September 2015 Bulletin

HPV Vaccinations for Girls and Boys: A Q&A With Dr. Rachel Katzenellenbogen

Dr. Rachel Katzenellenbogen Bulletin

Dr. Rachel Katzenellenbogen, Adolescent Medicine physician at Seattle Children’s, addresses questions about the HPV vaccine for girls and boys.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Seattle Children’s medical staff and executive director of Digital Health, and author of the Seattle Mama Doc blog, for submitting these questions.

Recommendations for HPV vaccine administration have undergone many changes since the original ACIP (Advisory Committee on Immunization Practices) recommendation to only administer to girls. Can you tell us about those shifts, including recommendations to vaccinate boys?

In 2006, ACIP recommended vaccinating girls against HPV and in 2008 added a recommendation for boys.

There are three HPV vaccines currently available for children ages 9 to 26. The bivalent vaccine, which is approved for girls, protects against two high-risk HPV types that are associated with about 70% of cervical cancers as well as other anogenital cancers and head and neck cancers.

The quadrivalent vaccine, approved for girls and boys, includes two more low-risk HPV types associated with 90% of genital warts. The 9-valent vaccine, which has just been recommended for use in girls and boys, protects against five additional high-risk HPV types and can replace the quadrivalent vaccine once available.

Since we’ve been giving the vaccine to girls for over eight years, what do we know about durability and what data is there to support it? Do you think we’ll need to continue to “boost” girls’ and boys’ immune systems through adulthood to maintain ongoing protection?

Several studies have followed the women who participated in the initial clinical trial that led to FDA approval of the quadrivalent vaccine. Those women have not developed infections from the four HPV types they were vaccinated against.

Other studies have looked at the peak of antibody titers in younger women and men who have been vaccinated against HPV. Those titers have leveled out and remained high over time, meaning there is likely long-lived protection.

At this time, there’s no recommendation to boost because there has been no evidence that the antibody levels drop below a certain point that would require a boost.

What concerns do you have about the HPV vaccine?

My only concern is that people need to be vaccinated before they engage in sexual activity. So, delays in getting vaccinated are what put people at risk. These vaccines are safe and give great protection from infection.

What are the real side effects of the vaccine and how do you weigh them against the benefits?

The most common side effect is swelling or irritation at the vaccination site. Headache, fever and fatigue can also occur. All other significant adverse effects, like ovarian failure, have not been validated in large studies. Syncope is a concern that’s been reported, so the recommendation is for teenagers to sit during the vaccination and for 15 minutes after so they don’t feel faint.

Any of these side effects are significantly outweighed by the benefits of avoiding the development of cancer or genital warts associated with HPV.

What concerns do you have about teens and families who decide to “wait until later” to immunize? Can you explain the science behind the immunogenicity of the vaccine – is it more effective at producing a robust response in younger girls and boys than older girls and boys?

In studies looking at antibody responses, researchers found that response is best for girls and boys ages 9 to 11. Since the younger you are, the better the antibody response, I don’t see any significant benefit in waiting.

75% of us have evidence of a current or prior HPV infection if you screen from adolescence to adulthood in the United States, so this is an extraordinarily common infection. My concern about parents who decide to wait until later is that it will be too late to protect their child.

The CDC and AAP recommend talking about the HPV vaccine as an anti-cancer vaccine. In your experience, what messages are most compelling to build trust with teens and parents who may have concerns about the vaccine?

When talking about this vaccine, it is important to know that it is safe and effective in protecting people from developing several types of cancer and genital warts. Not everyone gets cancer, but most people get HPV. If you remove HPV from the equation, you remove the risk of cervical cancer, other anogenital cancers, and some head and neck cancers.

Why do you think we’ve had such a hard time getting all teens the entire vaccine series? What suggestions do you have to help improve this vaccine rate – what can pediatricians do to help?

Once kids are school-age, parents have less of a reason to take their child to the doctor and receive vaccinations beyond annual flu vaccinations. I think pediatricians can normalize that this is part of the recommended vaccines for kids, and the earlier you do it, the better its efficacy will be. You can vaccinate girls and boys as young as age 9, but we typically bundle the HPV vaccine at the 11- or 12-year-old visit.

Seattle Children’s Welcomes Madlyn “Mady” Murrey As New Chief Nursing Officer

We are pleased to announce that Mady Murrey has joined Seattle Children’s as its next chief nursing officer (CNO). Mady brings with her a depth and breadth of experience – both as a nurse and an administrative leader – and a passion for pediatric healthcare.

Murrey worked as a staff nurse at Seattle Children’s from 1981 to 1993. After Seattle Children’s she served at MultiCare Mary Bridge Children’s Hospital in a variety of nursing and administrative leadership roles, including nurse executive. Most recently, she was vice president and chief administrative officer for Randall Children’s Hospital in Portland, Oregon.

She is an experienced nursing leader who is passionate about nurse engagement and retention, leadership development and the crucial role nurses play in patient outcomes and clinical quality. Her knowledge and insight about how to deliver safe, high-quality care is based on her first-hand experience as an ambulatory leader.

Murrey has a proven talent for working with community partners to make sure patients and families get the resources and support they need when they’re back home in their communities. She is an innovative thinker who sees problems as opportunities for improvement.

Murrey obtained her bachelor of science degree in nursing from Seattle University; her master of nursing from the University of Washington; and her executive nurse fellowship certificate from the Wharton School of the University of Pennsylvania. She is a self-proclaimed Vespa enthusiast, and she enjoys stand-up paddle boarding, bicycling, running and skiing.

