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  • December 19, 2016 12:08 PM | Deleted user
    Risk of hearing loss appears to be modestly higher in women who use acetaminophen or non-steroidal anti-inflammatory drugs - such as ibuprofen - for 6 years or more, compared with counterparts who use these painkillers for a year or less.

    older woman looking thoughtful
    Two thirds of women in the U.S. over the age of 60 report having some hearing loss.

    Researchers come to this conclusion in a study published in the American Journal of Epidemiology, in which they analyze the links between duration of painkiller or analgesic use and self-reported hearing loss in a large group of women in the United States.

    Senior author Gary Curhan, a Harvard Medical School professor and physician in the Channing Division of Network Medicine at Brigham and Women's Hospital in Boston, MA, says:

    "Although the magnitude of higher risk of hearing loss with analgesic use was modest, given how commonly these medications are used, even a small increase in risk could have important health implications."

    In the U.S., the use of analgesics such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDsis significant and more widespread than 2 decades ago.

    In 2010, around 43 million U.S. adults (19 percent) took aspirin regularly, and more than 29 million (12.1 percent) were regular users of NSAIDs. These numbers are considerably higher, at 57 and 41 percent, respectively, than they were in 2005.

    As many as two thirds of women in the U.S. over the age of 60 report some degree of hearing loss. Having previously reported a link between analgesic use and an increased risk of hearing loss in men, the researchers decided to look at women and focus on duration of painkiller use.

    Findings support a growing body of evidence

    For their new analysis, the researchers used data on 55,850 women enrolled in the Nurses' Health Study, one of the largest and longest running investigations into the health of U.S. women.

    Fast facts about hearing loss

    • In the U.S., an estimated 37.5 million adults (15 percent) report some trouble hearing
    • Nearly a quarter of those aged 65-74 and half of those aged 75 and older have disabling hearing loss
    • Men are more likely than women to report having hearing loss.

    Learn more about hearing loss

    They analyzed links between the women's self-reported hearing loss and their use of ibuprofen, acetaminophen, and aspirin.

    The results showed that prolonged use (lasting 6 years or more) of ibuprofen and acetaminophen was linked to a slightly higher relative risk of hearing loss, at 10 percent and 9 percent, respectively, in the women.

    The higher risk was relative to women who did not use the analgesics for more than a year.

    However, no such link was found for usual-dose aspirin use. The researchers note that hearing loss is a known side effect of high-dose aspirin use, but such dosages have become much less common in the last 2 decades.

    The findings support a growing body of evidence linking the use of NSAIDs or acetaminophen with hearing loss, although the underlying biological explanation is not known.

    Prof. Curhan says that, should the link be causal, then this would mean that about 16.2 percent of hearing loss occurring in the women that they studied could be due to their use of ibuprofen or acetaminophen.

    He and his colleagues urge caution in using their findings; the study was confined to a cohort of mainly white, older women. They say that studies of larger groups including other populations are needed in order to properly understand the link between painkiller use and hearing loss.

    "Hearing loss is extremely common in the U.S. and can have a profound impact on quality of life. Finding modifiable risk factors could help us identify ways to lower risk before hearing loss begins and slow progression in those with hearing loss."

    Prof. Gary Curhan

    Written by Catharine Paddock PhD


  • December 19, 2016 12:05 PM | Deleted user

    AAPA 
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  • December 19, 2016 12:00 PM | Deleted user

    Written by Heather Punke 

    Becker's Hospital Review

    The CDC had a busy year in 2016, working on Zika, antibiotic resistance and more. The federal agency highlighted seven health threats it focused on in 2016 and looked ahead at to what's to come in 2017.

    1. Zika and pregnancy. The CDC was on alert for Zika since it swept through Brazil in the middle of 2015, and the agency jumped into action in 2016 when the virus spread to the U.S. It has kept Zika and pregnancy in focus in particular, as the virus has been linked to birth defects like microcephaly. For instance, the CDC established registries to track outcomes of pregnancies of women with Zika.

    "Although there has been much progress understanding and combating Zika, CDC's work is far from finished," the agency wrote. "Every day, we are learning more about Zika, and we will not stop fighting to protect pregnant women and all people from the devastating effects of this disease."

    2. Antibiotic resistance. In 2016, the CDC supported the National Strategy to Combat Antibiotic-Resistant Bacteria and funded state health departments to help screen for and tackle antibiotic resistance. The agency also released the Antibiotic-Resistance Patient Safety Atlas web app this year, which shows the types of resistance most common in states and regions. Next year, the CDC plans to launch an interactive map to show its investments in health departments, labs and healthcare partners. It will also describe nationwide activities that combat antibiotic resistance.

    3. Cancer. This year, the CDC updated its guidelines on who should receive the human papillomavirus vaccine to help prevent cancers caused by HPV infections. Moving forward, the agency plans to improve HPV vaccination coverage through public policy and clinical practice.

    4. Prescription drug overdose. The CDC issued guidelines for opioid prescription for chronic pain this year in hopes it would reduce the risk of opioid addiction and overdose. It also increased funding for state programs aimed at preventing opioid overdoses. The agency will continue to fund and focus on such programs next year.

