral sex. And researchers haven’t determined which methods of STI prevention are most accessible and acceptable to young people. </p>
<p>Our study suggests that the most promising possibilities include comprehensive and inclusive sex education, available where young people can easily find it. </p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p><img src="https://counter.theconversation.com/content/175488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Oral sex is common among young people. Protection from STIs is not.Tammy Chang, Associate Professor of Family Medicine, University of MichiganArianna Strome, Medical Student, University of MichiganN'dea Moore-Petinak, PhD Candidate in Health Services Organization & Policy, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1708872021-11-04T15:10:35Z2021-11-04T15:10:35ZHPV vaccine cuts cervical cancer cases by almost 90% – but one in ten girls still haven’t been vaccinated<figure><img src="https://images.theconversation.com/files/430332/original/file-20211104-19-ssnszg.jpg?ixlib=rb-1.1.0&rect=49%2C8%2C5472%2C3612&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The HPV vaccine protects against cervical cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/teenager-asian-woman-showing-off-orange-2046010967">KT Stock photos/ Shutterstock</a></span></figcaption></figure><p>A vaccine to protect against human papillomavirus (HPV) has been found to cut cases of cervical cancer by <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02178-4/fulltext">nearly 90%</a>, according to a recent study published in The Lancet. </p>
<p>Cervical cancer, which can be caused by HPV, is one of the few cancers that can be prevented by a vaccine. This is why the HPV vaccination programme was introduced in UK schools in 2008, offered to girls aged 12-13. The programme has been <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/858872/hpr0220_HPV_2018.pdf">extremely successful</a> in the UK, with over 80% of eligible girls having received it to date. But <a href="https://pubmed.ncbi.nlm.nih.gov/34419303/">our research</a> has shown that there are still gaps in the vaccination programme. </p>
<p>HPV is one of the <a href="https://www.cdc.gov/std/hpv/stdfact-hpv.htm%20%20please%20replace%20with%20this%20reference%20https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer">most common</a> sexually transmitted infections in the world. While, in most cases, people can get over an HPV infection without treatment, it can sometimes turn into genital warts or even cervical cancer. </p>
<p>The HPV vaccination programme was introduced to vaccinate girls against HPV before they’re likely to become infected by it. But our research found that around one in ten girls in the UK hadn’t received the vaccination. We wanted to find out why these gaps exist. </p>
<p>To conduct our study, we used information from the Millennium Cohort Study – a UK-wide research study that contains detailed data on the health, social, economic and educational circumstances of children born in 2000-2002. As part of this study, at age 14 the parents of nearly 6,000 girls were interviewed and asked whether their daughters had had the HPV vaccine – and if not – the reasons they hadn’t. </p>
<p>From these interviews, we found that girls who hadn’t been vaccinated against HPV were more likely to live in the most disadvantaged areas of the UK, be home-schooled, temporarily or permanently excluded from attending school – for example, because of behavioural issues – or to be from a black or other minority ethnic background. </p>
<figure class="align-center ">
<img alt="A teen girl and her mom speak with their male GP." src="https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430283/original/file-20211104-13-ugx59q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Offering the vaccine through GPs may help improve uptake.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-doctor-mom-502228270">Andrey_Popov/ Shutterstock</a></span>
</figcaption>
</figure>
<p>There were many reasons girls weren’t vaccinated, according to their parents. About half said either they or their daughter didn’t want the vaccine or they were scared of the vaccination procedure. Others said their daughter had not been offered the vaccine in school, or had not been at school on vaccination day. We also found that girls living in the most disadvantaged areas were 56% less likely to have received the HPV vaccine than those in the most advantaged areas.</p>
<h2>Preventing cancer</h2>
<p>The UK’s school HPV vaccination programme has been very successful in reducing the number of young women who are <a href="https://doi.org/10.1016/S1473-3099(17)30468-1">infected with the virus</a>. The vaccination programme in the UK has also been shown to reduce the number of cases of <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02178-4/fulltext">cervical cancer</a> by nearly 90%. </p>
<p>The HPV vaccine currently offered protects against two strains of HPV that cause cancer, and two strains that cause genital warts. This year, a newer vaccine will be introduced that will provide young people with protection against a further five cancer-causing HPV strains. </p>
<p>Though this is great news, our research shows that there are still gaps in the vaccination programme that need to be addressed to ensure as many young women are being protected against HPV and cervical cancer as possible and that all benefit equally. While school immunisation teams already work hard to ensure all girls and their parents know about the vaccine – and sometimes even offer it outside of school settings – more needs to be done to improve vaccine uptake.</p>
<p>One way of improving uptake may be to involve family doctors in offering the vaccine to children who have missed out. This would allow families to discuss the vaccine with their GP and ask them any questions they may have. Some people may also feel more comfortable having the vaccine administered at their GP surgery. This may help reduce inequalities in vaccine uptake. </p>
<p>Since 2019, boys have also been included in the UK HPV vaccination programme. This is because boys can pass HPV infections on and can also develop cancers from HPV. The pandemic has had a major impact on the HPV vaccination programme and we now need a concerted effort across schools and with GPs to ensure all young people are protected against HPV.</p><img src="https://counter.theconversation.com/content/170887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carol Dezateux receives funding from NIHR, Barts Charity, the Wellcome Trust, MRC.</span></em></p><p class="fine-print"><em><span>Helen Bedford receives funding from ESRC and is a member of the National Institute for Health and Care Excellence's committee developing guidelines in improving vaccine uptake. </span></em></p><p class="fine-print"><em><span>Nicola Firman receives funding from Barts Charity.</span></em></p>Addressing these gaps in the vaccination programme will ensure more people are being protected against the type of cancer.Carol Dezateux, Professor of Clinical Epidemiology and Health Data Science, Queen Mary University of LondonHelen Bedford, Professor of Children's Health, UCLNicola Firman, PhD Researcher, Health Data Science, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1325122020-03-04T11:58:30Z2020-03-04T11:58:30ZA simple way to promote HPV vaccination among Asian American women: Storytelling<figure><img src="https://images.theconversation.com/files/318129/original/file-20200302-18308-n5pkyu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5000%2C3510&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rates of HPV screenings and vaccinations remain low for some subgroups of Asian American women.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/schoolgirl-getting-vaccinated-royalty-free-image/871552754?adppopup=true">Getty Images / Peter Dazeley</a></span></figcaption></figure><p>Asian Americans and Pacific Islanders – what demographers call AAPIs – are the nation’s fastest-growing minority. Close to <a href="https://www.diversity.va.gov/programs/aapi.aspx">20 million</a> now live in the U.S. But you wouldn’t know it from our public health data, where AAPIs are underrepresented. Nowhere is that more apparent than in the data on cervical cancer screenings. </p>
<p>In the U.S., AAPI women have the lowest risk of cervical cancer. However, when separating cancer statistics by subgroups, it shows the incidence and mortality rates of cervical cancer are <a href="http://www.aapcho.org/wp/wp-content/uploads/2015/08/Cancer-Facts-Asian-Americans-and-Cancer.pdf">two or three times higher</a> in Cambodian, Hmong, Korean, and Vietnamese women than in non-Hispanic white women. </p>
<p>At the same time, one subgroup, Korean American women, has the <a href="https://doi.org/10.1002/cncr.30391">lowest rates</a> of cervical cancer screening in the U.S. Breaking it down further, English-speaking, college-educated Korean American women have particularly <a href="https://doi.org/10.1007/s10900-019-00634-9">low awareness and knowledge</a> of HPV, the HPV vaccine and cervical cancer. </p>
<p>As a Korean immigrant, and a <a href="https://www.researchgate.net/profile/Minjin_Kim2">transcultural nurse implementation scientist</a>, I want to expand awareness of the need for HPV education among AAPI women. <a href="https://ipvsoc.org/hpv-day/">International HPV Awareness Day</a>, March 4, is perhaps the perfect time to remind all women that the human papillomavirus can cause cancer and that cervical cancer screening and HPV vaccination are the best ways to prevent those cancers. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=724&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=724&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=724&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=909&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=909&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318133/original/file-20200302-18287-ul199p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=909&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some subgroups of Asian American and Pacific Islander women are reluctant to get the HPV vaccine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/vaccination-royalty-free-image/184233413?adppopup=true">Getty Images / Peter Dazeley</a></span>
</figcaption>
</figure>
<h2>The cause of cervical cancer</h2>
<p><a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer">Nearly all cervical cancers</a> – over 99% – are caused by HPV infection. <a href="https://www.cdc.gov/std/hpv/stdfact-hpv.htm">HPV is the most common sexually-transmitted infection</a> in the U.S. that
strikes both men and women, and the only STI that causes cancer, including cervical, oral, anal, vulvar and penile cancers.</p>
<p>Studies show HPV infection is more prevalent in men than women. But women are more likely to have persistent, high-risk HPV infection that may lead to cervical cancer, the <a href="https://www.cancer.org/latest-news/facts-and-figures-2020.html">second-leading cause of cancer death</a> among women ages 20 to 39. Currently, cervical cancer is the only HPV cancer with a recommended screening test to detect it an early stage. </p>
