Human papillomavirus (HPV) consists of a group of more than 150 related viruses, some of which have been identified as causes of certain types of cancer. These types of cancer include cancer of the cervix, vulva, vagina, penis, anus, and throat (oropharyngeal cancer). Each virus in the HPV family is given a number, which is called its HPV type.1 Some types of HPV are linked to specific cancers. Other types are linked to genital warts. The most common high-risk, or cancer-causing types of HPV are types 16 and 18. The most common low-risk types, which are linked to genital warts, are types 6 and 11.2

Human papillomavirus can be transmitted through skin-to-skin contact and is most commonly transmitted through vaginal, anal, or oral sex. HPV is so common that nearly all men and women will get it at some point in their lives.1 Most cases of HPV do not present with symptoms and eventually resolve on their own. However, some cases present as certain types of cancer. HPV cancer usually does not have symptoms until it is quite advanced, very serious, and hard to treat.3 Virtually all cases of cervical cancer, as well as about 70% of oropharyngeal cancers and 95% of anal cancers are caused by HPV.2

HPV Vaccination
The HPV vaccine (Gardasil, Merck & Company.), first introduced in 2006, is a quadrivalent, recombinant vaccine that protects against HPV types 6, 11, 16, and 18, which are the most common types that cause either cancer or genital warts. A newer version of the vaccine, a 9-valent recombinant vaccine (Gardasil 9, Merck & Company) was introduced in 2014 and has now replaced the original vaccine. The 9-valent HPV vaccine protects against the same 4 types of HPV as the original vaccine, as well as types 31, 33, 45, 52, and 58.4 These added types have also been identified as cancer-causing types and their inclusion can help give patients extra protection against HPV cancers. Table 1 outlines the benefits in adding the extra 5 types.5-8

Vaccination Schedule
Vaccination with the 9-valent HPV vaccine is recommended for boys and girls as either a 2-dose series or 3-dose series, which can be started as early as age 9, but is usually started at age 11 or 12. The patient will receive 1 dose on day 0, followed by a second dose 6 to 12 months later. The 2-dose series can be used in all patients, provided it is started before their 15th birthday. Patients 15 to 26 years of age should follow a 3-dose series that includes doses at day 0, and then at 1 to 2 months and 6 months after the initial dose. There is no need to restart the schedule if the patient is late for a dose.4

Starting the series at age 11 or 12 is recommended because those patients have likely not been exposed to HPV at that point in their lives. As children age, the likelihood of becoming sexually active increases.9 If vaccination can be initiated before exposure, it will have the greatest chance for success. Additionally, children tend to have fewer well visits to the pediatrician as they get older. It is imperative to protect these children while the opportunity is available.

Vaccination Rates in Adolescents
According to the 2016 National Immunization Survey–Teen, 60% of teens 13 to 17 years of age have received one or more doses of the HPV vaccine. Approximately 65% of girls and 56% of boys have at least received their first dose.10 The vaccine had originally been perceived by the public as a vaccine for cervical cancer. Because of this perception, mostly girls were seeking vaccinations in the early stages of its availability. Vaccination rates for boys are steadily increasing now that more facts are known about risks of cancers to boys, and the fact that boys can be carriers, putting their female partners at risk. The survey indicates a 6-percentage point increase for boys over the 2015 survey. Figure 1 shows a coverage map in the United States for teens according to this survey.11     

College-aged Adults
Although vaccination rates for HPV seem to be moving in the right direction for children and adolescents, is the same true for young adults 18 to 26 years of age? These patients may not have had access to as much information from their parents and physicians as children do today. Without the benefit of receiving HPV as a routine vaccine during childhood, college-aged adults now have to decide for themselves if they want to be vaccinated. Do they have enough information to understand the prevalence of HPV and how it can affect them? Are they even aware that a vaccine is available? If so, do they realize that this vaccine is recommended for everyone in their age range? A common perception may still be that only girls and women are at risk because HPV can cause cervical cancer. Young adults who are not sexually active may not see the need to be vaccinated, but they would be ideal candidates to receive the vaccine before they have had any exposure. Young men need to be aware that of the almost 12,000 cases of oropharyngeal cancer diagnosed in the United States each year, about 70% are caused by HPV. These cancers are four times more common in men than in women.12

Environment Makes a Difference
Living environments can make a huge difference in access to information about HPV, especially in young adults. Students on college campuses can be reached much more easily than young adults who are in the workforce or those who may be in low-economic environments. Colleges can use their health centers and pharmacies to target vaccine-eligible students by making sure to ask about vaccination history during routine or sick visits to the center, or when a patient picks up prescriptions at the pharmacy. Pamphlets or informational posters can be posted in classrooms, common gathering areas, or even dormitories. Speakers from the health center can ask to be invited to educate groups of students at organizational meetings throughout the campus.