    5. Global health security. According to the CDC, "[K]eeping America safe means stopping — or better still, preventing — health threats everywhere." This year, the agency wound down its Ebola response in March but made other advances globally — for instance, its Global Rapid Response Team has responded to 18 countries for diseases like cholera, yellow fever, Ebola, measles, polio and Zika. The agency will continue this work in 2017 and has committed to the milestones of the Global Health Security Agenda.

    6. Tobacco use. 2016 was the fifth year of the CDC's "Tips From Former Smokers" tobacco education campaign, in which Americans share personal stories relating to tobacco illnesses. The CDC plans to continue running TFFS ads in 2017.

    7. Rapid response to outbreaks. The CDC used advanced molecular detection technology this year to sequence the DNA of bacteria, viruses, parasites and fungi and then used supercomputers to discover molecular patterns to better understand diseases. The process helped identify a source of a Legionnaires' disease outbreak and is being used to map Zika virus strains. In 2017, the agency plans to build AMD capacity in state and local labs.

    "The agency continues to reflect on the lessons learned over the past year and is committed to helping make 2017 the nation's healthiest year yet," the agency wrote.

    To receive the latest hospital and health system business and legal news and analysis from Becker's Hospital Review, sign-up for the free Becker's Hospital Review E-weekly by clicking here.


  • December 16, 2016 9:07 AM | Deleted user

    By Lisa Rapaport

    (Reuters Health) - Women who have more lean muscle mass or better grip strength may be less likely to experience a common type of urinary incontinence, a study suggests.

    That’s because strong muscles may help counter what’s known as stress urinary incontinence, which happens when the pelvic floor muscles supporting the bladder are too weak to prevent urine leaks when people do things like cough, sneeze or exercise. Childbirth is a common reason for weak pelvic muscles, and obesity makes the problem worse.

    In the study, researchers examined data on 1,475 elderly women, including 212 who experienced stress incontinence at least once a month and another 223 who had what’s known as overactive bladder, or urge incontinence, at least monthly.

    Women were less likely to develop or continue experiencing stress incontinence by the end of the three-year study when they didn’t have much decline in muscle strength, as assessed by grip strength. Women also had lower odds of stress incontinence when they lost substantial amounts of weight and fat mass.

    “Our study found that changes in body composition and grip strength are associated with changes in stress urinary incontinence frequency over time, but not with changes in urgency urinary incontinence frequency over time,” said lead study author Dr. Anne Suskind of the University of California, San Francisco.

    “This finding may be explained by the anatomic underpinnings of stress versus urgency incontinence,” Suskind added by email.

    Overactive bladder, or urge incontinence, happens when the body has a constant need to urinate and sometimes leads people to leak urine when they can’t get to a toilet quickly.

    High body mass index (BMI) – a ratio of weight relative to height – is a risk factor for incontinence in young and middle-aged adults, researchers note in the Journal of the American Geriatrics Society.

    As people age, however, the relationship between BMI and incontinence gets more complicated because of change in body composition and the amount of fat versus lean muscle mass, the researchers point out.

    For the current study, researchers asked participants to complete questionnaires about incontinence and also examined data on their BMI, grip strength, leg power in the quadriceps and walking speed.

    All of the women were between 70 and 79 years old at the start of the study.

    Women who experienced at least a 5 percent decrease in grip strength during the study were 60 percent more likely to have new or persistent stress incontinence by the end.

    In addition, women who had a 5 percent or greater drop in BMI during the study were 54 percent less likely to have stress incontinence three years later.

    After accounting for BMI, a 5 percent or greater increase in lean muscle mass was associated with 83 percent lower odds of stress incontinence, while at least a 5 percent decrease in fat mass was tied to 47 percent lower odds of stress incontinence.

    One limitation of the study is its reliance on women to accurately recall and report on the frequency and type of incontinence they experienced, the authors note. The women didn’t have exams to verify the details about incontinence they reported on questionnaires.

    Even so, the findings suggest that weight loss and exercise aimed at muscle strength may help prevent stress incontinence, Dr. Blayne Welk, a researcher at Western University and St. Joseph’s Hospital in London, Ontario, who wasn’t involved in the study, said by email.

    “By reducing weight and abdominal fat there is less pressure on the bladder resulting in less stress urinary incontinence,” said Dr. Cindy Amundsen of Duke University in Durham, North Carolina. “Better muscle strength may be associated with higher pelvic floor muscle strength and function, decreasing the susceptibility to urine leakage.”

    Women can work when they’re younger to lower their odds of incontinence as they age, Amundsen, who wasn’t involved in the study, added by email.

    “Women should optimize their body composition by achieving a normal BMI and improve their muscle strength, and they should continue to do so well into their 70s,” Amundsen said.

    SOURCE: bit.ly/2getN96 Journal of the American Geriatrics Society, online December 5, 2016.


  • December 16, 2016 9:04 AM | Deleted user

    Written by Hannah Nichols

    Published: Thursday 15 December 2016

    Colorectal cancer is the second leading cause of cancer-related death in the United States and the third most common cancer in men and women. Every day, 400 people in the U.S. are newly diagnosed with the disease. Researchers at the Ohio State University Comprehensive Cancer Center are working to reduce the number of cases, and their efforts look promising.

