1. ADOLESCENT IMMUNIZATIONS
Katalin Koranyi, MD
Professor of Pediatrics
Nationwide Children’s Hospital
Department of Pediatrics
College of Medicine
The Ohio State University

3. What is HPV? Skin (e.g., warts on the hands and feet)
Human papillomavirus (HPV) is the name of a group of viruses that infect:
Skin (e.g., warts on the hands and feet)
Mucous membranes (e.g., mouth, vagina, cervix)
There are more than 100 different types of HPV.

4. About 30 types of HPV affect the genital area
“High-risk” types:
Can cause abnormalities of the cervix (the lower portion of the uterus or womb) that sometimes turn into cancer.
“Low-risk” types:
Can cause genital warts and abnormal but noncancerous changes in the cervix.
All types of genital HPV can cause abnormal Pap tests.

5. How does a person get HPV?
Anyone (man or woman) who has any kind of sexual activity involving genital contact with an infected person can get HPV
Intercourse is not necessary
Most people do not know they have HPV
Because most infections do not cause symptoms

6. HPV Infections People can pass the virus on without even knowing it
Most people get HPV within their first 2 to 3 years of becoming sexually active
By age 50, at least 80% of women will have acquired genital HPV infection
American Cancer Society Cancer Reference Information – Frequently Asked Questions About Human Papilloma Virus (HPV) Vaccines;pg.20
American Cancer Society. Frequently asked questions about human papilloma virus vaccines. American Cancer Society Website.
Accessed July 14, 2008

7. Most new cases of HPV occur in adolescents and young adults
Women are at risk of acquiring an HPV infection from as few as 1 sex partner
Risky sexual behavior is not necessary
New cases of genital HPV in a year in the US
Approximately 6 million
1. Winer RL et al. J Infect Dis. 2008;197(2):

8. What are the consequences of HPV?
1.4 million new cases of
mildly abnormal cells
3,670 estimated deaths
1 million new cases of
genital warts
330,000 new cases of highly
abnormal cells
11,150 new cases of cervical cancer

9. Genital HPV and how it affects the female anatomy
The Female Reproductive Tract
The uterus is a hollow, muscular, pear-shaped organ located in the female pelvis between the bladder and the rectum. The main function of the uterus is to sustain a developing fetus during pregnancy. The cervix, often called the neck of the uterus, is the lower portion of the uterus that opens into the vagina.
The cervix is composed of squamous epithelium (which covers the exocervix or the part of the cervix next to the vagina), and columnar epithelium (which lines the endocervical canal, the part closest to the body of the uterus).
The transformation zone is the area of the cervix where the process of gradual replacement of the immature columnar cells with the new mature metaplastic squamous epithelium occurs.
Over the past few decades, the prevalence of adenocarcinomas appears to have increased. This could be due to an increase in the overall prevalence of Human Papillomavirus (including Types 16 and 18, which account for most adenocarcinomas) as well as the fact that adenocarcinomas are not as easily detected during cervical cancer screening as squamous cell carcinomas. This is because unlike squamous cell carcinomas, which usually originate in the transformation zone, adenocarcinomas often arise in the endocervical canal, which is less accessible to Pap testing.

10. How do Pap tests help prevent cervical cancer?
Pap test detects abnormal cervical cells
Treating abnormal cervical cells early can almost always prevent cervical cancer from developing

11. Cervical cancer
About half of all women diagnosed with cervical cancer are between 35 and 55 years old
Many of these women may not realize is that they were most likely exposed to one of the “high-risk” types of HPV during their teens and 20s

12. Genital warts
Genital warts are flesh-colored growths that are caused by certain “low-risk” types of HPV
The types of HPV that cause genital warts are different from the “high-risk” types that can cause cervical cancer
After sexual contact with an infected person, the warts may appear within weeks or months

13. What do genital warts look like?
Genital warts don’t always look the same
Some warts grow inside a woman’s vagina, or on the cervix, making them hard to see

14. Summary What is HPV? How can a person get HPV?
Human papillomavirus (HPV) is the name of a group of viruses that infect the skin and mucous membranes.
There are more than 100 different types of HPV, which include “high-risk” and “low-risk” types.
How can a person get HPV?
Anyone who has any kind of sexual activity involving genital contact with an infected person can get HPV. Intercourse isn’t necessary, and transmission can take place by oral-to-genital, hand-to-genital and genital-to-genital contact.
HPV affects both women and men.