<p>After the introduction of the <a href="https://www.cdc.gov/cancer/cervical/statistics/index.htm">Papanicolaou (Pap) test</a>, the incidence and mortality rates of cervical cancer decreased significantly. But not all women are getting regular Pap tests, and not all cervical cancer rates are declining. Moreover, screening alone does not protect against all types of cervical cancer. <a href="https://www.cdc.gov/hpv/parents/vaccine.html">HPV vaccination</a> provides the best protection against cervical and other HPV-associated cancers.</p>
<h2>Prevention is not always a priority</h2>
<p>Why do so many AAPI women know so little about HPV? </p>
<p>We set out to answer this question by interviewing Asian American ethnic groups and conducting surveys. </p>
<p>Our findings suggest their knowledge and attitudes toward HPV prevention <a href="https://doi.org/10.1007/s10900-019-00634-9">are closely tied</a> to health beliefs and cultural or language barriers. What’s more, we discovered preventive health care is not a top priority for immigrant populations. In general, they seek treatment only <a href="https://doi.org/10.1188/17.CJON.E239-E247">when already sick</a>. <a href="https://doi.org/10.1080/13557858.2018.1514455%20%20DOI:%2010.1007/s10900-019-00634-9">Our studies</a> also suggest many of them are skeptical about participating in research.</p>
<p>One woman who participated <a href="https://doi.org/10.1188/17.CJON.E239-E247">in our study</a> said, “Guys don’t have a cervix, so I thought this vaccine is for women only.” But HPV is a sexually transmitted infection. Both men and women can have it, and the vaccine works for both sexes. One reason for the misunderstanding is that the HPV vaccine is often advertised as <a href="https://doi.org/10.1188/17.CJON.E239-E247">“cervical cancer vaccine.”</a> This occurs in the U.S. as well as in South Korea. </p>
<p>Some of the AAPI women told us their <a href="https://doi.org/10.1188/17.CJON.E239-E247">doctor did not recommend</a> the vaccine because Asian women are less prone to cervical cancer. This is not true; doctors saying this are not familiar with how the data might mask differences in AAPI subgroups. <a href="https://doi.org/10.1007/s10900-019-00634-9">Other women said</a> they were confused by medical terminology or the way the U.S. health care system worked – hardly a singular experience, no matter what your nationality or ethnicity. </p>
<p>Another problem is the sheer number of the subgroups of AAPI women. There are about 50, and among them, hundreds of languages and dialects, and with little or no accurate population-based data outlining their vaccination rates. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318132/original/file-20200302-18283-1lnjf0v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A human papillomavirus infection. HPV is the most common sexually transmitted infection globally.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/human-papillomavirus-infection-virus-hpv-is-the-royalty-free-image/1060642876?adppopup=true">Getty Images / Naeblys</a></span>
</figcaption>
</figure>
<h2>Storytelling made a difference</h2>
<p>We discovered in our study that narrative storytelling – that is, mothers and their children sharing their experiences and having conversations about HPV vaccination – can increase HPV vaccination rates. </p>
<p>From that, we’ve developed what we call a <a href="https://doi.org/10.1093/her/cyz022">storytelling intervention</a> for young Korean American women using a “peer-paired” approach. Because the storytellers are about the same age as the participants, a meaningful conversation is more likely to occur. The women are less shy about sharing their personal experiences, feelings and fears. </p>
<p>In our study, three pairs of young Korean women told their stories about the HPV vaccination experience. They also discussed their cultural attitudes toward vaccines. <a href="https://doi.org/10.2196/14111">We also produced</a> an educational video that addressed common misconceptions about HPV, along with a research manual and a web-based interface where participants could watch storytelling video interviews.</p>
<p>A comparison group received basic written information about HPV, but it was non-narrative. In other words, dry facts and no storytelling.</p>
<p><a href="https://doi.org/10.1177/1090198119894589">Our findings are conclusive</a>: The storytelling intervention group was twice as likely to schedule an appointment for the HPV vaccine than the comparison group. Simple storytelling – human-centered, interactive, culture-specific and group-tailored – led to positive health outcomes. </p>
<p>We are now expanding our research to include both men and women and other underserved or understudied populations. Our storytelling intervention strategy, which leverages today’s technologies, can now be replicated to reach diverse groups and promote health, and prevent cancers and other diseases. </p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/132512/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Minjin Kim previously received funding from the American Cancer Society. </span></em></p>Researchers have found a way to encourage cervical cancer screenings and vaccinations in Korean American women. Might their findings also work in other underrepresented populations?Minjin Kim, Postdoctoral Research Associate, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/865942018-04-11T18:02:25Z2018-04-11T18:02:25ZParents want the HPV vaccine for their sons – new research<figure><img src="https://images.theconversation.com/files/193741/original/file-20171108-1987-1g326j3.jpg?ixlib=rb-1.1.0&rect=28%2C0%2C965%2C541&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/345038330?src=igLWyvF03Wk0BmdullSxIQ-1-49&size=medium_jpg">funnyangel/Shutterstock</a></span></figcaption></figure><p>Human papillomavirus (HPV) is a sexually transmitted infection that causes diseases that affect both men and women. In the UK, girls are vaccinated against HPV but boys are not.</p>
<p>There are more than <a href="http://www.tandfonline.com/doi/full/10.4161/hv.29137">100 types of HPV</a>. Two of the low risk types (six and 11) cause more than 90% of genital warts. Other high risk types of HPV (especially 16 and 18) can cause cervical, vulval, vaginal, head, neck and throat, anal and penile cancers. While the incidence of cervical cancer in the UK has <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer/incidence#heading-Two">fallen since the 1990s</a>, thanks to the NHS cervical screening programme, the incidence of those cancers that affect both men and women is <a href="https://www.analcancerfoundation.org/about-hpv/hpv-cancer">on the rise</a>.</p>
<p>More than <a href="http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/infections-hpv-and-cancer/hpv-and-cancer">80% of sexually active people</a> will be exposed to HPV in their lifetime. Genital HPV infection is spread during sexual intercourse and skin-to-skin contact of the genital areas. Wearing a condom reduces the risk of infection but does not provide complete protection. Once a person has been infected, their immune system will fight the virus and, in most cases, the virus will have no ill effects. But, for some people, the virus will progress to cause warts or cancer. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193751/original/file-20171108-26996-154w9ml.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">HPV causes a range of cancers, including cervical, penile, anal and throat cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/587325722?src=pu4d7ccQ2LgZnQq6mT8qVQ-1-6&size=medium_jpg">Tatiana Shepeleva/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Since 2008, 12- and 13-year-old girls in most of the UK (11 to 13 in Scotland) have been offered the chance to be vaccinated against HPV via a school-based programme. In a phased rollout from April 2018, men aged 45 or younger who have sex with men will be offered the HPV vaccination in England at sexual health clinics and HIV clinics, bringing England in line with the rest of the UK. But boys are not likely to be offered the HPV vaccine any time soon.</p>
<h2>Too little, too late</h2>
<p>One rationale for not vaccinating boys is that if enough girls are vaccinated (currently, around <a href="https://www.gov.uk/government/statistics/annual-hpv-vaccine-coverage-2015-to-2016-by-local-authority-and-area-team">85% of girls have the necessary two doses in England</a>), this provides <a href="https://theconversation.com/explainer-what-is-herd-immunity-52377">“herd immunity”</a> to men, meaning that if women don’t have the virus, men will not be able to catch it either. </p>
<p>The main problem with the herd immunity argument, when it is girls rather than boys who are vaccinated, is that it doesn’t provide protection for men who have sex with men, or for men who have sex with unvaccinated women – for example, women from countries without a vaccination programme, or women who are too old to have been eligible for the vaccination. </p>
<p>Men who have sex with men are particularly vulnerable to HPV-related anal cancer. Although they can now opt to have the vaccination, it is too little, too late. </p>
<p>The HPV vaccination is most effective when it is given before exposure to the virus (before sexual activity starts), and also when it is given before puberty, when immune systems are able to provide a stronger antibody response.</p>
<p>Gender-neutral vaccination has wide support among the medical community with professional organisations such as the British Dental Association and The Faculty of Public Health favouring vaccination for both boys and girls.</p>
<h2>Survey results</h2>
<p>It is not just professionals who want to see the vaccination extended to boys. A recent <a href="https://osf.io/s9qrp">Wellcome-funded survey</a> of 186 parents of teenage boys in North Staffordshire that we conducted found that many of the parents were not aware of the health consequences of HPV for men. The research, published in <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195801">PLOS ONE</a>, revealed that once they were provided with this information, however, most parents wanted the vaccine to be available to their sons. </p>
<p>Several countries vaccinate both girls and boys against HPV, including the US, Canada, Austria, Australia and New Zealand. It is unacceptable, as society strives for equality in so many areas, that the UK should not extend the protection afforded by the HPV vaccination to boys as well as girls.</p><img src="https://counter.theconversation.com/content/86594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sue Sherman has received funding from Wellcome Trust and North Staffordshire Medical Institute. </span></em></p>When British parents are informed of the risks of HPV, they want their sons to be vaccinated against the virus.Sue Sherman, Senior Lecturer in Psychology, Keele UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904962018-02-01T22:46:32Z2018-02-01T22:46:32ZDoctors must stop misleading women about cervical screening<figure><img src="https://images.theconversation.com/files/204382/original/file-20180201-123837-1a3j4bw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While cervical screening has saved countless lives, we overscreen in Canada. Women don't need to be screened until the age of 25 for cervical cancer.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Cervical screening is one of the most effective screening tests, responsible for substantial reduction in death from cervical cancer. This disease <a href="https://doi.org/10.1186/1471-2458-12-992">used to affect two per cent of Canadian women and kill one per cent</a>. </p>