    Testing diagnosed colorectal cancer patients for Lynch syndrome may prevent colorectal cancer in families.

    Colon cancer refers to cancer of the large intestine, which is the lower part of the digestive system. Rectal cancer refers to cancer of the last section of the colon. Combined, these are called colorectal cancers.

    Some factors can increase the risk of developing colorectal cancer. In particular, having certain inherited syndromes or a family history of colorectal cancer can contribute to this risk. These factors boil down to genetics.

    People are more likely to develop colorectal cancer if they inherit particular gene mutations. While these mutations do not make cancer inevitable, they can create a significantly increased risk. Inheriting gene mutations that make individuals more susceptible to colorectal cancer and other cancers is referred to as Lynch syndrome.

    If a person is diagnosed with Lynch syndrome, their parents, children, brothers, and sisters also have a 50 percent chance of developing the condition.

    Most people with Lynch syndrome unaware they have the condition

    Heather Hampel, principal investigator of Ohio Colorectal Cancer Prevention Initiative and licensed genetic counselor at the Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, points out that most people who have Lynch syndrome are unaware that they have the condition.

    "Lynch syndrome increases the risk for several types of cancer. The problem is 95 percent of those who have Lynch syndrome don't know they have it," says Hampel. "One of the keys to beating many types of cancer is catching it early, and the best way to do that is to know a patient's risk so we can monitor them closely and treat them at the first sign of trouble."

    Researchers say that an estimated 639 years of life could be saved through early detection of colorectal cancer. In a bid to take preventive action, Hampel and colleagues screened 3,000 individuals who had been newly diagnosed with colorectal cancer and their at-risk family members to find out if they had Lynch syndrome.

    "From that, we have actually offered genetic testing to about 370 at-risk relatives, and another 120 have tested positive, so you can see where it balloons once you get to the family members," reveals Hampel.

    It has been estimated that about 1 in every 30 colorectal cancer cases are due to Lynch syndrome. People with Lynch syndrome are also at a higher risk of developing colorectal cancer at an earlier age - usually before age 50.

    Early cancer detection based on genetic risk factors could save lives

    Hampel and collaborators analyzed a subset of colorectal patients who have been diagnosed since 2013, and who are under the age of 50. The team found that 1 in every 6 of the subset had at least one genetic mutation that put them at an increased risk of colorectal cancer.

    While the researchers expected a high rate of Lynch syndrome in the subset of colorectal patients under 50 years of age, surprisingly, they also found other gene mutations among the individuals, including mutations in genes typically linked to breast cancer. The findings were published in JAMA Oncology.

    "The prevalence of hereditary cancer syndromes among early-onset colorectal cancer patients - including Lynch syndrome - was quite high, which represents a tremendous opportunity for us to save lives through early detection based on genomic risk factors. It is critical that people find out at a young age if they are genetically predisposed to cancer so they can take steps to prevent cancer from occurring at all."

    Heather Hampel

    "Knowledge truly is power in this case where if you know that you're at increased risk for something, you can take the steps needed to keep yourself from getting that cancer and prevent it," she adds.

    People with Lynch syndrome can develop a cancer screening plan with their doctor to regularly screen for colorectal tumors. Finding and removing abnormal growths, or polyps, early can help to prevent colorectal cancer.

    "We hope our efforts through the Ohio Colorectal Cancer Prevention Initiative will have applications nationwide," says Hampel. "In all, 50 hospitals in Ohio tested patients, all of whom were diagnosed with colorectal cancer under the age of 50."

    "We hope to potentially expand to the region or to the nation. Really we believe all 50 states should be screening all of their newly diagnosed colorectal cancer patients for Lynch syndrome at the time of diagnosis," Hampel concludes.

    Learn about the discovery of a molecule that prevents colorectal cells becoming cancerous.

    Written by Hannah Nichols


  • December 16, 2016 8:51 AM | Deleted user

    AAPA

    The Dec. 31 deadline is almost here — submit your proposal today for the ePoster Session at AAPA 2017 in Las Vegas. Open to both PAs and PA student researchers, this session gives you the opportunity to showcase your original research in front of more than 8,000 attendees. Posters will be displayed on site at AAPA 2017 from Monday, May 15, to Friday, May 19.

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  • December 16, 2016 8:50 AM | Deleted user

    The Clinical Advisor

    Approximately 2 of 5 individuals in the United States have received the influenza vaccine this season as of early November, according to recent data from the U.S. Centers for Disease Control and Prevention (CDC).

    The CDC collected survey data through early November 2016 and found that vaccination levels are similar to this time last season. Overall, about 40 percent of people have reported receiving an influenza vaccine, including 37 percent of children between 6 months and 17 years of age and 41 percent of adults older than 18 years of age.

    Although the vaccine estimates for adults and children are similar to the rates from last year, the CDC is looking carefully at rates for children and for adults older than 50 years of age. The CDC observed a 3 percentage point decrease in vaccine coverage among adults older than 50 years of age between the 2014 to 2015 season and the 2015 to 2016 season. 

