HPV Vaccination: Information on HPV Infection & Genital Warts, Vaccination Against Human Papillomavirus & Doctors

The human papillomavirus (HPV) is a pathogen that infects cells in the skin and mucous membranes. Currently, over 100 different types of human papillomavirus are known.

Some types of human papillomavirus cause common skin warts on the feet, hands, or face. Such warts occur in 5 to 20 percent of all children and in 3 to 5 percent of all adults.

About 40 types of human papillomavirus are sexually transmitted. Among these genital types of HPV, a distinction is made between low-risk and high-risk types.

Low-risk types cause the development of unpleasant but harmless genital warts.

High-risk types can cause tissue changes

• in the mouth and throat,
• in the genital area,
• on the cervix,
• in the vagina,
• on the penis, or
• the anus

and lead to malignant tumors. The most common form of cancer caused by the human papillomavirus is cervical cancer (cervical carcinoma).

Infection with the human papillomavirus occurs through direct contact with infected skin areas. Infected cells are transmitted through microscopic skin lesions.

Because the virus is resistant to drying out, smear infection via contaminated surfaces is also possible. This can occur, for example, through the shared use of towels for the genital area.

In extremely rare cases, the HPV virus is transmitted to the newborn during childbirth.

The genital types of the human papillomavirus are primarily transmitted through vaginal, anal, and oral sexual intercourse. An exchange of bodily fluids is not required for transmission.

Over the course of their lives, about 70 percent of all sexually active people become infected with an HPV virus. Infection rates are particularly high among people aged 15 to 24. Frequent changes in sexual partners are considered the main risk factor for infection with the human papillomavirus.

The human papillomavirus can remain in the body undetected for years before symptoms appear. Therefore, the time of infection may have occurred years ago. If a person is infected with a genital HPV type, their partner is highly likely to be infected as well.

In over 80 percent of cases, the infection progresses without any symptoms. It clears up spontaneously within up to two years. In the majority of infected individuals, the immune system is able to successfully eliminate the virus. As a result, those affected are usually unaware that they are or were carriers of the human papillomavirus.

A persistent infection with a high-risk type of HPV increases the risk of developing cervical cancer. As a result, about 1 to 3 percent of all women with a long-term infection develop a tumor on the cervix. HPV types 16 or 18 were detected in 70 percent of cervical tumors.

If a persistent infection with the human papillomavirus is compounded by factors such as

• a weakened immune system,
• chronic nicotine use,
• sexually transmitted infections such as chlamydia,
• long-term use of birth control pills, or
• a high number of births

are also factors that increase the risk of cervical cancer even further.

Worldwide, 440,000 women are diagnosed with cervical cancer each year, particularly in developing countries. In Germany, there are 5,500 new cases per year, and 1,500 women die from the disease. Among women aged 15 to 49, cervical cancer is the second most common cancer after breast cancer. It accounts for 9 percent of all cancer cases.

Cervical cancer develops through various precancerous stages, known as intraepithelial neoplasia. The term “intraepithelial” means that the cellular changes occur exclusively on the epithelium—that is, the outermost layers of the skin.

If left untreated, the abnormal cell growths can invade deeper layers of the skin. Once they reach the blood and lymphatic vessels, they are no longer considered a precancerous condition but are classified as cancer. On average, it takes 10 to 15 years from infection with the human papillomavirus to the onset of cancer.

In the majority of cases, there are no symptoms at all when cervical cancer or its precancerous stages are present. Possible signs, however, include

• irregular bleeding,
• bleeding during sexual intercourse, or
• unusual discharge.

As part of cancer screening, the gynecologist checks for precancerous lesions. Early detection can prevent the development of cancer before it occurs.

For girls and women, the HPV vaccine has been recommended for children and adolescents for several years. It prevents infection with HPV types 16 and 18, thereby providing effective protection against cervical cancer.

Anal cancer is a rare tumor, with an incidence of 0.7 per 100,000 women and 0.4 per 100,000 men. In 80 percent of all anal cancers, infection with the human papillomavirus can be detected.

A weakened immune system and frequent receptive anal sex are risk factors for anal cancer. Consequently, HIV-positive gay men and HIV-positive women who engage in anal sex are affected significantly more often. These high-risk groups should therefore undergo an annual digital rectal exam and anal smear tests.

If precancerous lesions are found during a screening exam, local therapy with imiquimod is administered. The cream is applied to the affected areas three times a week, triggering a local inflammatory response.

In the long term, this reduces the amount of human papillomavirus and prevents the progression of cellular changes. As a result, cancer cannot develop.

Human papillomavirus type 16 is considered the most common cause of anal cancer. The HPV vaccine for women covers this type. Therefore, it is believed that early vaccination also protects men from developing anal cancer. Further research is needed in this area.

Sexual abstinence is considered the most effective protection against infection with the human papillomavirus. Condoms do not always completely cover infected areas of the skin. They merely reduce the risk of infection with the human papillomavirus. They do not provide complete protection.

Vaccination can protect against infection with the human papillomavirus. However, it is not suitable for treating existing disease or cellular changes.

Gels, creams, or foam suppositories do not offer protection against infection with the human papillomavirus.