<p>But as with so many good things, the procedure can be overused, and Canadian doctors are overscreening their female patients.</p>
<p>It is time to change cervical screening policy: Start at a later age, and do it less often. Canadian provinces used to start testing from a woman’s first sexual activity. In 2011, Alberta changed this to start screening at age 21, and other provinces followed suit. </p>
<p>After examining the evidence, I maintain <a href="https://doi.org/10.1503/cmaj.160636">we should start even later — at age 25</a>. Alberta and British Columbia have made this change; other provinces are considering it.</p>
<h2>Screening under age 25 has little impact</h2>
<p>Cervical cancer is largely a late result of an earlier infection with human papilloma virus (HPV) — a wart virus. It can <a href="https://www.dx.doi.org/10.1158/1055-9965.EPI-08-0707">develop several years after women become sexually active but mainly shows up when women are in their 40s or older</a>. </p>
<p>I was a member of a team of epidemiologists and a gynecologist who examined the Canadian evidence from before screening started. We found that there was <a href="https://doi.org/10.1186/1471-2458-12-992">almost no cervical cancer in women under age 25 and very little under age 30</a>. For many years, Canadian doctors performed pap tests when they prescribed contraception, so young women were tested annually. Yet this made no measurable difference to the numbers of invasive cancers.</p>
<p>In Britain, a large case-control study found that <a href="https://doi.org/10.1136/bmj.b2968">screening women aged 20 to 24 had little or no impact on rates of invasive cervical cancer up to age 30</a>. Sadly, the few women who do get cervical cancer at these ages have rapidly advancing disease, and neither screening nor treatment seems to help much.</p>
<h2>Screening causes harm</h2>
<p>If excess screening was only an unpleasant nuisance for women, it might be acceptable, but there is more: It causes harm. </p>
<p>When young women are infected with vaginal warts, it is difficult to distinguish the cellular changes from cancer. Consequently, <a href="https://content.cancerview.ca/download/cv/prevention_and_screening/cccic_microsite/documents/cccicmonitoringevalqualityindicatorspdf?attachment=0">more than 10 per cent of women under 30 have “abnormal” pap tests</a>, but this rate drops for older women. </p>
<p>A positive screening test <a href="http://sti.bmj.com/content/85/7/508">causes anxiety</a> for many women, though HPV warts often go away on their own by the time a repeat test is done.</p>
<p>If the tests appear abnormal, women are referred for further examination by colposcopy (when the cervix is examined under magnification, usually by a gynecologist) and small samples (biopsies) are removed for microscopic examination. </p>
<p>Some biopsies appear abnormal — a “pre-cancer” — and such women may have a larger <a href="http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/cone-biopsy/?region=on">“cone biopsy”</a> or “<a href="http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/loop-electrical-excision-procedure/?region=on">loop electrosurgical excision</a>” taken to remove the abnormal area at the entrance of the cervix. This “cures” the pre-cancer, but leaves a weakened cervix. Even though most abnormalities would resolve themselves, a few would not, so doctors treat them all.</p>
<p>The cervix, however, has an important biological role: It holds in babies until the time comes to release them. <a href="https://www.dx.doi.org/10.1002/14651858.CD012847">Women who have had a cone biopsy have a higher rate of pre-term births</a>, and some of these babies die. Having a weakened cervix may not matter for older women who are no longer having babies, but for young women who want to birth children, this is a serious potential harm.</p>
<h2>Balancing harms and benefits</h2>
<p>What this means is that cervical screening policies and guidelines must balance the potential benefits against the harms of such screening, and recognize that the probabilities change with age. </p>
<p>The Canadian Task Force on Preventive Health Care <a href="https://doi.org/10.1503/cmaj.121505">examined the evidence</a>, and in 2013 recommended that there should be no screening under age 20. Screening should start some time in a woman’s mid-20s, with an interval of every three years. Alberta and British Columbia <a href="https://doi.org/10.1503/cmaj.160636">changed their policies in accordance with the science</a>.</p>
<p>Other provinces still start at age 21, and some still screen every two years. The reasons are not clear. Too often Canadians look south to the United States, where <a href="https://www.dx.doi.org/10.3322/caac.21392">early frequent screening persists</a>. </p>
<p>We might do better to check the rest of the world, where <a href="https://www.dx.doi.org/10.1016/j.ejca.2009.07.020">few countries start before 25, and some not until age 30</a>. </p>
<h2>Women should decide</h2>
<p>If women were fully informed, how many would choose to have cervical screening so early and so often? They should have the choice, rather than being given uninformative positive encouragement of the type that’s found on many provincial websites. </p>
<p>Physicians need better information to share with their patients, and should not routinely perform cervical screening tests on young women at least until their mid-20s. </p>
<p>Women who start sexual activity later in life can wait even longer, since the earliest cancers <a href="http://cebp.aacrjournals.org/content/18/4/1070">do not develop</a> until at least four years after first sexual activity, and mostly not until 10 to 20 years later. For those who have been immunized against HPV, the probabilities will be even lower.</p>
<p><a href="http://annals.org/aim/fullarticle/2450218/screening-pelvic-examinations-adult-women-grand-rounds-discussion-from-beth">Some doctors argue</a> that women should still get regular pelvic examinations and test for sexually transmitted infections (STI). But pelvic examinations look for an enlarged uterus or ovarian disease, which mainly affect older women. And urine tests detect STIs. <a href="http://www.cfp.ca/content/62/3/211">So doing routine pelvic examinations is unnecessary</a>. </p>
<p>In provinces that do not have screening registries that remind women to get examined every three years, they may neglect to do so. So some physicians argue women should be told to come at two-year intervals to ensure they come within three years. </p>
<p>This means that compliant women will be screened more often than necessary, and subjected to extra risk of harm, but changes nothing for those who do not attend.</p>
<p>Instead, women and their doctors should follow the science, not inappropriate policies, and women should decide for themselves what is right for them.</p><img src="https://counter.theconversation.com/content/90496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Dickinson was a member of the Canadian Task Force on Preventive Health Care, 2009-2016, and was the lead author on their report on cervical screening. The Task Force is funded by the Public Health Agency of Canada, and members are not paid, but receive travel funding to attend meetings. </span></em></p>Medical research suggests cervical cancer screening for women under the age of 25 has little impact. Women should therefore be screened at a later age, and less often.James Dickinson, Professor of Family Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909222018-01-30T18:54:47Z2018-01-30T18:54:47ZNew Gardasil 9 vaccine boosts teens’ protection from HPV and cervical cancer by 23%<figure><img src="https://images.theconversation.com/files/203938/original/file-20180130-170439-z90app.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While the previous Gardasil vaccine protected against 70% of cervical cancers, the updated Gardasil 9 version will protect against up to 93% of these.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>As 12 and 13-year-old boys and girls start a new school year, they will have access to the new, improved vaccine to protect against the human papillomavirus (HPV), which causes cervical cancer in women. </p>
<p>While the previous Gardasil vaccine protected against 70% of cervical cancers, the updated Gardasil 9 version will protect against up to 93% of these. And compared to the three doses required with the previous regimen, only two are needed now. </p>
<p>In Australia, around 900 new cases are <a href="https://cervical-cancer.canceraustralia.gov.au/statistics">diagnosed</a> and around 250 women die from the disease each year. But cervical cancer rates have halved in the past 30 years due to the high quality national Pap cytology screening program. </p>
<p>Prevention against cervical cancer is the main aim of the Gardasil 9 vaccine. But HPV is also linked to a large proportion of anal, vaginal and head and neck cancers, and the vaccine offers protection for these too.</p>
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Read more:
<a href="https://theconversation.com/interactive-body-map-what-really-gives-you-cancer-52427">Interactive body map: what really gives you cancer?</a>
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<h2>What is HPV?</h2>
<p>Genital HPV is a common group of viruses, mainly transmitted through sexual contact, including contact of genital skin to genital skin. Most people are infected with HPV shortly after the onset of sexual activity and most clear the infection on their own. </p>
<p>But for a small number of those infected, the HPV becomes persistent. A proportion of these people will go on to develop abnormal cells that are the precursor to cervical cancer. HPV is the cause of nearly all cervical cancers. But the virus is <a href="http://www.hpvvaccine.org.au/parents/parents-what-is-hpv.aspx?link=home">also linked</a> to 90% of anal cancers, 65% of vaginal cancers, 50% of vulva cancers and 35% of penile cancers and 60% of oropharyngeal cancers (cancers of the back of the throat, including the base of the tongue and tonsils).</p>
<p>The Australian government was one of the first to introduce a free Gardasil vaccine to all female students aged 12 to 13 years in 2007 (with a catch up to the end of 2009 for those up to 26 years of age). This protected against four different strains of HPV. Two of those strains (HPV 16 and 18) cause about 70% of cervical cancers; the other two cause the majority of genital warts (HPV 6 and 11). </p>