    Read More

  • December 15, 2016 12:59 PM | Deleted user

    On December 14, 2016, CDC issued guidance related to Zika for people living in or traveling to Brownsville, Cameron County, TX. On November 28, the Texas Department of State Health Services reported the state’s first case of local mosquito-borne Zika virus infection in Brownsville. Additional cases of mosquito-borne Zika have been identified in the area, suggesting that there is a risk of continued spread of Zika virus in Brownsville. As a result, CDC has designated Brownsville as a Zika cautionary area (yellow area).

    CDC designates areas for Zika virus transmission prevention in the continental United States and Hawaii as red or yellow.

    Guidance for Zika cautionary areas (Yellow areas)

    Zika cautionary area (yellow area): A geographic area where local spread of Zika virus has been identified, but there is not yet any evidence of widespread, sustained local spread. Although the specific level of risk in yellow areas is unknown, there is still a risk to pregnant women. Brownsville, TX, is currently designated as a yellow area.

    Travel

    • Pregnant women who live in other areas should consider postponing travel to Brownsville, TX.

    Prevention

    • Pregnant women, women trying to get pregnant, and their partners who live in or travel to Brownsville should be aware of local Zika virus transmission and should strictly follow steps to prevent mosquito bites.
    • Pregnant women and their partners who live in or travel to Brownsville should use condoms every time they have sex or not have sex during the pregnancy.

    Testing and Diagnosis

    • Pregnant women who live in, traveled to, or had sex without a condom with someone who lives in or traveled to Brownsville on or after October 29, 2016, should be tested for Zika virus.
      • Pregnant women with symptoms of Zika should be tested for Zika virus.
      • Pregnant women without Zika symptoms with ongoing risks for exposure (they live in or frequently travel [daily or weekly]) to Brownsville should talk to their healthcare provider to obtain routine testing for Zika virus in both the first and second trimesters.
      • Pregnant women without Zika symptoms who had limited travel to Brownsville or who had sex without a condom with a person who lives in or traveled to Brownsville should be tested for Zika virus.

    Pregnancy Planning

    • Women who had limited travel to Brownsville or had sex without a condom with a person who lives in or traveled to Brownsville may consider waiting at least 8 weeks after symptoms started or last possible exposure before trying to get pregnant.
    • Men who had limited travel to Brownsville or had sex without a condom with a person who lives in or traveled to Brownsville may consider waiting at least 6 months after symptoms started or last possible exposure before trying to get their partner pregnant.
    • People living in Brownsville should talk to their healthcare provider about the possible risk for Zika infection and about their pregnancy plans.
    • Women who live in or frequently travel to Brownsville who are diagnosed with Zika should wait at least 8 weeks after symptoms started before trying to get pregnant.
    • Men who live in or frequently travel to Brownsville who are diagnosed with Zika should wait at least 6 months after symptoms started before trying to get their partner pregnant.
    • Given the limited data available about the persistence at the time of conception, some couples with a partner with possible Zika virus exposure may choose to wait longer or shorter than the recommended period to try to get pregnant.

    Zika cautionary area in Brownsville, TX

     Map of Brownsville, Texas where a locally-transmitted case of Zika was reported

    Brownsville, TX. Yellow shows areas where pregnant women should consider postponing travel.


  • December 15, 2016 12:51 PM | Deleted user

    Looking to curb the record number of STDs and help primary care physicians discuss these diseases with their patients, the National Coalition for Sexual Health recently published Sexual Health and Your Patients: A Provider’s Guide.

    According to Michael Horberg, MD, MAS, FACP, FIDSA, one of the publication’s authors, the guide, unlike other resources, provides a convenient means to access the latest STD research, and, if used as a companion piece to the same coalition’s Take Charge of Your Sexual Health guide, helps providers with consistent educational efforts regarding STDs.

    Michael Horberg

    Michael Hornberg

    “Many providers are not trained in discussing sexual health with patients or may have their own ‘hang ups’ about sexual health. And most providers are really busy and short on time,” Horberg, a member of the National Coalition for Sexual Health Healthcare Action Committee, told Healio Family Medicine. “As such, sexual health often gets short shrift in medical encounters. Yet so many STDs, phobias, unwanted pregnancies, and risky behaviors go unchecked because the provider didn't take the time to address them with their patients. Our goal is to change all that.”

    The new guide provides the latest STD research, ‘essential questions’ primary care physicians can ask patients about sexual health, recommendations on delivering preventive sexual health services, and answers to frequently asked patient questions on screening, testing, STDs, contraceptives, partner issues and sexual performance and function. The guide also provides information on recommended screening tests for syphilis, HIV, hepatitis B and C, chlamydia, gonorrhea and cervical cancers.

    Horberg acknowledged STDs may not be an easy topic for primary care physicians to bring up with their patients, but the statistics on STD prevalence necessitate the discussions. He offered advice to doctors uncomfortable with the subject matter.

    “Get a script in your mind and use it and practice it. We all feel awkward and uncomfortable the first time we do anything. Think back to your first patient encounters in medical school. You were nervous…” Horberg said. “But now it comes so naturally to you — it's likely your second skin. Do that with sexual health questions and conversations and it'll be the same way.”  

