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HPV

LD

Lisa DeLong

Transcript

HUMAN PAPILLOMA VIRUS (HPV)

ADVANCED HEALTH ASSESSMENT

Lisa DeLong, Erin Stephens & Karla Zuniga Reyes

FEBRUARY 22, 2020

DISEASE PREVALENCE

DISEASE PREVALENCE

  • HPV is the most common sexually transmitted infection (STI)
  • CDC estimates nearly 90% of all sexually active will contract HPV at some point
  • 42.5% of all non-institutionalized adults aged 18-59 in the U.S. are infected
  • Prevalence significantly higher in sexually active, non-Hispanic males
  • 79 million Americans, most in their late teens and early 20s, are infected
  • 14 million new cases occur annually in the US (50% in persons ages 15-24)

(CDC, 2019e)

Prevalence (Continued)

  • 90% of infections do not cause symptoms and resolve within two years
  • 35,000 new cases of HPV-associated cancers and 355,000 cases of anogenital warts in 2009
  • 8 billion dollars spent annually on management of HPV

THE GOOD NEWS:

One study showed a 63% decrease in HPV in vaccine-targeted population ages 14-19

PREVALENCE (CONT.)

(CDC, 2019e)

ETIOLOGY

ETIOLOGY AND PATHOPHYSIOLOGY

  • HPV is a viral infection that commonly causes skin or mucous membrane growths (warts)
  • There are more than 100 varieties of HPV
  • Majority of HPV types lead to warts (low-risk, nononcogenic)
  • Low risk strains (HPV 6 and 11) cause most cases of genital warts
  • A small number may lead to cancer (high-risk, oncogenic)
  • 2 HPV types (16 and 18) cause 70% of cervical cancers and pre-cancerous cervical lesions
  • Primary source of HPV is sexual contact or skin-to-skin transmission

(CDC, 2019b)

RISK FACTORS

RISK

FACTORS

  • Unprotected intercourse
  • Multiple sexual partners
  • Young age at initiation of sexual activity
  • Weakened immune system (HIV, immunosuppressant medications)
  • Smoking
  • Infection with herpes or gonorrhea
  • Uncircumcised (controversial)

(CDC, 2019e)

(Hernandez et al., 2008)

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

OF HPV

WHAT IS HPV?

DESCRIPTION OF HPV VIRUS

  • Small, circular double-stranded DNA virus protected by capsid proteins (vaccine mimics proteins)
  • Affects the mucosal or cutaneous epithelium
  • Since HPV affects the epithelial cells and does not enter the bloodstream, infection in one area should not affect another part of the body
  • Oncogenic types may cause cancer in the cervix, oropharynx, anus, rectum, penis, vagina and vulva

(National Cancer Institute, 2018)

PATHOPHYSIOLOGY OF HPV

  • HPV enters the epithelial cell through a break in the skin and produces proteins that may interfere with normal cell functions, causing uncontrollable growth
  • Infection occurs at the basal layer
  • Affected cells display a broad range of response ranging from benign hyperplasia to dysplasia to invasive carcinoma
  • It may take 10-20 years for HPV-infected cells to develop into a cancerous tumor

PATHOPHYSIOLOGY

(National Cancer Institute, 2018)

Infection by HPV

Click to edit text

HPV

SEQUENCE OF EVENTS

(National Cancer Institute, 2018)

Click to edit text

PATHOGENESIS

(National Cancer Institute, 2018)

PATHOPHYSIOLOGY OF HPV

HPV IN ACTION

https://www.youtube.com/watch?v=AZOnAuElJHk

STOP AT 3:33

Diagnostic Work Up: Testing

SUBJECTIVE DATA AND PHYSICAL ASSESSMENT

  • History, Head to Toe physical, Gonorrhea and Chlamydia Culture, Chlamydia Smear, Serology test to r/o syphilis.

  • Pap smear, colposcopy, DNA testing, eg. Hybrid Capture 2 DNA Test, biopsy of cervix or unresponsive or unusual lesion on vulva for histologic exam, HIV Testing (Hawkins et al., 2010)
  • Detecting High Risk HPV Types 16 & 18: Cobas HPV test screens for 14+ types of high risk HPV types,it can identify types 16 and 18 separately due to its distinct wavelengths

  • HPV DNA and HPV 16/18 Typing vs Cytology for CervicalCancer Screening: https://dx.plos.org/10.1371/journal.pone.0119755

(Agorastos, et al., 2015, p. 4)

Click to edit text

Diagnostic

Screening

(Workowski, 2015)

Physical Exam - Subjective

Physical Exam

Subjective

  • Patient's chief complaint, referral or voluntary
  • Sexual History 5 P's: Partners, Practices, Previous,

Protection from STDs and Prevention of Pregnancy

  • Sexual activity, exposure and most recent contact
  • Last Menstrual Period (LMP) and Birth Control Method
  • Vaginitis, Pelvic Inflammatory Disease (PID)
  • Sexually Transmitted Infections (STIs): Genital warts,

Herpes simplex, history of or reactivation of STIs

  • Description of discharge
  • Abnormal Pap and treatment
  • Self infection from condyloma
  • Lifestyle: smoking, environment
  • Resource: Sexually Transmitted Diseases Treatment Guidelines 2015 https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm

(Melville, 2015)

Condyloma Acuminata. https://www.kesehatan-kelamin.com/wp-content/uploads/2016/03/Condyloma.png.

