In a series of video vignettes, young adult female patients discuss issues of human papillomavirus (HPV) infection and HPV prevention with their health-care providers. The vignettes, which take place in an ob-gyn’s office and in a college student health setting, set the stage for a roundtable discussion of the clinical and educational challenges posed by HPV infection today. A multidisciplinary faculty including ob-gyns, a nurse practitioner, and a pharmacist share best practices for (a) counseling patients on prevention of HPV and other sexually transmitted infections and (b) explaining how to maximize opportunities for HPV vaccination of young women. The focus is on timely, optimal implementation of the HPV recommendations issued by the Advisory Committee on Immunization Practices and on the development and implementation of best vaccination practices by clinicians and staff within an office or clinic setting.

The program emphasizes a team approach to care, one that encompasses the responsibilities of everyone in an office or clinic—office manager, support staff, nurses, nurse practitioners, and physicians. After participating in this educational activity, clinicians who care for female patients of all ages will be better prepared for the optimal teachable moment: recommending and/or administering the HPV vaccine to appropriate candidates, and reinforcing the critical importance of continued Pap testing for the detection and prevention of cervical cancer.

The availability of a vaccine to protect against certain types of human papillomavirus (HPV) that cause cervical cancer and genital warts has changed the clinical landscape and provided an important new tool for disease prevention. Randomized, double-blind, placebo-controlled studies have shown that vaccinations significantly reduce the incidence of cervical pre-cancer and non-invasive cervical cancer related to HPV types 16 and 18.^1-3 These studies suggest that vaccination is likely to reduce HPV infection and thus the incidence of cervical cancer. Approximately 20 million Americans are infected with HPV.⁴ The need for clinicians who care for teenaged girls and young women to become more active in HPV counseling and immunization took on greater urgency with the release of a report in 2008 by the Centers for Disease Control and Prevention (CDC).⁵ The study found that at least 1 in 4 teenagers aged 14 to 19 were infected with HPV (18%)—the most common sexually transmitted disease in this population—Chlamydia (3.9%), trichomoniasis (2.5%), or herpes simplex virus-2 (1.9%).⁵ Also of critical importance to clinicians who care for young women, the prevalence of HPV in college students may be as high as 45%.^6,7  

The Advisory Committee on Immunization Practices (ACIP) of the CDC and the American College of Obstetricians and Gynecologists (ACOG) recommend HPV vaccination for females between the ages of 9 and 26 years.^4,8,9 Use of the vaccine in boys and in women older than 26 years is also being investigated. "Obstetrician-gynecologists should be proactive in educating our patients about the vaccine so that as many women as possible are able to take advantage of this medical milestone,” ACOG officials said. “We must be prepared both to administer the vaccine and to answer patient and parent questions that will arise.” The ACOG recommendation also underscores the importance of continued cervical cytology screening regardless of vaccination status.⁹

Interactive dialogue with patients is also needed on a range of issues related to HPV prevention, treatment of clinical disease (including genital warts), compliance with HPV vaccine recommendations, and the continuing role of Pap testing. The clinician must be able to advise and counsel girls and women of all ages based on their individual risk profiles and medical, social, and sexual histories. The relative “silence” of HPV and the potential devastation of its sequelae make ongoing education and immunization strategies critical factors in reducing the incidence of HPV and cervical cancer. Knowledge gained from recent clinical experience will help ob-gyns and nurse practitioners overcome barriers to providing optimal care for their older adolescent and young adult female patients.
 

References

1. Mao C, Koutsky LA, Ault KA, et al. Efficacy of human papillomavirus-16 vaccine to prevent cervical intraepithelial neoplasia: a randomized controlled trial. Obstet Gynecol. 2006;107:18-27.
2. Harper DM, Franco EL, Wheeler C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infections with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet. 2004;364:1757-1765.
3. Villa LL, Costa RL, Petta CA, et al. Prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in young women: a randomised double-blind placebo-controlled multicentre phase II efficacy trial. Lancet. 2005;6:271-278.
4. Centers for Disease Control and Prevention. Sexually Transmitted Diseases. Genital HPV Infection—CDC Fact Sheet. Available at: http://www.cdc.gov/std/HPV/STDFact-HPV.htm.  Accessed October 3, 2008.
5. Forhan S, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections and bacterial vaginosis among female adolescents in the United States: data from the National Health and Nutrition Examination Survey (NHANES) 2003-2004. 2008 National STD Prevention Conference; March 10-13, 2008; Chicago, Illinois: Oral Abstract D4a.
6. Bauer HM, Ting Y, Greer CE, et al. General human papillomavirus infection in female university students as determined by a PCR-based method. JAMA. 1991;265:472-477.
7. Sellors JW, Mahony JB, Kaczorowski J, et al. Prevalence and predictors of human papillomavirus infection in women in Ontario, Canada: Survey of HPV in Ontario Women (SHOW) Group. CMAJ. 2000;163:503-508.
8. American College of Obstetricians and Gynecologists Committee Opinion No. 344: human papillomavirus vaccination. Obstet Gynecol. 2006;108:699.
9. ACOG releases HPV vaccine recommendations for Ob-Gyns. Available at: http://www.acog.org/from_home/publications/press_releases/nr08-08-06.cfm. Accessed October 28, 2008.