    Recent CDC data suggest STDs are a health and financial burden in the United States. The agency said 2015 was the second year in a row where increases were seen in the three nationally reported STDs — syphilis, gonorrhea and chlamydia. The CDC estimates there are almost 20 million new cases of STDs diagnosed each year in the United States, totaling approximately $16 billion in health care costs, but also acknowledges that many cases go unreported or undiagnosed, suggesting the actual number of infections may be higher. – by Janel Miller

    Disclosure: Horberg is a physician with the Kaiser Permanente Mid-Atlantic States.

    Further reading:

    http://nationalcoalitionforsexualhealth.org/tools/for-healthcare-providers/sexual-health-and-your-patients-a-providers-guide

    http://www.ncshguide.org/


  • December 15, 2016 12:50 PM | Deleted user

    Introduction

    Vaccination against human papillomavirus (HPV) is recommended to prevent HPV infections and HPV-associated diseases, including cancers. Routine vaccination at age 11 or 12 years has been recommended by the Advisory Committee on Immunization Practices (ACIP) since 2006 for females and since 2011 for males (1,2). This report provides recommendations and guidance regarding use of HPV vaccines and updates ACIP HPV vaccination recommendations previously published in 2014 and 2015 (1,2). This report includes new recommendations for use of a 2-dose schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years. Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons.

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    Background

    HPV infection causes cervical, vaginal, and vulvar cancers in women; penile cancers in men; and oropharyngeal and anal cancers as well as genital warts in both men and women (3). Three HPV vaccines are licensed for use in the United States. All are noninfectious. Quadrivalent and 9-valent HPV vaccines (4vHPV and 9vHPV, Gardasil and Gardasil 9, Merck and Co, Inc., Whitehouse Station, New Jersey) are licensed for use in females and males aged 9 through 26 years (1). Bivalent HPV vaccine (2vHPV, Cervarix, GlaxoSmithKline, Rixensart, Belgium) is licensed for use in females aged 9 through 25 years (1). As of late 2016, only 9vHPV is being distributed in the United States. The majority of all HPV-associated cancers are caused by HPV 16 or 18, types targeted by all three vaccines. In addition, 4vHPV targets HPV 6 and 11, types that cause genital warts. 9vHPV protects against these and five additional types: HPV 31, 33, 45, 52, and 58. All three vaccines have been approved for administration in a 3-dose series at intervals of 0, 1 or 2, and 6 months. In October 2016, after considering new clinical trial results (4), the Food and Drug Administration (FDA) also approved 9vHPV for use in a 2-dose series for girls and boys aged 9 through 14 years (5). In October 2016, ACIP recommended a 2-dose schedule for adolescents initiating HPV vaccination in this age range. This report provides recommendations for use of 2-dose and 3-dose schedules for HPV vaccination.

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    Methods

    During November 2015–October 2016, the ACIP HPV Vaccines Work Group held monthly telephone conferences to 1) review and evaluate the quality of the evidence assessing immunogenicity, efficacy, and postlicensure effectiveness of a 2-dose schedule; 2) consider benefits and harms of a 2-dose schedule; 3) weigh the variability in the values and preferences of patients and providers for a 2-dose schedule; and 4) examine health economic analyses. During teleconferences, summaries of findings were presented for Work Group discussion.

    A systematic review was conducted to identify studies involving human subjects* that reported primary data on any important or critical health outcomes related to HPV vaccination† after 2 doses of 9vHPV, 4vHPV, or 2vHPV, administered at an interval of 0 and ≥6 months (±4 weeks) to persons aged 9 through 14 years. The review focused on this age group given available 2-dose trial data for 9vHPV (4). Immunogenicity outcomes of interest were seroconversion, geometric mean titers (GMTs), or antibody avidity. Studies were excluded if they lacked a comparison group in which efficacy of 3 doses of HPV vaccine against clinical endpoints was demonstrated in clinical trials (e.g., females aged 15 through 26 years).§ Evidence regarding a 3-dose schedule for HPV vaccine was reviewed previously (1,2).

    Quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Detailed methods and GRADE tables can be found online (6). Other studies from the search and from the broader literature informed additional expert guidance that extended beyond the research question addressed formally via GRADE analysis (7). Evidence was reviewed by the Work Group, summarized, and publicly presented at the February and June 2016 ACIP meetings. CDC vaccine recommendations are developed using the GRADE framework (8). Proposed recommendations were presented, and after a public comment period, were approved unanimously¶ by the voting ACIP members at the October 2016 ACIP meeting.

