We’ve all been hearing more and more about HPV infections; that they cause cervical cancer, vaginal cancer, anal cancer, throat cancer, mouth cancer and venereal warts. I’ve written several articles about the need to immunize girls and boys with the HPV vaccine. The most common vaccine, Gardasil is given in 3 doses, it is a quadravalent vaccine, which means it gives immunity to 4 types of HPV (6,11,16 and 18). These are the ones that cause 70% of cervical cancers, many of the other above mentioned cancers as well as venereal warts. But alas, despite the multiple direct to consumer ads in the media, recommendations by most doctors and the studies in peer-reviewed journals, only one third of adolescents are currently being immunized.

We would certainly expect the prevalence of these infections to be significantly diminished in those whose parents had the clinical acumen to have their children immunized. But they represent just 30% of their peers. So it was pleasantly surprising to find that a study published online in the Journal of Infectious Diseases reported that the prevalence of infections with the human papilloma virus types included in the Gardasil vaccine dropped by almost 60% among females aged 14 to 19 years during the four-year period after the vaccine became available and was recommended. Dr. Thomas Frieden, the CDC director, said during a press conference held to announce the results of the study, that increasing the vaccination rate to 80% would prevent about 50,000 cases of cervical cancer among girls alive today. “We owe it to the next generation- our sisters, our daughters, our nieces and to protect them against cervical cancer.”

Just to remind you, a three dose series of the quarivalent HPV vaccine was recommended in 2006 by the CDC as a routine vaccination for females age 11 to 12 years and for females aged 13 to 26 years who had not been previously vaccinated. In 2011, the recommendation for the vaccine was expanded to include boys aged 11 and 12 years and for non vaccinated males up to 26 years. No data is yet available on the proportion of males who have been vaccinated and/or the impact of vaccination on their infection rates.

The nearly 60% drop in HPV infection is greater than expected but can be due to “herd immunity” from vaccination (nothing to do with animals, it means that those who got the vaccination were unable to infect those who did not).

Remember, HPV is the most common STD in United States. The estimate is that 14 million people becoming infected with HPV every year. According to the CDC, 79 million of the those who have become infected with HPV are in their late teens and early 20s. Every year, about 19,000 cancers in women are caused by HPV; most are cervical cancer. And of 8,000 cancers caused by HPV that occur in men in the United States, most of them are oropharyngeal (mouth and throat).

Wow, this vaccine can make a huge difference. It may be too late for many of us who are over the age of 26 but we certainly can make sure that the younger (and youngest) generation are vaccinated… Not to do so is malparenting!

As most of you know there are 2 kinds of herpes infections:

Herpes 1 (HSV-1), which when activated causes sores on the lips, gums and even the eyes. (It used to be called the herpes above the waist.)
Herpes 2 (HSV-2) or genital herpes, which can appear on the labia, vagina cervix (obviously in men in different genital areas…) and all sorts of places on the lower body (inner thighs, buttocks, back)….this is the one we are most concerned about.
A recent postgraduate Obstetrics and Gynecology publication gives an excellent synopsis on herpes and I thought it would be appropriate to go over some of the facts that were presented in this review.

HSV is a DNA virus and is classified as either 1 or 2 by its glycoproteins (i.e. not by where it infects but what is in its molecular structure). It’s transmitted though direct contact with mucosa or abraded skin. That’s the official wording…. when it comes to HSV-1 in “lay” expression you get it from kissing, or oral contact including oral sex. When it comes to HSV-2, transmission is through genital contact…. pretty easy to imagine how it can occur with intercourse, but those lesions women often get on their buttocks, back or thigh can occur via post coital contact (spooning, or getting close to a member that is shedding the virus…. member here usually refers to a penis).

Once transmitted, the virus incubates for 2 to 12 days and then replicates in the layers of the skin causing inflammation and ulceration. But that’s not all…. the virus then enters the sensory neurons and then travels to their root (or ganglia) where it then becomes dormant.  Weeks, months or years later it can become reactivated, spread back down along the nerve root to the skin and cause a recurrent ulcer-like lesion or simply shed from the skin without a visible sore or irritation. Antibodies to the virus develop within several weeks of the infection. The initial infections tend to be more severe than recurrent ones; there may be swelling of adjacent lymph nodes and the lesions may last 3 to 6 weeks. Recurrent infections are usually mild and last 3 to 10 days.  The frequency of recurrences can vary…. they are more likely to occur when your resistance is diminished, i.e. you are sick, have a fever, or are physically or emotionally stressed. After the first infection, about 50% of individuals will have a recurrence in 6 months.

The estimate of how many of us have had HSV-1 or HSV-2 is based on antibody testing which if positive is termed seroprevalence. The seroprevalence of HSV-2 in the US is 16.2% but women are at higher risk with a rate of 20.9%. The amazing fact is that only 19% of adults who are HSV-2 positive (and hence can spread the virus) are aware or their diagnosis! (I have frequently seen patients who come to my office with a complaint of “something down there” but deny any previous history of herpes…they may have had similar symptoms in the past but thought they were due to yeast infections or friction and never had these checked or diagnosed. Now… I am telling them that they have herpes. (And of course, the recriminations begin.) In most cases, especially if they are abstinent or have been with the same partner for years, it’s a recurrent infection. Remember that the virus can also be transmitted from the skin without a viable lesion. This is an STD that is chiefly spread without knowledge that it was there in the first place.