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Read more:
<a href="https://theconversation.com/new-study-shows-hpv-vaccine-is-working-to-reduce-rates-of-genital-warts-75129">New study shows HPV vaccine is working to reduce rates of genital warts</a>
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<p>Australia was also one of the first countries to adopt a school-based, gender-neutral vaccine program in 2013, by introducing free, ongoing vaccinations to young boys 12 to 13 years of age.</p>
<h2>What does Gardasil 9 offer?</h2>
<p>The new Gardasil 9 vaccine, available from this week, targets nine strains, seven of which cause around 93% of all cervical cancers (in addition to HPV 6/11 so protects against 90% of genital warts). It includes protection for the five next most common cancer-causing HPVs globally (HPV 31/33/45/52/58).</p>
<p>The new vaccine has been tested in global clinical trials involving more than 14,000 women in 18 countries, aged 16 to 26 years. They received either the new Gardasil 9 vaccine or the original Gardasil vaccine. Published in the New England Journal of Medicine and the Lancet, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31821-4/fulltext?rss%3Dyes">the study</a> looked at the rate of pre-cancerous cell changes in women six years later. </p>
<p>It found the new vaccine was far more effective, targeting an extra five of the most common cancer-causing strains of HPV and potentially preventing 23% more cervical cancers. Thus infection with the new types was markedly reduced too. With a reduction in infection, there is a reduction in the diseases that the HPV can cause.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-gardasil-9-the-vaccine-that-could-soon-protect-against-cervical-cancer-in-fewer-doses-82826">Weekly Dose: Gardasil 9, the vaccine that could soon protect against cervical cancer in fewer doses</a>
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<p>The common side effects with Gardasil 9 in the clinical trial were the same as with the older Gardasil vaccine. These were pain at the injection site, local swelling in the arm at the injection site and redness. There were no differences between the serious adverse events between the two vaccines.</p>
<h2>Who should get the new vaccine?</h2>
<p>Australia was one of the first countries to adopt an HPV vaccination program and has one of the <a href="http://www.hpvregister.org.au/research/coverage-data">highest coverage rates</a>, with around 79% of girls and 73% of boys having received the Gardasil vaccine.</p>
<p>Those who have already had the original vaccine have excellent protection from HPV, so we are not recommending they should go back for the new vaccine.</p>
<p>The new vaccine is free to 12- to 13-year-olds as part of the <a href="http://www.immunise.health.gov.au/">National Immunisation Program</a>. It’s also available at a cost to adults and has been shown effective in protecting against HPV in people up to the age of 45 years. </p>
<p>Those who have not been infected by the strains of HPV gain the most benefit from the vaccine. However, the vaccine boosts the immune response in sexually active individuals who have been infected previously with any of these HPV strains targeted by the vaccine, should they come into contact with the virus again.</p>
<h2>Regular screening important</h2>
<p>It’s important women continue to have regular screening to avoid abnormal cells developing into cervical cancer, even if they have had the vaccine. In December 2017, Australia’s screening program changed. The Pap test was replaced by a cervical swab testing for HPV DNA. This is a more sensitive test to detect underlying cellular abnormalities than the Pap test.</p>
<p>A <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002388">five year study involving 5,000 women</a> found the new HPV test was far more effective in detecting high grade pre-cancerous changes to the cervix compared to the traditional Pap test. It has the potential to prevent 30% more cervical cancers.</p>
<p>Women will now have their first test at age 25 instead of 18. After their first HPV test, women will be tested every five years instead of every two years. They will be tested up to age 74, and, in an important development, self-collection will be an option for some women who may have difficulty with a vaginal test.</p>
<p>We are already seeing the benefit of the original Gardasil vaccine on rates of HPV. With high coverage of the new Gardasil 9 vaccine, and adoption of the new HPV screening test it is predicted we will see a rapid decline in the cervical cancer rate in Australia in the coming years.</p>
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Read more:
<a href="https://theconversation.com/never-had-a-pap-smear-now-theres-a-diy-option-for-you-70706">Never had a Pap smear? Now there's a DIY option for you</a>
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<img src="https://counter.theconversation.com/content/90922/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Marie Garland has received advisory board fees and grants from CSL and the GSK group of companies, and lectures fees from Merck, the GSK group of companies and Sanofi Pasteur. In addition, she received funding through her institution to conduct HPV vaccines studies for MSD and the GSK group of companies. She is a member of the Merck Global Advisory Board as well as the Merck Scientific Advisory Committee for HPV.</span></em></p>Prevention against cervical cancer is the main aim of the Gardasil vaccine. But HPV is also linked to a large proportion of anal, vaginal and head and neck cancers.Suzanne Marie Garland, Professor, Melbourne University, The Royal Women's HospitalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/828262017-08-31T01:51:27Z2017-08-31T01:51:27ZWeekly Dose: Gardasil 9, the vaccine that could soon protect against cervical cancer in fewer doses<figure><img src="https://images.theconversation.com/files/183928/original/file-20170830-23696-1ffj6mj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new version of Gardasil, the HPV vaccine that protects against cervical cancer, has just been approved for listing on the Pharmaceutical Benefits Schedule.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/637851685?src=YkYHp0roOsC412pAJx7Mpg-1-15&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Gardasil is a vaccine that protects against cervical and other cancers. It works by boosting the immune response against the types of <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/human-papillomavirus-hpv-fact-sheet.pdf">human papillomavirus (HPV)</a> known to be behind most of these cancers.</p>
<p>Girls aged 12-13 have been receiving Gardasil as part of Australia’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/cda-cdi3702i.htm">school-based immunisation program</a> since 2007. And from 2013, boys of the same age were also included in the program.</p>
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Read more:
<a href="https://theconversation.com/boys-should-also-get-the-hpv-vaccine-to-protect-themselves-from-oral-and-genital-cancers-58772">Boys should also get the HPV vaccine to protect themselves from oral and genital cancers</a>
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<p>The vaccine has been <a href="http://www.abc.net.au/news/2017-08-10/new-vaccine-may-nearly-eliminate-cervical-cancer/8793316">in the news recently</a> because the committee that advises the federal government on which medicines should be publicly funded has recommended a new version of Gardasil (Gardasil 9) <a href="http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2017-07/positive-recommendations-2017-07.pdf">be subsidised</a>. It is likely to replace the original Gardasil in the school vaccination program from 2018. </p>
<p>Gardasil 9, as its name suggests, protects against nine types of HPV (five more than the existing Gardasil). Recent studies have also shown that if you vaccinate people under 15 <a href="http://jamanetwork.com/journals/jama/fullarticle/1682939">only two</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338934/">doses</a>, not three doses, are needed to achieve good immunity. This obviously has implications both for cost and convenience, and only two doses of Gardasil 9, 12 months apart, will be given in the new school program. Those older than 14 will still need three doses of the new vaccine. </p>
<p>While Gardasil 9 is <a href="https://www.tga.gov.au/auspar/auspar-human-papillomavirus-9-valent-vaccine">licensed for use in Australia</a>, it is not yet available, nor is it clear when it will be introduced in all states. However, it is already used in the US, New Zealand and Europe.</p>
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<h2>HPV: common, infectious and potentially deadly</h2>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0042682213003565">Over 120 different types of HPV infect humans</a> and 15 of them, almost always sexually transmitted, are linked to cancers of the genital area and throat.</p>
<p>HPV is highly infectious and by age 50, <a href="https://www.cdc.gov/cancer/hpv/basic_info//">some 80% of sexually active people</a> will have picked up at least one type of genital HPV.</p>
<p>Most HPV infections settle within two years, but in a small number of people the virus secretes itself within the cell nucleus, evading the immune system and increasing the risk of future cancer. HPV contributes to almost all cancers of the cervix, vulva and vagina, and is also the trigger for many cancers of the anus and throat. </p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs380/en/">Cervical cancer</a> is the fourth most common female cancer worldwide and the cause of about 270,000 deaths each year. <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/key-statistics-2">About 250</a> of those who die each year are Australian women.</p>
<h2>Gardasil</h2>
<p>The 1990s saw the development of the first HPV vaccine, Gardasil. The vaccine contains no infectious material. Instead, it contains four different <a href="https://www.ncbi.nlm.nih.gov/pubmed/20923267">virus-like particles</a>, identical to those in the protective capsule around HPV types 6, 11, 16 and 18. These are produced inside yeast cells. </p>
<p>Types 6 and 11 <a href="http://www.sciencedirect.com/science/article/pii/S0090825807005446?via%3Dihub">cause 90% of genital warts</a>, while types 16 and 18 are <a href="http://www.sciencedirect.com/science/article/pii/S0090825807005446?via%3Dihub">associated with around 70% of cervical cancers</a>.</p>
<p>Once injected, the virus-like particles generate a strong immune “memory”, providing protection from those particular HPV types in the future. Three injections were required over six months to ensure the best immune response.</p>
<p>It was recommended that age 12-13 was the best time for Gardasil vaccination for a number of reasons. Mainly because vaccination at this age is likely to be before their first sexual encounter (and HPV exposure). Also, the immune response tends to be <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm?s">stronger and more long-lasting</a> when the vaccine is given to pre-adolescents.</p>