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    Summary of Key Findings

    Immunogenicity. In the 9vHPV clinical trial that was the basis for FDA approval of a 2-dose series, participants were girls and boys aged 9 through 14 years, compared with young females aged 16 through 26 years (4). Among 1,377 participants, ≥97.9% seroconverted to all nine vaccine-preventable HPV types by 4 weeks after the last dose. For girls and boys who received 2 doses of 9vHPV 6 months apart (0, 6 month schedule) or 12 months apart (0, 12 month schedule), noninferiority criteria were met for seroconversion and GMTs. Furthermore, GMTs were significantly higher for all 9vHPV types among persons aged 9 through 14 years who received 2 doses compared with females aged 16–26 years who received 3 doses (0, 2, 6 month schedule). Six additional studies found similar results for 4vHPV and 2vHPV (6). Immunogenicity was found to be noninferior with 2 doses in persons aged 9 through 14 years compared with 3 doses in a group in which clinical efficacy was demonstrated (GRADE evidence type 3).

    Efficacy and effectiveness. Although efficacy and postlicensure effectiveness studies were reviewed, none met the inclusion criteria detailed above. The prelicensure HPV vaccine efficacy trials were conducted with 3-dose series; post hoc analyses conducted with data from some of these trials found high efficacy against infection among vaccinees who received 2 doses and those who received 3 doses (9,10). A large study comparing 2 doses with 3 doses also suggested similar efficacy against infection (11). Postlicensure effectiveness studies have found lower effectiveness against various HPV-associated outcomes among vaccinees who received 2 doses compared with those who received 3 doses, but methodologic challenges with these studies limit interpretation of the findings.**

    Duration of protection. Through 10 years of follow-up from clinical trials, no evidence of waning protection after a 3-dose series of HPV vaccine has been found (1). Because antibody kinetics are similar with 2-dose and 3-dose series, duration of protection is also expected to be long-lasting after a 2-dose series (12,13).

    Health impact and cost-effectiveness modeling. Population-level effectiveness and cost-effectiveness of 2-dose and 3-dose schedules of 9vHPV in the United States have been modeled (14). Assuming both efficacy and duration of protection are similar with either schedule, a 2-dose series would be cost-saving and have similar population impact to a 3-dose series. Even if duration of protection is 20 years for a 2-dose series and lifelong for a 3-dose series, additional benefits of a 3-dose series would be relatively small, and a 2-dose series would be more cost-effective (14).

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    Rationale

    HPV vaccines are highly effective and safe, and a powerful prevention tool for reducing HPV infections and HPV-associated cancers (1,2). Based on the available immunogenicity evidence, a 2-dose schedule (0, 6–12 months) will have efficacy equivalent to a 3-dose schedule (0, 1–2, 6 months) if the HPV vaccination series is initiated before the 15th birthday (GRADE evidence type 3) (6). ACIP recommends a 2-dose schedule for HPV vaccination of girls and boys who initiate the vaccination series at ages 9 through 14 years (Category A recommendation).

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    Recommendations

    Routine and catch-up age groups. ACIP recommends routine HPV vaccination at age 11 or 12 years. Vaccination can be given starting at age 9 years. ACIP also recommends vaccination for females through age 26 years and for males through age 21 years who were not adequately vaccinated previously. Males aged 22 through 26 years may be vaccinated. (See also: Special populations, Medical conditions)

    Dosing schedules. For persons initiating vaccination before their 15th birthday, the recommended immunization schedule is 2 doses of HPV vaccine. The second dose should be administered 6–12 months after the first dose (0, 6–12 month schedule)†† ( Table).

    For persons initiating vaccination on or after their 15th birthday, the recommended immunization schedule is 3 doses of HPV vaccine. The second dose should be administered 1–2 months after the first dose, and the third dose should be administered 6 months after the first dose (0, 1–2, 6 month schedule)§§ (Table).

    Persons vaccinated previously. Persons who initiated vaccination with 9vHPV, 4vHPV, or 2vHPV before their 15th birthday, and received 2 doses of any HPV vaccine at the recommended dosing schedule (0, 6–12 months), or 3 doses of any HPV vaccine at the recommended dosing schedule (0, 1–2, 6 months), are considered adequately vaccinated.

    Persons who initiated vaccination with 9vHPV, 4vHPV, or 2vHPV on or after their 15th birthday, and received 3 doses of any HPV vaccine at the recommended dosing schedule, are considered adequately vaccinated.

    9vHPV may be used to continue or complete a vaccination series started with 4vHPV or 2vHPV.

    For persons who have been adequately vaccinated with 2vHPV or 4vHPV, there is no ACIP recommendation regarding additional vaccination with 9vHPV.

    Interrupted schedules. If the vaccination schedule is interrupted, the series does not need to be restarted. The number of recommended doses is based on age at administration of the first dose.

    Special populations. For children with a history of sexual abuse or assault, ACIP recommends routine HPV vaccination beginning at age 9 years.

    For men who have sex with men,¶¶ ACIP recommends routine HPV vaccination as for all males, and vaccination through age 26 years for those who were not adequately vaccinated previously.

    For transgender persons, ACIP recommends routine HPV vaccination as for all adolescents, and vaccination through age 26 years for those who were not adequately vaccinated previously.

    Medical conditions. ACIP recommends vaccination with 3 doses of HPV vaccine (0, 1–2, 6 months) for females and males aged 9 through 26 years with primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity,*** such as B lymphocyte antibody deficiencies, T lymphocyte complete or partial defects, HIV infection, malignant neoplasms, transplantation, autoimmune disease, or immunosuppressive therapy, because immune response to vaccination might be attenuated (Table) (7).