Vaginal and Penile Condyloma Acuminata

Physical Exam - Objective

Anal Condyloma Acuminata. (n.d.). Retrieved from https://www.bing.com/images/search?view=detailV2&id=3EC14EBC1A83F8872E6BDFA78F2C7B841E0973CC&thid=OIP.RcUn-a0QCHd_VvJO-GQ16gHaIH&mediaurl=https://www.researchgate.net/profile/Michelle_Inkster/publication/301264561/figure/download/fig4/AS:535331217657856@1504644316187/Anal-condyloma-acuminata-in-the-region-of-the-corrugator-cutis.png?_sg=kNhik_wSZwmqXz6mVw2KWiJFZiTrqIF4C2Scd7G0WbWOPlRnrRaJ_qxU9DZi2gs3RDOE9jPpdnc&exph=724&expw=660&q=condyloma acuminata anal area&selectedindex=0&ajaxhist=0&vt=0&eim=0,1,2,3,4,6,8,10

Anal Condyloma Acuminata

Physical Exam

Objective

Extragenital Areas: Head, Nose, Eyes, Mouth, Throat, Hands and Feet.

  • Look for multiple individual warts flowing together.
  • Look for lesions that have complications from trauma such as scratching.
  • Check all areas that have hair-bearing skin for lesions.

Inspect External Anatomy

  • Look for small, pink or skin colored, warty lesions in the following areas: penile shaft, periclitoral area, vestibule,posterior perineal and perianal areas.

Vaginal Exam with Speculum

  • Observe the vaginal walls and cervix for the same lesions as above

Cervical Cells. (n.d.). Retrieved from https://www.bing.com/images/search?view=detailV2&ccid=FUWHnuiY&id=91B8FA75846E159EC8A6766F50EAA61571F0A641&thid=OIP.FUWHnuiYKJvse6i0X9G28gAAAA&mediaurl=https://i0.wp.com/www.doctortipster.com/wp-content/uploads/2011/09/Cervical-Cancer1.jpg&exph=176&expw=176&q=cervical cancer&simid=608054664359710144&selectedindex=31&adlt=demote&shtp=GetUrl&shid=30b2ab32-c6c7-4fa8-bb87-f12210ba3ecd&shtk=U29tZSB1c2VmdWwgSG9tZW9wYXRoaWMgcmVtZWRpZXMg4oCTIFBhcnQgNTIuIHwgRHIuIFJhamVzaCBWaXNod2FuYXRoYW4=&shdk=Rm91bmQgb24gQmluZyBmcm9tIGRycmFqZXNodi5jb20=&shhk=mHUcnpKpsKiXk6cxPORzrQ+oDKuetZ6tai9Ky4t7yII=&form=EX0023&shth=OSH.YSpwco%2BBe095SLYAvc9RwQ

(Melville, 2015)

Cervical Cell Changes

Differential Diagnosis: External Genitalia

DIFFERENTIAL DIAGNOSIS AND TREATMENT

Misdiagnosis can lead to psychological distress and delayed treatment (Medscape, 2020).

  • Normal Anatomy: Pearly papules, Tyson Glands, Fordyce Spots
  • Skin Tags, Molluscum Contagiousum
  • Condyloma Lata (Syphillis Presentation)
  • Epidermoid cysts
  • Dermatofibromas
  • Intra-epithelial neoplasia
  • Malignant lesions

(Hawkins et al., 2010)

Female External Genitalia

Condylomata Acuminata (HPV)

Female

Condylomata Lata (Syphillis)

Vulvar Papillae

Condyloma Acuminata vs Conlyloma Lata. (n.d.). Retrieved from https://www.netterimages.com/images/vpv/000/000/063/63743-0550x0475.jpg

Vulvar Papillae. (n.d.). Retrieved from http://www.idoj.in/viewimage.asp?img=IndianDermatolOnlineJ_2017_8_1_63_198777_f2.jpg

Male External Genitalia

Male

Pearly Papules

Tyson Glands

Pearly Papules. (n.d.). Retrieved from http://3pgel.com/before-after-pearly-penile-papule-pictures

Tyson Glands. (n.d.). Retrieved from https://mens.funa-biyou.com/wp/wp-content/uploads/2014/11/kito.jpg

Fordyce Spots

Fordyce Spots. (n.d.). Retrieved from https://www.firstderm.com/sebaceous-gland/

Treatment

(Workowski, 2015, p. 87)

Treatment

Goal of Treatment: Reduce symptoms and prevent re-occurrence. Follow patient closely based on their diagnosis and treatment modality.