<p>By 2011, only four years after the school-based vaccination program in Australia began, sexual health clinics were reporting a <a href="http://www.bmj.com/content/346/bmj.f2032.long">73% reduction</a> in genital warts in young heterosexual women and their male partners. And 2014 saw a <a href="https://www.mja.com.au/journal/2016/204/5/hpv-vaccine-impact-australian-women-ready-hpv-based-screening-program">significant drop</a> in the numbers of high-grade cervical pre-cancers in those under 30, while the figures for their older sisters remained stable. These high-grade changes are associated with a greater risk of cervical cancer later on. </p>
<h2>What does Gardasil 9 add?</h2>
<p><a href="https://www.tga.gov.au/auspar/auspar-human-papillomavirus-9-valent-vaccine">Gardasil 9</a> contains five more virus-like particles than the original vaccine and offers protection against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58. </p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/ijc.30871/full">extra viral types</a> are responsible for another 20% of female genital cancers and the new vaccine could potentially increase the protection rate for cervical cancer to around 90%.</p>
<p>Women still need regular cervical screening but even fewer should find themselves facing further testing and treatment over time.</p>
<h2>Side-effects and controversies</h2>
<p>Neither Gardasil or Gardasil 9 is licensed for use during pregnancy. Vaccination should be delayed if the person is very unwell or has a high temperature; medical advice is recommended if the person is allergic to yeast or has had a severe reaction to a previous vaccine; and anyone who has the vaccine is recommended to sit for 15 minutes to reduce the risk of fainting.</p>
<p>Vaccines, and HPV vaccines in particular, have attracted a significant amount of <a href="http://www.sciencedirect.com/science/article/pii/S0264410X12004860">online concern</a> about their safety.</p>
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Read more:
<a href="https://theconversation.com/the-best-shot-at-overcoming-vaccination-standoffs-having-doctors-listen-to-not-shun-reluctant-parents-81592">The best shot at overcoming vaccination standoffs? Having doctors listen to – not shun – reluctant parents</a>
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<p>Gardasil 9 has been studied in more than <a href="https://www.tga.gov.au/sites/default/files/auspar-human-papillomavirus-9-valent-vaccine-170103-pi.pdf">13,000 females and males</a> before release overseas. Five people in those trials had significant side-effects such as tonsillitis, fever, allergy and asthma. The commonest side-effect (in more than 80% of people) was pain, redness and swelling at the injection site.</p>
<p>More than <a href="http://www.who.int/vaccine_safety/committee/GACVS_HPV_statement_17Dec2015.pdf">200 million doses</a> of the original Gardasil vaccine have been administered in over 100 countries worldwide with <a href="https://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html">over 10 million doses of Gardasil 9</a> given in the US alone in the past year.</p>
<p>Given those numbers, the problems reported have been few. Though ongoing safety monitoring is important, it would appear that for most young people <a href="https://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html#A1">the benefits of this new vaccine far outweigh the risks</a>.</p><img src="https://counter.theconversation.com/content/82826/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Terri Foran has worked in the past as a consultant and has developed educational material around contraception for Merck Sharpe and Dohme, the company which distributes Gardasil and Gardasil 9 in many countries. She has never been involved in any consultancy work relating to either of these vaccines. She has no association whatsoever with the Australian distributor of these vaccines. </span></em></p>A new version of the HPV vaccine Gardasil protects against nine types of the virus, and is already being used overseas.Terri Foran, Lecturer in the School of Women's and Children's Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814002017-08-28T20:10:18Z2017-08-28T20:10:18ZHealth Check: which vaccinations should I get as an adult?<figure><img src="https://images.theconversation.com/files/181632/original/file-20170810-4244-1cw5cph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaccines are one of the greatest public health achievements in history.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Before vaccines were developed, infectious diseases such as diphtheria, tetanus and meningitis were the <a href="https://www.quora.com/What-is-the-most-common-cause-of-human-death-in-history">leading cause of death</a> and illness in the world. Vaccines are one of the <a href="http://www.who.int/bulletin/volumes/86/2/07-040089/en/">greatest public health achievements in history</a>, having drastically reduced deaths and illness from infectious causes.</p>
<p>There is a large <a href="https://newsroom.unsw.edu.au/news/health/millions-australian-adults-missing-out-free-vaccines">gap between vaccination rates</a> for funded <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">vaccines for adults in Australia</a> and those for infants. More than 93% of infants are vaccinated in Australia, while in adults the rates are between 53-75%. Much more needs to be done to prevent infections in adults, particularly those at risk. </p>
<p>If you are an adult in Australia, the kinds of vaccines you need to get will depend on several factors, including whether you missed out on childhood vaccines, if you are Aboriginal or Torres Strait Islander, your occupation, how old you are and whether you intend to go travelling.</p>
<h2>For those born in Australia</h2>
<p>Children up to four years and aged 10-15 receive vaccines under the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a>. These are for hepatitis B, whooping cough, diphtheria, tetanus, measles, mumps, rubella, polio, haemophilus influenzae B, rotavirus, pneumococcal and meningococcal disease, chickenpox and the human papillomavirus (HPV).</p>
<p>Immunity following vaccination varies depending on the vaccine. For example, the measles vaccine protects for a long duration, possibly a lifetime, whereas immunity wanes for pertussis (whooping cough). Boosters are given for many vaccines to improve immunity. </p>
<p><strong>Measles, mumps, rubella, chickenpox, diphtheria and tetanus</strong></p>
<p>People born in Australia before 1966 likely have <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-9">natural immunity to measles</a> as the viruses were circulating widely prior to the vaccination program. People born after 1965 should have received two doses of a measles vaccine. Those who haven’t, or aren’t sure, can safely receive a vaccine to avoid infection and prevent transmission to babies too young to be vaccinated. </p>
<p>Measles vaccine can be given as MMR (measles-mumps-rubella) or MMRV, which includes varicella (chickenpox). The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-22">varicella vaccine</a> on its own (not combined in MMRV) is advised for people aged 14 and over who have not had chickenpox, especially women of childbearing age.</p>
<p>Booster doses of diphtheria, tetanus and whooping cough vaccines, are available free at age 10-15, and recommended at 50 years old and also at 65 years and over if not received in the previous ten years. Anyone unsure of their tetanus vaccination status who sustains a tetanus-prone wound (generally a deep puncture or wound) should get vaccinated. While tetanus is rare in Australia, most cases we see are in older adults.</p>
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<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=838&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=838&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=838&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1053&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1053&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1053&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
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<p><strong>Whooping cough</strong></p>
<p>Pregnant women are recommended to get the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/pregnant-women">diphtheria-tetanus-acellular pertussis</a> vaccine in the third trimester to protect the vulnerable infant after it is born, and influenza vaccine at any stage of the pregnancy (see below under influenza). </p>
<p>Pertussis (whooping cough) is a contagious respiratory infection dangerous for babies. One in <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/whooping-cough">every 200 babies</a> who contract whooping cough will die. </p>
<p>It is particularly important for women from 28 weeks gestation to ensure they are vaccinated, as well as the partners of these women and anyone else who is taking care of a child younger than six months old. Deaths from pertussis are also documented in elderly Australians.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/no-vax-no-visit-if-mum-was-vaccinated-baby-is-already-protected-against-whooping-cough-59374">'No Vax, No Visit'? If mum was vaccinated baby is already protected against whooping cough</a>
</strong>
</em>
</p>
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<p><strong>Pneumococcal disease and influenza</strong></p>
<p>The pneumococcal vaccine is funded for everyone aged 65 and over, and <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">recommended for anyone</a> under 65 with risk factors such as chronic lung disease.</p>
<p>Anyone from the age of six months can get the flu (influenza) vaccine. The vaccine can be given to any adult who requests it, but is only funded if they fall into defined risk groups such as pregnant women, Indigenous Australians, peopled aged 65 and over, or those with a medical condition such as chronic lung, cardiac or kidney disease. </p>
<p>Flu vaccine is matched every year to the anticipated circulating flu viruses and is quite effective. The vaccine covers four strains of influenza. Pregnant women are at increased risk of the flu and recommended for influenza vaccine any time during pregnancy. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/millions-of-australian-adults-are-unvaccinated-and-its-increasing-disease-risk-for-all-of-us-74991">Millions of Australian adults are unvaccinated and it's increasing disease risk for all of us</a>
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</em>
</p>
<hr>
<p>Health workers, childcare workers and aged-care workers are a priority for vaccination because they care for sick or vulnerable people in institutions at risk of outbreaks. Influenza is the most important vaccine for these occupational groups, and some organisations provide free staff vaccinations. Otherwise, you can ask your doctor for a vaccination.</p>