This CME activity is intended for obstetricians, gynecologists, and nurse practitioners.

At the conclusion of this CME activity, participants should be better able to:

• Delineate the potential sequelae of HPV types
• Identify barriers and challenges to HPV vaccine utilization in actual ob-gyn and college health-care settings
• Discuss the role of male partners in HPV transmission
• Dispel myths and recommend means of copying with the psychological impact of a positive HPV diagnosis
• Describe strategies to overcome barriers to vaccination in young adult women and incorporate them in routine practice

J. Thomas Cox, MD (Program Chair)
Director
Women's Clinic
University of California, Santa Barbara (UCSB)
Santa Barbara, California

Alison Moriarty Daley, MSN, APRN, PNP-BC
Associate Professor
Yale University School of Nursing
Master’s Program, Pediatric Nurse Practitioner Specialty
New Haven, Connecticut

Lisa C. Flowers, MD
Associate Professor
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Emory University School of Medicine
Atlanta, Georgia

Stephan L. Foster, PharmD, FAPhA
Professor and Vice Chair for Community Practice
Department of Clinical Pharmacy
University of Tennessee College of Pharmacy
Memphis, Tennessee

Stanley A. Gall, MD
Professor of Obstetrics, Gynecology and Women’s Health
Department of Obstetrics, Gynecology and Women’s Health
University of Louisville School of Medicine
Louisville, Kentucky

CME Course Director
Elizabeth A. Stier, MD
Department of Obstetrics and Gynecology
Boston Medical Center
Boston, Massachusetts

Boston University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Boston University School of Medicine designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

There are no fees for participating and receiving CME credit for this activity. During the period December 2008 through December 31, 2009, participants must:

• Register for the program where prompted in iQueue
• Complete the posttest by recording the best answer to each question
• Complete the evaluation questions
• Submit directly on-line
• A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better.

Estimated time to complete the activity: 2.0 hours

For CME questions, please contact Boston University School of Medicine www.bu.edu/cme

BUSM CME private policy www.bu.edu/cme/policies/privacy_policy.html

Boston University School of Medicine asks all individuals involved in the development and presentation of Continuing Medical Education (CME) activities to disclose all relationships with commercial interests. This information is disclosed to CME activity participants. Boston University School of Medicine has procedures to resolve any apparent conflicts of interest. In addition, faculty members are asked to disclose when any discussion of unapproved use of pharmaceuticals and/or devices occurs.

J. Thomas Cox, MD, has served on scientific advisory boards for Diamics, Inc., Gen-Probe, Takeda Pharmaceutical Co Ltd, and Tigris Pharmaceuticals, Inc., and has been on an advisory board for Graceway Pharmaceuticals LLC. He participates in the HPV Vaccine Data and Safety Monitoring Board for Merck & Co., Inc.

Alison Moriarty Daley, MSN, APRN, PNP-BC, has served on the Cervical Cancer Nurse Practitioner Advisory Board for GlaxoSmithKline.

Lisa C. Flowers, MD, is on the speakers’ bureau for Merck & Co., Inc.

Stephan L. Foster, PharmD, FAPhA, is a consultant for Sanofi Pasteur Inc, and is a member of the speakers’ bureaus for Merck & Co., Inc., and GlaxoSmithKline Vaccine.

Stanley A. Gall, MD, has received grant/research support and is a consultant and a member of the speakers’ bureaus for GlaxoSmithKline, Merck & Co., Inc., and Sanofi Pasteur Inc.

Elizabeth A. Stier, MD, has served on the speakers’ bureau for Merck & Co., Inc.

Elizabeth R. Gifford, Boston University School of Medicine, has nothing to disclose.

Elizabeth A. Selkowe, Haymarket Medical Education, has nothing to disclose.

Susan M. Basilico, Haymarket Medical Education, has nothing to disclose.

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA.

THESE MATERIALS AND ALL OTHER MATERIALS PROVIDED IN CONJUNCTION WITH CONTINUING MEDICAL EDUCATION ACTIVITIES ARE INTENDED SOLELY FOR THE PURPOSES OF SUPPLEMENTING CONTINUING MEDICAL EDUCATION PROGRAMS FOR QUALIFIED HEALTH-CARE PROFESSIONALS. ANYONE USING THE MATERIALS ASSUMES FULL RESPONSIBILITY AND ALL RISK FOR THEIR APPROPRIATE USE. TRUSTEES OF BOSTON UNIVERSITY MAKES NO WARRANTIES OR REPRESENTATIONS WHATSOEVER REGARDING THE ACCURACY, COMPLETENESS, CURRENTNESS, NONINFRINGEMENT, MERCHANTABILITY, OR FITNESS FOR A PARTICULAR PURPOSE OF THE MATERIALS. IN NO EVENT WILL TRUSTEES OF BOSTON UNIVERSITY BE LIABLE FOR ANY DECISION MADE OR ACTION TAKEN IN RELIANCE ON THE MATERIALS. IN NO EVENT SHOULD THE INFORMATION IN THE MATERIALS BE USED AS A SUBSTITUTE FOR PROFESSIONAL CARE.