Two vaccines are available in Germany to protect against infection with the human papillomavirus: Cervarix® and Gardasil®. Both protect against infection with human papillomaviruses 16 and 18.

Gardasil® also prevents infection with human papillomaviruses 6 and 11, which are responsible for the development of genital warts.

Since March 2007, the Standing Committee on Vaccination has recommended that girls between the ages of 12 and 17 receive a vaccination against the human papillomavirus. In 2009, this vaccination recommendation was reviewed again and found to remain valid. Statutory health insurance plans cover the costs of the HPV vaccination.

The human papillomavirus vaccination is administered in three doses for both vaccines. It should be completed before the first sexual intercourse.

According to studies, the effectiveness of both HPV vaccines is 99 percent in uninfected women. Gardasil® provides protection against infection for at least eight years, and Cervarix® for at least five years. In women already infected with the human papillomavirus, the vaccine’s effectiveness is significantly lower.

No efficacy of the vaccines has been demonstrated with regard to existing cellular changes in the cervix.

Both Gardasil® and Cervarix® are considered well-tolerated. Side effects associated with the vaccine include skin reactions at the injection site, fatigue, or temporary fever.

In Germany, there is no public vaccination recommendation against the human papillomavirus for boys. However, studies show that boys also benefit from vaccination against the human papillomavirus.

For example, compared to unvaccinated boys, those vaccinated against HPV had

• anal cancer as well as
• warts and
• precancerous lesions in the perineal area, on the penis, and in the anus

. Vaccinating boys is also considered beneficial for preventing transmission to female partners. This helps to curb the spread of the human papillomavirus.

Once a person becomes sexually active, the benefits of vaccination against HPV decrease significantly. However, after an individual risk-benefit assessment, HPV vaccination for girls and boys may still be advisable.

Vaccines containing so-called “virus-like particles” (VLPs) are available for HPV vaccination. They are developed from the viruses themselves and contain a very small viral component. This is the so-called major capsid protein L1, which, however, is not carcinogenic.

Two HPV vaccines are currently approved in Germany and available at pharmacies.

Gardasil ©: The HPV vaccination with this vaccine targets HPV types 16 and 18, as well as types 6 and 11. The latter can cause genital warts. The vaccine therefore contains the VLPs of these four different HPV types. Gardasil © helps prevent

• high-grade precancerous lesions of cervical cancer,
• cervical cancer itself,
• high-grade precancerous lesions of vulvar cancer, and
• external genital warts

.

Cervarix ©: HPV vaccination with this vaccine prevents infection with HPV types 16 and 18. The vaccine is designed to prevent the development of

• high-grade precancerous lesions of cervical cancer,
• cervical cancer itself, and
• high-grade precancerous lesions of vulvar cancer.

Cervarix © contains the viral protein components (VPLs) of HPV types 16 and 18.

The HPV vaccination with either of the two vaccines is administered via an intramuscular injection. It leads to an increased concentration of antibodies against the corresponding HPV types in the blood. The concentration after vaccination is 100 to 1,000 times higher than after a natural infection.

To prevent infection with HPV types 16 and 18, a completed primary vaccination series (3 doses) is considered effective. However, this applies only to girls and young women before their first sexual intercourse.

In some cases, sexually active women who have already been infected may also benefit from the HPV vaccine. The HPV vaccine can then prevent the recurrence of genital warts.

Newer vaccines combine various components of HPV into a single vaccine. These vaccines demonstrate broader efficacy against both low- and high-risk types than previously available vaccines. They prevent genital warts and skin warts.

The vaccine must undergo further clinical trials and be approved by the Federal Institute for Drugs and Medical Devices (BfArM). However, scientists are confident about the introduction of this new vaccine for HPV immunization. It is already available as a component of the primary vaccine series in Gardasil and Cervarix and has a very good safety profile.

Furthermore, as a standalone vaccine, it offers an economic advantage over the HPV vaccines already on the market.

HPV vaccination effectively prevents infection with HPV types 16 and 18. This infection is the leading cause of cervical cancer and its precancerous stages. The vaccine therefore effectively protects against the development of this type of cancer and represents the best form of prevention. However, the protection is only effective in young women and girls.

That said, the vaccination rate in Germany is lower than in other countries where the vaccine is also administered.

A newer HPV vaccine could be a promising measure for preventing HPV infections. Unfortunately, even the new HPV vaccine does not cover all HPV types during immunization. In addition to the high-risk types 16 and 18, there are others that also have this carcinogenic potential.

The HPV vaccine does not provide 100% protection. Vaccine failure—and thus inadequate immunization—is rare but possible. Experts recommend the HPV vaccine; however, even vaccinated women should undergo screenings for early cancer detection.

If the new HPV vaccine becomes widely adopted, people with weakened immune systems will also benefit from its preventive effect against skin warts.

Health insurance companies may then also cover the cost of the HPV vaccine for boys aged 9 to 14. If both genders are vaccinated against HPV, an even greater decline in cervical cancer is expected.

Other types of cancer associated with HPV infections may also be reduced. These include, among others, penile cancer and laryngeal cancer.