<p>Any person whose immune system is <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-3#3-3-3">weakened through medication</a> or illness (such as HIV) is at increased risk of infections. However, live viral or bacterial vaccines must not be given to immunosuppressed people. They must seek medical advice on which vaccines can be safely given.</p>
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<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1780&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1780&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1780&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
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<p><strong>Hepatitis</strong> </p>
<p>Australian-born children receive four shots of the hepatitis B vaccine, but some adults are advised to get vaccinations for hepatitis A or B. Those recommended to receive the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4">hepatitis A vaccine</a> are: travellers to hepatitis A endemic areas; people whose jobs put them at risk of acquiring hepatitis A including childcare workers and plumbers; men who have sex with men; injecting drug users; people with developmental disabilities; those with chronic liver disease, liver organ transplant recipients or those chronically infected with hepatitis B or hepatitis C.</p>
<p>Those recommended to get the hepatitis B vaccine are: people who live in a household with someone infected with hepatitis B; those having sexual contact with someone infected with hepatitis B; sex workers; men who have sex with men; injecting drug users; migrants from hepatitis B endemic countries; healthcare workers; Aboriginal and Torres Strait Islanders; and some others at high risk at their workplace or due to a medical condition.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
</strong>
</em>
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<p><strong>Human papillomavirus</strong></p>
<p>The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv">human papillomavirus (HPV) vaccine</a> protects against cervical, anal, head and neck cancers, as well as some others. It is available for <a href="https://theconversation.com/boys-should-also-get-the-hpv-vaccine-to-protect-themselves-from-oral-and-genital-cancers-58772">boys</a> and girls and delivered in high school, usually in year seven. There is benefit for older girls and women to be vaccinated, at least up to their mid-to-late 20s. </p>
<h2>The elderly</h2>
<p>With ageing comes a progressive decline in the immune system and a <a href="https://theconversation.com/vaccination-isnt-just-for-kids-a-guide-for-over-65s-27869">corresponding increase</a> in risk of infections. Vaccination is the <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=41210">low-hanging fruit</a> for healthy ageing. The elderly are advised to receive the influenza, pneumococcal and shingles vaccines.</p>
<p>Influenza and pneumonia are <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16308520?via%3Dihub">major preventable causes</a> of illness and death in older people. The flu causes deaths in children and the elderly during severe seasons. </p>
<p>The most common cause of pneumonia is streptococcus pneumonia, which can be prevented with the <a href="https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html">pneumococcal vaccine</a>. There are two <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">types of pneumococcal vaccines</a>: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). Both protect against invasive pneumococcal disease (such as meningitis and the blood infection referred to as septicemia), and the conjugate vaccine is proven to reduce the risk of pneumonia.</p>
<p>The <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">government funds</a> influenza (annually) and pneumococcal vaccines for people aged 65 and over.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vaccination is the low-hanging fruit for healthy ageing.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Shingles is a reactivation of the chickenpox virus. It causes a high burden of disease in older people (who have had chickenpox before) and can lead to debilitating and chronic pain. The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-24">shingles vaccine</a> is recommended for people aged 60 and over. The government funds it for people aged 70 to 79. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-how-do-you-get-shingles-and-who-should-be-vaccinated-against-it-64436">Explainer: how do you get shingles and who should be vaccinated against it?</a>
</strong>
</em>
</p>
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<h2>Australian travellers</h2>
<p>Travel is a major vector for transmission of infections around the world, and travellers are at high risk of preventable infections. Most <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16306065">epidemics of measles</a>, for example, are imported through travel. People may be under-vaccinated for measles if they missed a dose in childhood. </p>
<p>Anyone travelling should discuss vaccines with their doctor. If unsure of measles vaccination status, vaccination is recommended. This will depend on where people are travelling, and may include vaccination for yellow fever, Japanese encephalitis, cholera, typhoid, hepatitis A or influenza. </p>
<p>Travellers who are visiting friends and relatives overseas often <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111124/">fail to take precautions</a> such as vaccination and do not perceive themselves as being at risk. In fact, they are at higher risk of preventable infections because they may be staying in traditional communities rather than hotels, and can be exposed to risks such as contaminated water, food or mosquitoes.</p>
<h2>Aboriginal Australians and Torres Strait Islanders</h2>
<p>Indigenous Australians are at <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-1">increased risk of infections</a> and have access to funded vaccines against influenza (anyone over six months old) and pneumococcal disease (for infants, everyone over 50 years and those aged 15-49 with chronic diseases). </p>
<p>They are also advised to get hepatitis B vaccine if they haven’t already received it. Unfortunately, overall <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi32suppl.htm">vaccine coverage for these groups</a> is low – between 13% and 50%, representing a real lost opportunity.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Dr G. Yunupingu's legacy: it's time to get rid of chronic hepatitis B in Indigenous Australia</a>
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</em>
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<h2>Migrants and refugees</h2>
<p>Migrants and refugees are at risk of vaccine-preventable infections because they <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12602/full">may be under-vaccinated</a> and come from countries with a high incidence of infection. There is no systematic means for GPs to identify people at risk of under-vaccination, but the new <a href="https://www.humanservices.gov.au/customer/services/medicare/australian-immunisation-register">Australian Immunisation Register</a> will help if GPs can check the immunisation status of their patients.</p>
<p>The funding of catch-up vaccination has also been a major obstacle until now. In July 2017 the government announced <a href="http://www.sbs.com.au/news/article/2017/07/12/refugees-all-ages-now-eligible-governments-national-vaccination-program">free catch-up vaccinations</a> for children aged 10-19 and for all newly arrived refugees. This covers any childhood vaccine on the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a> that has been missed. </p>
<p>While this does not cover all under-vaccinated refugees, it is a welcome development. If you are not newly arrived but a migrant or refugee, check with your doctor about catch-up vaccination.</p><img src="https://counter.theconversation.com/content/81400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and ARC. In the past she has received funding for investigator driven research or educational grants from Merck, GSK, Seqirus and Pfizer. </span></em></p><p class="fine-print"><em><span>Rob Menzies has been engaged as a consultant by Seqirus.</span></em></p>The kinds of vaccines adults need depend on several factors, including whether you were born here, how old you are and whether you intend to travel overseas.C Raina MacIntyre, Professor of Infectious Diseases Epidemiology, Head of the School of Public Health and Community Medicine, UNSW SydneyRob Menzies, Senior Lecturer, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/820142017-08-10T17:26:11Z2017-08-10T17:26:11ZThe secret behind Rwanda’s successful vaccination rollouts<figure><img src="https://images.theconversation.com/files/181289/original/file-20170807-27840-17vqe3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rwandan girls were targeted in the country's successful HPV vaccination programme.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The best medical treatment option in the world can’t save a single patient unless it is delivered at the proper time, with the proper plans and processes in place. </p>
<p>That’s why <a href="http://bit.ly/1Nr3S1Q">implementation science for health</a> matters. It can best be described as a collection of principles that, if applied, will ensure the best possible health care is delivered to a specific community. It involves using <a href="https://www.ncbi.nlm.nih.gov/books/NBK2659/">evidence-based research</a>
to identify the obstacles to delivering health services, and the best ways to overcome them. The research must take into account things like geographical limitations, the social and economic make up of a community as well as cultural practices. Once established for one community, the methodology can be reused in others. </p>
<p>Through my own experience – as an academic and as former health minister of Rwanda – I am convinced that, unless we adopt this approach we won’t be able to achieve universal health coverage and other <a href="http://bit.ly/1FVTbUr">United Nation’s Sustainable Development Goals</a>. This is particularly true for Africa where health services are stretched because of a lack of resources. </p>
<p>If we incorporate efficient, evidence-based practices into our service delivery models in Africa we’ll save millions of lives, as well as millions of dollars. </p>
<p>A vaccination programme rolled out in Rwanda illustrates what I mean.</p>
<h2>The Rwandan example</h2>
<p>In 2011 Rwanda began a <a href="http://bit.ly/2vCeUoo">vaccination programme </a> for <a href="http://bit.ly/2gCyxk8">human papillomavirus (HPV)</a> – the most common sexually transmitted disease in the world. 33 countries <a href="http://bit.ly/2utSlgP">had rolled out</a> vaccination programmes, but few of them were in developing countries and none were in Africa. </p>
<p>In 2010, when we were preparing our first campaign, Rwanda seemed an improbable candidate for achieving near-universal HPV vaccination coverage. After all, we were ranked the 15th poorest nation in the world. International <a href="http://bit.ly/2vBYFaQ">skeptics </a>argued that developing countries couldn’t manage because of their weak scientific base, poor infrastructure, economic difficulties and overemphasis on curative, rather than preventative, medicine. </p>