    Contraindications and precautions. Contraindications and precautions, including those related to pregnancy, are unchanged from previous recommendations (1,2). Adverse events occurring after administration of any vaccine should be reported to the Vaccine Adverse Event Reporting System (VAERS). Reports can be submitted to VAERS online, by fax, or by mail. Additional information about VAERS is available by telephone (1-800-822-7967) or online (https://vaers.hhs.gov ).

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    Acknowledgments

    Members of the Advisory Committee on Immunization Practices (ACIP) (member roster for July 2016–June 2017 is available online at https://www.cdc.gov/vaccines/acip/committee/members-archive.html); ACIP HPV Vaccines Work Group: Jorge E. Arana, MD, Atlanta, Georgia; Joseph Bocchini, MD, Shreveport, Louisiana; Harrell Chesson, PhD, Atlanta, Georgia; Tamera Coyne-Beasley, MD, Chapel Hill, North Carolina; C. Robinette Curtis, MD, Atlanta, Georgia; Carolyn D. Deal, PhD, Bethesda, Maryland; Shelley Deeks, MD, Toronto, Ontario, Canada; John Douglas, MD, Greenwood Village, Colorado; Linda Eckert, MD, Seattle, Washington; Sandra Adamson Fryhofer, MD, Atlanta, Georgia; Julianne Gee, MPH, Atlanta, Georgia; Bruce G. Gellin, MD, Washington, DC; Samuel Katz, MD, Durham, North Carolina; Alison Kempe, MD, Denver, Colorado (Chair); Aimée R. Kreimer, PhD, Bethesda, Maryland; Joohee Lee, MD, Silver Spring, Maryland; Lauri E. Markowitz, MD, Atlanta, Georgia (CDC Lead); Elissa Meites, MD, Atlanta, Georgia; Amy B. Middleman, MD, Oklahoma City, Oklahoma; Chris Nyquist, MD, Denver, Colorado; Sean O’Leary, MD, Aurora, Colorado; Sara E. Oliver, MD, Atlanta, Georgia; Cynthia Pellegrini, Washington, DC; Jeff Roberts, MD; Rockville, Maryland; José R. Romero, MD, Little Rock, Arkansas; Jeanne Santoli, MD, Atlanta, Georgia; Mona Saraiya, MD, Atlanta, Georgia; Debbie Saslow, PhD, Atlanta, Georgia; Margot Savoy, MD, Wilmington, Delaware; Shannon Stokley, DrPH, Atlanta, Georgia; Lakshmi Sukumaran, MD, Atlanta, Georgia; Elizabeth R. Unger, PhD, MD, Atlanta, Georgia; Patricia Whitley-Williams, MD, New Brunswick, New Jersey; Rodney Willoughby, MD, Wauwatosa, Wisconsin; JoEllen Wolicki, Atlanta, Georgia; Sixun Yang, MD, Rockville, Maryland; Jane Zucker, MD, New York, New York.

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    Corresponding author: Elissa Meites, emeites@cdc.gov, 404-639-8253.

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    1Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 2HPV Vaccines Work Group, Advisory Committee on Immunization Practices, Atlanta, Georgia; 3Department of Pediatrics, University of Colorado Anschutz Medical Campus, Denver, Colorado.

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    * No primary data on special populations or medical conditions, including immunocompromising conditions, were available for 2-dose intervals and age ranges specified.

    † No primary data on other important and critical outcomes, including genital warts, precancers, oropharyngeal cancer, anal cancer, cervical cancer, vaginal/vulvar cancer, and penile cancer, were available for 2-dose intervals and age ranges specified.

    § Studies were excluded when 2-dose interval was not ≥5 months.

    ¶ Twelve votes to none, with one recusal.

    ** In studies conducted in the setting of a 3-dose HPV vaccine recommendation or policy, many 2-dose recipients received HPV vaccine doses at a 1–2 month interval; in addition, 2-dose recipients differed from 3-dose recipients in ways that suggested differences in HPV exposure.

    †† In a 2-dose schedule of HPV vaccine, the minimum interval between the first and second doses is 5 months. If the second dose is administered after a shorter interval, a third dose should be administered a minimum of 12 weeks after the second dose and a minimum of 5 months after the first dose.

    §§ In a 3-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second doses, 12 weeks between the second and third doses, and 5 months between the first and third doses. If a vaccine dose is administered after a shorter interval, it should be readministered after another minimum interval has elapsed since the most recent dose.

    ¶¶ Including men who identify as gay or bisexual, or who intend to have sex with men.

    *** The recommendation for a 3-dose schedule of HPV vaccine does not apply to children aged <15 years with asplenia, asthma, chronic granulomatous disease, chronic liver disease, chronic lung disease, chronic renal disease, central nervous system anatomic barrier defects (e.g., cochlear implant), complement deficiency, diabetes, heart disease, or sickle cell disease.