15. GARDASIL: An HPV Vaccine
HPV 6/11/16/18 L1 virus-like particle (VLP) vaccine
The vaccine is effective
Prevents cervical, vulvar and vaginal cancers caused by HPV 16 and 18
70% of cervical cancer
Prevents genital warts caused by HPV 6 and 11
90% of genital warts
Adverse reactions to the vaccine
Pain and swelling at the injection site
Fainting

16. CDC, AAP, AAFP Recommendations
CDC/p. 16/col 2/¶2.
Routine vaccination with 3 doses of HPV vaccine for females 11–12 years of age
Can be started as young as 9 years of age
Catch-up vaccination for females 13–26 years of age not previously vaccinated or who have not completed the full vaccine series
Ideally, vaccine should be administered before potential exposure to HPV
CDC/p. 16/col 2/¶3.
CDC/p. 17/col 1/¶2.
CDC/p. 17/col 1/¶3.
CDC/p. 17/col 1/¶6.
Package insert/
p.8/lines 249, 252
Key Point
ACIP recommendations for the quadrivalent HPV vaccine indicate routine vaccination for females 11 to 12 years of age with catch-up vaccination in females 13 to 26 years of age.
Background
Recommendations for use of quadrivalent HPV vaccine1:
Routine vaccination with 3 doses of quadrivalent HPV vaccine is recommended for females 11 to 12 years of age. The vaccination series can be started in females as young as 9 years of age.
Catch-up vaccination is recommended for females 13 to 26 years of age who have not been vaccinated previously or who have not completed the full vaccine series. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact. However, females who might have been exposed to HPV should be vaccinated.
Quadrivalent HPV vaccine can be administered at the same visit that other age- appropriate vaccines are provided, such as Tdap and quadrivalent meningococcal conjugate (MCV4).
– NOTE: Although ACIP states that the quadrivalent HPV vaccine can be administered with these other vaccines, per the prescribing information, co-administration of GARDASIL® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine] with these vaccines has not been studied.
Reference:
1. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56(RR-2):1–24.
1/CDC/p. 16/col 2/¶2.
1/CDC/p. 16/col 2/¶3.
1/CDC/p. 17/col 1/¶6.
Package insert/
p.8/lines 249, 252

17. Summary: GARDASIL
GARDASIL is a vaccine indicated in girls and women 9 to 26 years of age for the prevention of cervical, vulvar, and vaginal cancers; precancerous; and genital warts caused by HPV Types 6, 11, 16, and 18
GARDASIL is contraindicated in individuals with severe allergic reactions to yeast
Gardasil does not substitute for routine cervical cancer screening

18. Pertussis in an adolescent 10 fold rise in incidence in recent years

19. Adolescent Pertussis on the Rise
Incidence
2004
23.86
10-fold Increase in 10- to 19-year olds
Incidence
1994
2.33
Adult Incidence
Slide 37. Adolescent Pertussis on the Rise
The highest incidence of pertussis is among infants <6 months old (not shown on this graphic).
Although infant pertussis is particularly disturbing, the incidence of pertussis disease had begun to shift and increase among the adolescent population in the 1990s. Between 1990 to 1993 and 1994 to 1996, the reported incidence of pertussis increased among children and older individuals; however, the largest increase (106%) occurred among adolescents aged 10 to 19 years. Between 1994 and 2004, a further 10-fold increase was seen in reported incidence in this age group (solid blue line).
Centers for Disease Control and Prevention. Pertussis Surveillance Report – 8/12/05.
Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, MMWR. 1995;43:1.
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, Wolfe S, eds. 9th ed. Washington, DC: Public Health Foundation, 2006;79-95.
Murphy TV. Epidemiology of pertussis in the United States in the context of a childhood DTaP vaccination program. Presented at: ACIP, February 11, 2005.

20. Licensed Tdap Vaccines for adolescents
Composition PT +
FHA
+ +
PRN
+ +
FIM +
Boostrix
Adacel
*PT = Pertussis toxin; FHA= Filamentous hemagglutinin; PRN = Pertactin; FIM = fimbrial agglutinogens

21. Meningococcal infections

24. Recommendations for Meningococcal conjugate vaccine
All children aged yrs
Adolescents entering high school (if not previously vaccinated)
College freshmen living in dormitories
Persons ≥ 11 yrs at high risk for meningococcal infection
Children aged 2-10 years if at high risk for meningococcal infection