Young adults in the workforce may be more difficult to reach. Many companies are now requiring annual visits to a primary care provider or other health care provider to obtain insurance, or to get a discount on premiums. Employers can—and should—include vaccination history as part of the screening process for all employees. It would then be up to health care providers to make suggestions or supply information about HPV and other vaccine-preventable diseases.

College-aged adults in low-economic environments may be the hardest to reach. Often these patients work difficult jobs with long hours. Costs of health care may be prohibitive in this type of environment, and opportunities to interact with health care providers might be limited. These patients need an advocate to help keep them informed about the importance of vaccinations. The advocate could be a nurse, doctor, or staff member at a community walk-in clinic.

A pharmacist can be a huge influence on these patients. Education about how to make vaccines affordable through federally funded programs and discount cards, or by working directly with the manufacturer to control costs can make a difference here.

Community Pharmacy Outreach
Pharmacists in a community setting should make an effort to reach out to all recommended age groups, especially those who may be in their early twenties and about to age out of the recommendation window. Pamphlets and brochures can be requested from the manufacturer to help target specific groups. Young women who pick up birth control medication could be educated about the benefits of being vaccinated for HPV, along with a reminder to share that information with their partner. Young adults who come in from an urgent care facility or those who have prescriptions for attention deficit hyperactivity disorder also provide a great opportunity for pharmacists to discuss vaccination history and recommend an HPV vaccine when the time is appropriate. Healthy individuals should receive a strong recommendation to initiate their first dose while they are at the pharmacy. Pharmacists can offer to run an insurance claim to check the price for them. If they leave without being vaccinated, it is likely that the initial dose will be delayed or never initiated again. Pharmacists must make the most of opportunities when they have the chance.

Conclusion
The 9-valent HPV vaccine can prevent cancer. Some of the cancers that can be avoided cannot be detected by screening and are usually not discovered until they are in the late stages. Vaccination rates are on the rise, suggesting that parents of young kids and adolescents are on the right track.

Discussing HPV, especially with a parent, can be difficult because of what may be a perceived implication that their kids are sexually active at a young age. Pharmacists should not let a potentially uncomfortable conversation deter them from doing what is best for their young patients. Young adults should be targeted because they may be the least informed patients regarding HPV. We must all remember that the result of this type of outreach may be saving a young person from developing cancer.
 
Brady Cole, RPH, is pharmacy manager at Tom Thumb Pharmacy in Plano, Texas, and an active preceptor at Texas Tech University and the University of Houston. He is also founder of the website Helpful Pharmacist, helpfulpharmacist.com.

References
  1. The Centers for Disease Control and Prevention. What is HPV? CDC website. https://www.cdc.gov/hpv/parents/whatishpv.html. Updated December 20, 2016. Accessed February 6, 2018.
  2. National Cancer Institute. Human Papillomavirus (HPV) Vaccines. NCI website. https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-vaccine-fact-sheet. Reviewed November 2, 2016. Accessed February 20, 2018.
  3. The Centers for Disease Control and Prevention. The Link Between HPV and Cancer. CDC website. https://www.cdc.gov/hpv/parents/cancer.html. Updated December 16, 2016. Accessed February 6, 2018.
  4. The Centers for Disease Control and Prevention. HPV Vaccination Information for Clinicians. CDC website. https://www.cdc.gov/hpv/hcp/need-to-know.pdf. Updated December 20, 2016. Accessed February 6, 2018.
  5. de Sanjose S, Quint WGV, Alemany L, et al. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol. 2010;11(11):1048–1056.
  6. Alemany L, Saunier M, Tinoco L, et al. Large contribution of human papillomavirus in vaginal neoplastic lesions: a worldwide study in 597 samples. Eur J Cancer. 2014;50(16):2846–2854.
  7. de Sanjose S, Alemany L, Ordi J, et al. Worldwide human papillomavirus genotype attribution in over 2000 cases of intraepithelial and invasive lesions of the vulva. Eur J Cancer. 2013;49(16):3450–3461.
  8. Alemany L, Saunier M, Alvarado-Cabrero I, et al. Human papillomavirus DNA prevalence and type distribution in anal carcinomas worldwide. Int J Cancer. 2015;136(1):98–107.
  9. Vaccinating preteens. Merck vaccines website. https://www.merckvaccines.com/Products/Gardasil9/preteens. Accessed February 12, 2018.
  10. Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases. National Immunization Survey–Teen. A User’s Guide for the 2016 Public-Use Data File. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF16-DUG.pdf. October 2017. Accessed February 21, 2018.
  11. HPV Coverage Maps – Infographic. CDC Website. https://www.cdc.gov/hpv/infographics/vacc-coverage.html. Updated August 24, 2017. Accessed February 12, 2018.
  12. The Centers for Disease Control and Prevention. HPV and Oropharyngeal Cancer. CDC website. https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm. Updated July 17, 2017. Accessed February 14, 2018.