<p>At the time even the developed world had achieved only moderate coverage of HPV vaccinations. The US had less than <a href="http://bit.ly/2v8MEXt">35%</a> of its adolescent female population fully vaccinated, and France also had a <a href="http://bit.ly/2fhRFsS">low coverage</a>. If countries like this couldn’t realise HPV universal vaccination roll-outs, how could low and medium income countries manage? </p>
<p>But we weren’t deterred. We convinced HPV vaccine producers to ignore the global disapproval by presenting our evidence-based strategy of how we would roll-out a programme across the country. They listened, and then signed a public private partnership agreement, which <a href="http://reut.rs/2udXr5j">funded the programme</a>.</p>
<p>Despite the seemingly impossible odds, Rwanda achieved <a href="http://bit.ly/2vrP4TJ">93%</a> HPV vaccination coverage within a year of initiating the campaign. The coverage level has been <a href="http://bit.ly/2whc717">maintained ever since</a> </p>
<p>What is the secret to Rwanda’s success? The answer is simple. We put our trust in implementation science. </p>
<h2>Implementation science in action</h2>
<p>For the rollout we collected evidence, adapted distribution methods to our setting and set clear targets and outcomes.</p>
<p>Every step of HPV distribution was evidence-based. To analyse the cultural implications of our program, the Ministry of Health conducted a series of interviews and discussions with community members. We set up a task force which included all stakeholders - religious, educational, political, parliamentary, and community leaders - and designed a strategy of nationwide community education to spread awareness of cervical cancer, the benefits of the vaccine, and the proper time to receive it. Since almost all types of cervical cancer are caused by the human papillomavirus, it was important first <a href="http://bit.ly/2gU2Qqs">to explain</a> the link with cancer. </p>
<p>Using the same focus groups, we developed a method of defining and reaching the target population. Since HPV is a sexually transmitted disease, we wanted to vaccinate girls before they became sexually active. The task force researched the proper age bracket for this. Its conclusion was that a school-based vaccination scheme of 12-year-old girls would be most effective. Over <a href="http://bit.ly/2vA3alH">97%</a> of female Rwandan pre-teens are enrolled in primary school and few have sexual intercourse at that age. </p>
<p>Another research component was on the cold chain management. We needed to know how much vaccine to procure, how much storage space and money this would require, how many transport vehicles we would have to mobilise and where to send them. We also drew from our experience in rolling out other vaccination programs to create a rotating decentralized storage system. </p>
<p>Once all the evidence had been evaluated, we put a detailed delivery plan in place. We organised a distribution system to transport the vaccine from the cargo plane, to Kanombe International Airport, to the national warehouse, to the 30 district hospitals, to the 436 health centres – at that time, to the primary schools.</p>
<p>We also collaborated with Rwanda’s 45000 community health workers and all the teachers concerned. They identified girls who were absent from school on the day of vaccination to make sure they were covered too. And teachers were taught how to monitor students in the days after the vaccination so that they could report any adverse side-effects and be a key pillar of the HPV vaccine pharmacovigilance system.</p>
<p>The principles of implementation sciences applied for the success of the HPV vaccination roll-out have been used in other vaccination campaigns. Today in Rwanda we have more than 90% of all children fully vaccinated for 11 vaccines, with an additional <a href="http://bit.ly/2vA2jkG">HPV vaccine for all girls</a>.</p>
<h2>The need for research and education</h2>
<p>As Vice Chancellor of the University of Global Health Equity in Rwanda we are introducing researchers to implementation science.</p>
<p>Like any science, it requires research. At the moment, the global focus (and therefore global funding) is on clinical research and fundamental sciences. Last year less than 2% of all <a href="http://bit.ly/2vBWhAW">research grants</a> offered by the National Institute of Health, the largest funder of health research in the world, have been dedicated to implementation science. </p>
<p>But to improve health care we must also invest in implementation research to improve service delivery. Sure, we need basic science to create cheaper, more effective technology. But we also need implementation science to provide cost-effective ways of delivering and promoting universal health coverage.</p><img src="https://counter.theconversation.com/content/82014/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Binagwaho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s vaccination programme for girls against HPV, the most common sexually transmitted disease was a huge success, thanks to implementation science.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/740772017-03-09T19:23:31Z2017-03-09T19:23:31ZFive myths about the new cervical screening program that refuse to die<figure><img src="https://images.theconversation.com/files/160114/original/image-20170309-21034-c9ch1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are confused about what changes to the cervical screening program will mean for their sexual health.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?source_location=minibar">online petition</a> against changes to Australia’s <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1">cervical cancer screening program</a> has revealed more than 70,000 people (most of whom we could assume are women) are deeply concerned about what the upcoming changes mean.</p>
<p>Their comments also reveal a number of misconceptions about the new screening program, which will now be rolled out in <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr17-dept-dept002.htm">December 2017</a>, rather than in May as planned.</p>
<p>It seems that in concentrating on the science behind shifting away from Pap smears every two years to <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/content/future-changes-cervical">testing for the human papillomavirus (HPV) every five years</a>, our medical authorities have <a href="https://theconversation.com/delays-and-confusion-cloud-roll-out-of-new-cervical-cancer-screening-program-73605">failed to convince</a> many Australian women this move <a href="https://theconversation.com/recommended-cervical-screening-regime-will-save-even-more-lives-26034">will save lives</a>.</p>
<p>Convincing women to come on board is, of course, critical to the success of the new screening program, which is forecast to <a href="http://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667%2817%2930007-5.pdf">improve cervical cancer detection rates</a> by at least 15% and is <a href="http://www.smh.com.au/comment/the-end-of-the-pap-smear-is-good-news-for-women-20170227-gum0q2.html">good news for women</a>.</p>
<p>So let’s have a look at some common misconceptions and concerns about <a href="http://www.nps.org.au/__data/assets/pdf_file/0016/310534/HPV-testing-for-primary-cervical-screening.pdf">changes</a> to the cervical cancer screening program raised by some of my patients and by the many people signing up to the <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?source_location=minibar">change.org petition</a>.</p>
<h2>Myth #1: no more Pap tests means no more invasive examinations</h2>
<p>Quite a few of my patients have thought the new screening program means the end of invasive examinations. And I say “unfortunately not”. For most women the collection procedure will be exactly the same as before. This means you will still have to lie on a couch and a doctor or nurse will still insert the dreaded speculum. This instrument is needed to hold the vaginal walls gently apart so that the cervix at the end of the vagina can be seen. </p>
<p>Two small brushes are used to sample cells from both the outside of the cervix and from the opening which leads up to the uterus. Rather than the specimen being smeared on a slide (as with Pap smears), the two brushes are swizzled around in a preservative liquid, which separates out most of the collected cells and any HPV, the virus responsible for <a href="https://www.ncbi.nlm.nih.gov/pubmed/10451482">at least 99.7%</a> of cervical cancers.</p>
<p>But it’s not until the specimen gets to the pathology lab that the process really changes.</p>
<p>First, the specimen is checked for HPV and only if HPV is present will cells be examined for signs of pre-cancer or cancer. </p>
<p>There is also the option for women who have previously avoided having Pap tests for cultural, religious or personal reasons to collect their own HPV sample. It is estimated that even if a woman has only <a href="https://www.ncbi.nlm.nih.gov/pubmed/26985849">one self-collected test</a> at age 30 she reduces her risk of cervical cancer by about 40%.</p>
<h2>Myth #2: the new test could miss types of cervical cancer not related to HPV</h2>
<p>Almost 85% of cervical cancers are actually skin cancers, triggered not by the sun but by HPV. This type of cervical cancer usually takes about <a href="http://www.who.int/mediacentre/factsheets/fs380/en/">15-20 years</a> to develop. So, HPV testing gives us a chance to detect potential problems long before there is anything to see on a Pap test. </p>
<p>In the new program, women who carry the highest risk HPV types will then have their cells examined using a more sensitive test known as liquid-based cytology. They will also be automatically referred to a gynaecologist for further tests. If other kinds of HPV are found, a check whether the cells show any changes will guide whether the woman is referred for other tests or simply monitored more closely. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new screening program relies on detecting human papillomavirus (HPV), which cause the vast majorities of cervical cancers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/391299166?src=JfnpCIQhNAVe0XK5cR8iCQ-2-64&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some 15% of cervical cancers start in glandular cells. HPV also triggers these cancers but they are often beyond the reach of the little brushes used to collect cells in a Pap test. They can hide away quietly, growing and spreading for many years before they are detected. </p>
<p>When you hear of someone diagnosed with cervical cancer after previously normal Pap tests it is almost always a <a href="https://www.jostrust.org.uk/forum/cervical-cancer-newly-diagnosed/smear-missed-my-cancer-anyone-else-out-there-same">glandular-type cancer</a>. </p>
<p>The good news is that HPV testing should pick up this kind of cancer earlier and more reliably than a regular Pap test.</p>