Register for Seattle Children’s Pediatric Advanced Life Support (PALS) Provider Course for Physicians and Advanced Practitioners on September 12

Registration is available online through Sept. 7. For information about other upcoming courses, visit the website.

Upcoming CME Event for September 2015

St. Francis Pediatric Section CME: Concussion Update, Fall 2015

  • Presented by Celeste Quitiquit, MD, Orthopedics and Sports Medicine
  • Monday, September 14 from 12:15–1:15 p.m.
  • St. Francis Hospital, Federal Way, in the Education Room
  • Free Category 2 CME
  • Lunch will be served.
  • For more information, email Patti Kilburn.

Grand Rounds for September 2015 (CME Credit Available)

Upcoming Grand Rounds

  • Sept. 10: The Crisis of Connection and Its Consequences for Our Health
  • Sept. 17: Personalizing Treatment for Children with Neuroblastoma: An Old Paradigm with a New Tool
  • See all upcoming grand rounds.

Watch Past Grand Rounds Online

  • Mosaicism, a New Frontier in Pediatric Genetics: How Many Mutations Are We Missing by Only Testing Our Patient's Blood?
  • Building Healthcare Capacity in Low-Resource Countries
  • Firearm Violence in the U.S.: Lessons for Clinicians
  • Newborn Screening: The Future Is Here
  • Evolution of Allogeneic Transplant for Leukemia: New Sources, Insights, Therapies and Outcomes
  • See all online grand rounds.

For Provider Grand Rounds information, visit our website.

New Medical Staff and Allied Health Professionals for September 2015

Medical Staff

  • Diane Ack, MD, Pediatric Associates–Bellevue, Pediatrics
  • Markus Boos, MD, PhD, Seattle Children’s, Dermatology
  • Karen Chisholm, MD, PhD, Seattle Children’s, Pathology
  • Michael Cronin, MD, MPH, Seattle Children’s, Critical Care
  • Christopher Denton, MD, University of Washington, Neonatology
  • Mylien Duong, PhD, Seattle Children’s, Psychiatry and Behavioral Medicine
  • Patrick Evers, MD, Seattle Children’s, Hospital Medicine
  • Joshua Friedland-Little, MD, Seattle Children’s, Cardiology
  • Megan Gray, MD, Seattle Children’s, Neonatology
  • Lorie Hamiwka, MD, Seattle Children’s, Neurology
  • Lisa Herzig, MD, Seattle Children’s, Developmental Medicine
  • Sarah Jacobs, MD, MEd, Harborview Medical Center, Ophthalmology
  • Aruna Kamath, MD, MPH, Seattle Children’s, Anesthesiology and Pain Medicine
  • Katherine Kenningham, MD, Seattle Children’s, Emergency Medicine
  • Carl Koschmann, MD, Seattle Children’s, Hematology-Oncology
  • Theodore Kung, MD, Harborview Medical Center, Plastic Surgery
  • Allison LaRoche, MD, MPH, Seattle Children’s, Pediatrics
  • Sarah Mahoney, MD, PhD, Seattle Children’s, Hospital Medicine
  • Eric Monroe, MD, Seattle Children's, Radiology
  • Gerhard Mundinger, MD, University of Washington, Plastic Surgery
  • Michael Nuara, MD, Virginia Mason Medical Center, Otolaryngology
  • Pratik Parikh, MB BS, University of Washington, Neonatology
  • Jack Percelay, MD, MPH, Seattle Children’s, Hospital Medicine
  • Denise Shushan, MD, Seattle Children’s, Emergency Medicine
  • Michelle Starr, MD, MPH, Seattle Children’s, Hospital Medicine
  • David Straus, MD, Harborview Medical Center, Neurosurgery
  • Elizabeth Swedo, MD, MPH, Seattle Children’s, Emergency Medicine
  • Lindsay Tarr, MD, Seattle Children’s, Emergency Medicine
  • Sonja Tarrago, MD, Richmond Pediatric Clinic, Pediatrics
  • Rodrigo Tarrago, MD, Seattle Children’s, Critical Care
  • Tyler Tate, MD, Seattle Children’s Met Park West, Bioethics
  • Sean Timpane, MD, Seattle Children’s, Pediatrics
  • Demet Toprak, MD, Seattle Children’s, Pulmonary and Sleep Medicine
  • Giang Tran, MD, Seattle Children’s, Emergency Medicine
  • Anthony Wang, MD, Seattle Children’s, Neurosurgery
  • Jessica Warner-Grant, MD, PhD, Seattle Children’s, Hospital Medicine
  • Benjamin Watkins, MD, Seattle Cancer Care Alliance, Hematology-Oncology
  • Danielle Wendel, MD, Seattle Children’s, Gastroenterology and Hepatology
  • Amy Williams, MD, Seattle Children’s, Orthopedics and Sports Medicine
  • Sarah Zaman, MD, Seattle Children’s, Hospital Medicine
  • Rodolfo Zamora Rendich, MD, Harborview Medical Center, Orthopedics and Sports Medicine

Allied Health Professionals

  • Lindsay Augenthaler, ARNP, Seattle Children’s, Emergency Medicine
  • Lara Clark, ARNP, Seattle Children’s, Otolaryngology
  • Karen Corlett, ARNP, Seattle Children’s, Critical Care
  • Melina Handley, ARNP, Seattle Children’s, Critical Care