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    References

    1. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2014;63(No. RR-05). PubMed
    2. Petrosky E, Bocchini JA , Hariri S, et al. . Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2015;64:300–4. PubMed
    3. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers—United States, 2008–2012. MMWR Morb Mortal Wkly Rep 2016;65:661–6. CrossRef  PubMed
    4. Iversen O-E, Miranda MJ, Ulied A, et al. Immunogenicity of the 9-valent HPV vaccine using 2-dose regimens in girls and boys vs a 3-dose regimen in women. JAMA 2016;316:2411–21.CrossRef  PubMed
    5. Food and Drug Administration. Prescribing information [package insert]. Gardasil 9 [human papillomavirus 9-valent vaccine, recombinant]. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2016. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM426457.pdf
    6. CDC. Grading of Recommendations Assessment, Development and Evaluation (GRADE) of a 2-dose schedule for human papillomavirus (HPV) vaccination. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/vaccines/acip/recs/grade/hpv-2-dose.html
    7. Rubin LG, Levin MJ, Ljungman P, et al. ; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014;58:e44–100. CrossRef  PubMed
    8. Ahmed F, Temte JL, Campos-Outcalt D, Schünemann HJ; ACIP Evidence Based Recommendations Work Group (EBRWG). Methods for developing evidence-based recommendations by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC). Vaccine 2011;29:9171–6. CrossRef  PubMed
    9. Kreimer AR, Struyf F, Del Rosario-Raymundo MR, et al. ; Costa Rica Vaccine Trial Study Group Authors; PATRICIA Study Group Authors; HPV PATRICIA Principal Investigators/Co-Principal Investigator Collaborators; GSK Vaccines Clinical Study Support Group. Efficacy of fewer than three doses of an HPV-16/18 AS04-adjuvanted vaccine: combined analysis of data from the Costa Rica Vaccine and PATRICIA Trials. Lancet Oncol 2015;16:775–86. CrossRef  PubMed
    10. Kreimer AR, Rodriguez AC, Hildesheim A, et al. ; CVT Vaccine Group. Proof-of-principle evaluation of the efficacy of fewer than three doses of a bivalent HPV16/18 vaccine. J Natl Cancer Inst 2011;103:1444–51. CrossRef  PubMed
    11. Sankaranarayanan R, Prabhu PR, Pawlita M, et al. ; Indian HPV Vaccine Study Group. Immunogenicity and HPV infection after one, two, and three doses of quadrivalent HPV vaccine in girls in India: a multicentre prospective cohort study. Lancet Oncol 2016;17:67–77. CrossRef  PubMed
    12. Romanowski B, Schwarz TF, Ferguson L, et al. Sustained immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine administered as a two-dose schedule in adolescent girls: five-year clinical data and modeling predictions from a randomized study. Hum Vaccin Immunother 2016;12:20–9. CrossRef  PubMed
    13. Dobson SR, McNeil S, Dionne M, et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs 3 doses in young women: a randomized clinical trial. JAMA 2013;309:1793–802.CrossRef  PubMed
    14. Laprise JF, Markowitz LE, Chesson HW, Drolet M, Brisson M. Comparison of 2-dose and 3-dose 9-valent human papillomavirus vaccine schedules in the United States: a cost-effectiveness analysis. J Infect Dis 2016;214:685–8. CrossRef  PubMed

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    Return to your place in the textTABLE. Recommended number of doses and intervals for human papillomavirus (HPV) vaccine, by age at series initiation and medical conditions — United States, 2016
    Population Recommended number of HPV vaccine doses Recommended interval between doses
    Persons initiating HPV vaccination at ages 9 through 14 years,* except immunocompromised persons† 2 0, 6–12 months§
    Persons initiating HPV vaccination at ages 15 through 26 years¶ and immunocompromised persons† initiating HPV vaccination at ages 9 through 26 years 3 0, 1–2, 6 months**

    *ACIP recommends routine HPV vaccination for adolescents at age 11 or 12 years; vaccination may be given starting at age 9 years.
    † Persons with primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity (see also: Medical conditions)
    § In a 2-dose schedule of HPV vaccine, the minimum interval between the first and second doses is 5 months.
    ¶ For persons who were not adequately vaccinated previously, ACIP recommends vaccination for females through age 26 years and for males through age 21 years; males ages 22 through 26 years may be vaccinated. Vaccination is recommended for some persons aged 22 through 26 years; see Medical conditions and Special populations.
    ** In a 3-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second doses, 12 weeks between the second and third doses, and 5 months between the first and third doses.

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    Recommendations for use of vaccines in children, adolescents and adults are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the Centers for Disease Control and Prevention (CDC) on use of vaccines and related agents for the control of vaccine-preventable diseases in the civilian population of the United States. Recommendations for use of vaccines in children and adolescents are harmonized to the greatest extent possible with recommendations made by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG). Recommendations for routine use of vaccines in adults are harmonized with recommendations of AAFP, ACOG, and the American College of Physicians (ACP). ACIP recommendations approved by the CDC Director become agency guidelines on the date published in the Morbidity and Mortality Weekly Report (MMWR). Additional information about ACIP is available at https://www.cdc.gov/vaccines/acip.


    Suggested citation for this article: Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405–1408. DOI: http://dx.doi.org/10.15585/mmwr.mm6549a5 .

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