<p>There are also some very rare cervical cancers (less than 1%) that start off from muscle, nerve or pigment cells deep within the cervix and are not related to HPV infection. It is true that the new screening program is not designed to detect these types of cancer but then they were also almost impossible to detect on a traditional Pap test as well.</p>
<h2>Myth #3: young women will miss out on early detection if screening starts at 25</h2>
<p>There are many online testimonies from women signing the change.org petition saying they had cervical cancer before the age of 25. It is more likely that most of these were pre-cancerous changes because cervical cancer in this age group is really rare – around <a href="https://cervical-cancer.canceraustralia.gov.au/statistics">1.7 in 100,000</a> Australian women under 25.</p>
<p>Unfortunately, in the nearly 30 years our present screening program has been running there has been <a href="https://www.mja.com.au/journal/2016/205/8/impact-australian-national-cervical-screening-program-women-different-ages">no significant impact</a> on the numbers of cervical cancers reported in Australian women under 25. </p>
<p>Another complication in this younger age group is that cellular changes may look worse than they actually are because of a robust immune reaction to the HPV infection. Unfortunately this can lead to well-meaning advice to treat changes that are very likely to get better on their own.</p>
<h2>Myth #4: less cervical testing reduces the chances of picking up other cancers such as ovarian and uterine cancer</h2>
<p>Pap tests were designed to pick up pre-cancerous changes in the cells of the cervix. They are absolutely useless at detecting endometriosis, polyps, ovarian cancer or sexually transmitted infections other than HPV. They occasionally pick up uterine cancer if it is advanced enough for the cells to be shedding through the cervix that day. </p>
<p>The important point here is that screening tests are only for women with no symptoms. If a woman develops symptoms, such as irregular bleeding, pain or abnormal vaginal discharge, she needs to see her doctor for advice regardless of when she had her last cervical screening test. </p>
<h2>Myth #5: the government is motivated by a cheaper option and will shift the costs of the test to the woman herself</h2>
<p>The new tests are more expensive than a traditional Pap test, but because they are so much more sensitive there is no need to do them as frequently. </p>
<p>They will be funded under Medicare just as the Pap test is now. Any out-of-pocket costs depend on whether health care providers bulk bill (as they often do with screening tests) or charge the scheduled fee.</p><img src="https://counter.theconversation.com/content/74077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Terri Foran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is a lot of misinformation about the government’s new cervical cancer screening program that involves less frequent tests. Here are the facts.Terri Foran, Lecturer in the School of Women's and Children's Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/151782013-06-25T20:59:35Z2013-06-25T20:59:35ZFour things you should know about HPV vaccinations<figure><img src="https://images.theconversation.com/files/26155/original/448phyg7-1372141408.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The benefits of the human papillomavirus vaccine far outweigh risks.</span> <span class="attribution"><span class="source">VCU CNS/Flickr</span></span></figcaption></figure><p>The human papillomavirus (HPV) vaccine has attracted attention in the past week for two contradictory reasons: the Japanese government has <a href="http://ajw.asahi.com/article/behind_news/social_affairs/AJ201306150057">withdrawn its recommendation</a> for the shot, while public health officials in the United States have attributed a <a href="http://www.nytimes.com/2013/06/20/health/study-finds-sharp-drop-in-hpv-infections-in-girls.html?nl=todaysheadlines&emc=edit_th_20130620&_r=1&">massive drop in the prevalence</a> of the virus among teenage girls to its use. </p>
<p>The Japanese government’s decision is the result of 1,968 reported cases of possible side effects, 43 of which have been examined by a health ministry task force. Since 2010, 3.28 million Japanese women have received the human papillomavirus vaccination. </p>
<p>In the United States, on the other hand, there’s good news with virus thought to be half as common as it used to be, despite only about a third of young women receiving the full vaccine course of three shots. </p>
<p>So, what are we to make of the vaccine? Here are answers to four common questions about it, based on <a href="http://www.infectagentscancer.com/content/8/1/22/abstract">a research paper</a> I recently published with two co-authors. </p>
<h2>Does the vaccine prevent infection with the virus?</h2>
<p>Both the human papillomavirus vaccines (<a href="http://www.ncbi.nlm.nih.gov/pubmed/17494925?dopt=Abstract&holding=f1000,f1000m,isrctn">Gardasil</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/15541448?dopt=Abstract&holding=f1000,f1000m,isrctn">Cervarix</a>) have been shown to reduce the virus infection rate by over 90%. This reduction is maintained for at least five years. </p>
<p>The catch (and there’s always a catch) is that for the vaccine to be this effective, it has to be given to people who have not been exposed to the virus. </p>
<p>This is why the vaccine is given to 12 to 13-year-olds in <a href="http://www.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv">Australia</a> and 14 to 19-year-olds in the United States. </p>
<h2>Will the vaccine cause a rise in other HPV types?</h2>
<p>The human papillomavirus vaccines available in Australia target two (types 16 and 18) of the 15 high-risk virus strains associated with cancer. </p>
<p>Questions have been <a href="http://www.hpv.org.nz/patient/myths.htm#top">asked</a> about whether one or more of the remaining 13 cancer-causing virus types will become more common to “fill the gap” left by their reduction. </p>
<p><a href="http://www.infectagentscancer.com/content/8/1/22">Clinical trials</a> have shown that both HPV vaccines provide significant protection against five other oncogenic types: 31, 39, 45, 59, and 86. And the Cervarix vaccine also protects against types 33 and 52. </p>
<p>The vaccine’s strength and duration of effect on other non-vaccine HPV types is still being studied.</p>
<h2>Does the vaccine prevent cervical cancer?</h2>
<p>This is a harder question to answer because human papillomavirus vaccines have only been widely used in Australia since 2007, and internationally since 2006. </p>
<p>It takes between 10 and 20 years from initial infection to the <a href="http://www.cancer.gov/cancertopics/factsheet/Risk/HPV">development of cancer</a>. So the direct effect of the vaccination on cervical cancer rates is currently difficult to assess. </p>
<p>But we can glean an effect by looking at the early warning signs of cervical cancer – pre-cancerous lesions called cervical intraepithelial neoplasia (CIN). CIN grade 2 and grade 3 lesions are considered good surrogate markers of cervical cancer because they’re likely to progress to disease <a href="http://www.ncbi.nlm.nih.gov/pubmed/8463044?dopt=Abstract&holding=f1000,f1000m,isrctnhttp://example.com/">5% and 12% of the time</a>, respectively. </p>
<p>The vaccine reduces these two grades of pre-cancerous lesion by over <a href="http://www.infectagentscancer.com/content/8/1/22/table/T2">99%</a>. And the two HPV types covered by the vaccine are linked to approximately 70% of cervical cancers. </p>
<p>This suggests that a significant decline in cervical cancer will be observable within the next decade. Human papillomavirus infection has also been linked to a number of other cancers such as those of the penis (40% are HPV-associated), vulva or vagina (40%), anus (90%), mouth (3%) and oropharynx (12%).</p>
<h2>Is the vaccine safe?</h2>
<p>This is probably the most often asked question due, in part at least, to certain (online) organisations using scare tactics against the vaccine (particularly Gardasil). </p>
<p>Like any medical procedure, these vaccines can have side effects. But these are overwhelmingly (more than 93%) <a href="http://www.ncbi.nlm.nih.gov/pubmed/19690307?dopt=Abstract&holding=f1000,f1000m,isrctn">minor</a>, and are largely injection site reactions (redness, swelling and pain where the injection was given). </p>
<p>Some other minor self-limiting reactions, which go away without treatment, such as fainting, headache and nausea have also been reported. </p>
<p><a href="http://www.infectagentscancer.com/content/8/1/22/table/T3">Clinical trials</a> involving over 44,000 women showed no differences in serious side effects between the human papillomavirus vaccines and control groups. But monitoring the safety of the vaccines doesn’t stop when these trials are finished. <a href="http://ncirs.edu.au/surveillance/index.php">Post-marketing surveillance</a> continues to examine possible vaccine side effects.</p>
<p>It’s sometimes claimed that the human papillomavirus vaccine is associated to premature death. These claims are inevitably linked to reports of deaths on the <a href="http://vaers.hhs.gov/index">US Vaccine Adverse Event Reporting System</a> (VAERS). As this is an open system where any member of the public can enter information, it’s difficult to analyse such claims without further investigation. </p>
<p>When such reported deaths are <a href="http://www.ncbi.nlm.nih.gov/pubmed/19690307?dopt=Abstract&holding=f1000,f1000m,isrctn">investigated</a>, they are found to not occur any more in vaccinated people than in those who haven’t been vaccinated.</p>
<p>There’s also <a href="http://www.ncbi.nlm.nih.gov/pubmed/19690307?dopt=Abstract&holding=f1000,f1000m,isrctn">no evidence</a> of a link between human papillomavirus vaccination and autoimmune conditions.</p>
<h2>And for the future…</h2>
<p>The rapidly growing body of research from fields including <a href="http://www.ncbi.nlm.nih.gov/pubmed/23632723">immunology</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23722024">virology</a>, <a href="http://jid.oxfordjournals.org/content/early/2013/06/18/infdis.jit192.abstract">public health and epidemiology</a>, among others, should help the community, including doctors and parents, to be confident about the benefits of the human papillomavirus vaccine. </p>
<p>These benefits far outweigh its risks, and mechanisms are in place to continue monitoring any future adverse events. </p><img src="https://counter.theconversation.com/content/15178/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dave Hawkes is currently supported by funding from the National Health and Medical Research Council.</span></em></p>The human papillomavirus (HPV) vaccine has attracted attention in the past week for two contradictory reasons: the Japanese government has withdrawn its recommendation for the shot, while public health…Dave Hawkes, Postdoctoral Researcher (Viral tools and Neuropeptides), Florey Institute of Neuroscience and Mental HealthLicensed as Creative Commons – attribution, no derivatives.