So what is the best way to diagnose HSV? When a “classic” group of vesicles (blisters) or ulcers occur, a culture of the lesions can be done. Especially in primary (first) infections, the culture will be positive in 48 to 72 hours. The sensitivity of the culture decreases the longer the lesion has been present. A positive culture is evidence of herpes, but a negative one doesn’t mean it’s not there, it simply means it was too late to find it or that the culture wasn’t sensitive enough. So ultimately the way to definitively diagnosis herpes and to distinguish between types 1 and 2 is with antibody testing…in a blood test called HerpesSelect 1 and 2. It can usually detect antibodies within 2 to 3 weeks of infection.

The treatment is usually oral with an antiviral medication. The generic and oldest form of medication is acyclovir. The dose for a primary infection is 400mg tablets three times a day for 7 to 10 days. There are 2 other antiviral medications that have somewhat better absorption and longer half-lives than acyclovir but essentially are converted to the same substance in the body. These are valcyclovir (Valtrex) and famcyclovir (Famvir). These are generally more expensive. The dose for Valtrex in a primary infection is 1 g twice daily, again for 7 to 10 days.  For Famvir it’s also 1g twice daily…..in recurrent infections, less is needed (and works best if started with the very first sign of infection, such as local tingling or pain). Acyclovir is given in a dose of 400mg, 3 times a day for 5 days, Valtrex, 500mg, twice a day for 3 days and Famvir two tabs of 500mg twice a day for just one day. And for suppression (it’s not complete but may decrease viral shedding and transmission to a partner) the prescribed dose is 500 mg of Valtrex daily or 250 mg of Famvir twice daily.  (I know this is getting very specific, but so many women ask for prescriptions, I thought I should include dosing.)

What should be done if herpes occurs during pregnancy?  How great is the risk for neonatal infection? About 1200 to 1500 babies are born in the US each year with neonatal herpes. The most likely cause for their infection is through contact with the active virus in the lower maternal genital tract during vaginal delivery. The majority of the infected babies are born to women who had no history of HSV infection (i.e. they acquired a new infection before delivery) and one third of the cases are caused by HSV-1. Only 3% of the infections are among women with recurrent clinically evident HSV-2 infection. A primary genital herpes outbreak is associated with a higher risk of perinatal transmission than a recurrent outbreak, presumably because the mother has no preformed antibodies that are transferred to the fetus. Neonatal herpes can be serious; 30% of seriously infected babies die and up to 40% of survivors have serious neurological problems. In the past, many women underwent C-section just because they had a history of herpes even though they didn’t have any active lesions at the time of delivery. (This falls into to the “you never know, let’s be safe” category.) But it’s the women who are seronegative (have no antibodies) and who get infected in the last trimester that are the most likely to pass the virus to the baby during delivery. Nor is it completely “safe” for women with active vaginal lesions to deliver vaginally. The current recommendations are:

During pregnancy all symptomatic infections (primary or recurrent) should be treated with a 7-day course of antiviral medication.
All women who have had recurrent herpes or a new infection in pregnancy should be given prophylactic antiviral medication beginning at 36 weeks (And if at risk for a preterm delivery, this should be started earlier.)
C-section is indicated in any women with active perineal (in and around the vagina and labia) lesions or prodromal symptoms (sense that a herpes lesion is starting).
C-section is not indicated in women with a history of HSV without active lesions or symptoms at the time of labor,
C-section is not indicated for nongenital lesions (if there is a lesion on the thigh or buttock in can just be covered with a bandage.)
Bottom line: Many of us have herpes. No, we don’t have a vaccine but short courses of antiviral therapy or daily medication will help diminish recurrence of lesions and spread of the virus.  Recurrences should be treated during pregnancy and at 36 weeks prophylactic antiviral medication may help prevent the need for C-section. If, however, an active lesion is present at time of labor, C-section is advised.

We could ask our kids (rarely works), speak to the school administrators (they are probably the last to know),  read Seventeen and Cosmo or just look with despair at the promiscuous styles offered to and requested by young girls (and boys).

In my perusal of journals, I found a fascinating study which addresses this question. It comes from the National Youth Risk Behavior Survey conducted from 1999 though 2007. (Remember it takes a year or two to collect, analyze and publish information of this sort, hence it did not include ‘08 and ‘09.) Researches analyzed data from this survey to determine age at first intercourse in 66,882 black, Latino and Latina, white and Asian students in grades 9 though 12. According to the students’ anonymous self reports, the probability for “coital debut” by their 17th birthday (I’m assuming they meant vaginal intercourse, the use of euphemisms in medical reportage is astounding!) was: 82% for black males, 74% for black females, 69% for Latinos, 59% for Latinas, 53% for white males, 58% for white females, 33% for Asian males and 28% for Asian females

Now before we take this report and approach our children or grandchildren with queries as to whether they fall into the above listed statistics (“did you or didn’t you?”), I should point out that the survey was based on self-reported data. Girls are more likely to underreport sexual activity, whereas boys tend to over report. The survey did not stratify the groups by parental income or educational level, nor did it differentiate between public or private school attendance. And the study did not include youths who had dropped out of school (who would, most likely, skew early coital debut to higher probability).

I realize that parents don’t always like to look at gross statistics when it comes to their own progeny. But this large study does show us that a majority of teens self report that they were sexually active before the age of 17. It’s way better than rumors… and should help parents decide when to make sure that their daughters have access to appropriate contraception. (This may have the appearance of a plug for Planned Parenthood and I should disclose that in the past I was on the board of the LA chapter of this organization). We know that timing is important for HPV vaccination. The best results will be achieved if the vaccine is given before a girl becomes sexually active. Hence most pediatricians now discuss this with parents at a time when they are not quite ready to consider that their “little girl” will engage in sexual activity. But they will… Finally this survey emphasizes what we already know; all young teens should be taught about STD’s and the need for protection before they have that first, often too early, sexual encounter.

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