Warts: Reduce or eradicate the symptoms. Treatment based on size, number and location of warts.

Cervix: Eliminate abnormal cells, Squamous Intraepithelial Lestions (SILs) and High Grade SILs.

Malignancies: Refer to oncology for staging and treatment to prevent morbidity and mortality.

(Workowski, 2015, p. 87)

HEALTH PROMOTION AND RISK REDUCTION

HEALTH PROMOTION AND RISK REDUCTION

  • Vaccine (9-Valent) - prior to start of sexual activity
  • Mutually monogamous relationship
  • Condoms
  • Routine screening (Pap smear)

(CDC, 2019a & 2019d; Saraiya, et al, 2015)

VACCINE 9-valent

VACCINE

  • Targets HPV 6/11/16/18 and 5 oncogenic types, extending prevention to 90% of all cervical cancers
  • High efficacy in preventing cervical, vulvar, anal cancers and pre-cancerous cervical lesions
  • May be effective in preventing oral HPV infections

(ACIP, 2019; Sairaiya, et al, 2015)

WHEN TO VACCINATE

When to vaccinate?

  • Recommended for boys and girls at age 11 or 12
  • Ages 27-45, vaccine not recommended unless it's decided upon through a shared-decision making process
  • 51% of adolescents aged 13-17 were vaccinated in 2017-2018

(ACIP, 2019; CDC, 2019c)

(Johns Hopkins Medicine, 2020)

Why choose not to vaccinate?

RESOURCES

  • CDC
  • Planned Parenthood
  • Vaccines For Children Program

RESOURCES

TEACHING

STRATEGIES

TEACHING STRATEGIES

  • Verbal
  • Including provider recommendation for vaccine
  • Focus on concerns parents have for their children receiving the vaccine
  • Written information
  • Videos

(CDC, 2018; CDC, 2019a & 2019c, Johns Hopkins Medicine, 2020)

REFERENCES

REFERENCES

Advisory Committee on Immunization Practices. (2019). ACIP Evidence to Recommendation for HPV Vaccinations of Adults. [PDF]. Retrieved from https://www.cdc.gov/vaccines/acip/recs/grade/HPV-adults-etr-H.pdf

Agorastos, T., Chatzistamatiou, K., Katsamagkas, T., Koliopoulos, G., Daponte, A., Constantinidis, T., & Constantinidis, T. C. (2015). Primary Screening for Cervical Cancer Based on High-Risk Human Papillomavirus (HPV) Detection and HPV 16 and HPV 18 Genotyping, in Comparison to Cytology. Plos One, 10(3). doi: 10.1371/journal.pone.0119755

Centers for Disease Control and Prevention. (2018). HPV Vaccine Safety and Effectiveness. [PDF]. Retrieved from https://www.cdc.gov/vaccines/partners/downloads/teens/vaccine-safety.pdf

Center for Disease Control and Prevention. (2019a). Genital HPV Infection Fact Sheet. [PDF]. Retrieved from https://www.cdc.gov/std/hpv/HPV-FS-print.pdf

Center for Disease Control and Prevention. (2019b). Morbidity and Mortality Weekly Report. [PDF]. retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6833a2-H.pdf

Centers for Disease Control and Prevention. (2019c). Vaccinating Boys and Girls Against HPV. Retrieved from https://www.cdc.gov/hpv/parents/vaccine.html

Center for Disease Control and Prevention. (2019d). Vaccine Information Statement: HPV. [PDF]. Retrieved from https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv.pdf

Centers for Disease Control and Prevention. (2019e). Human Papilloma Virus. Retrieved from https://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html

Hawkins, Joellen W., et al. Guidelines for Nurse Practitioners in Gynecologic Settings, 11th Edition, Springer Publishing Company, 2010. ProQuest Ebook Central, https://ebookcentral-proquest-com.pointloma.idm.oclc.org/lib/pointloma-ebooks/detail.action?docID=4102335.

Hernandez, B. Y., Wilkens, L. R., Zhu, X., McDuffie, K., Thompson, P., Shvetsov, Y. B., Ning, L., & Goodman, M. T. (2008). Circumcision and human papillomavirus infection in men: a site-specific comparison. The Journal of infectious diseases, 197(6), 787–794. https://doi.org/10.1086/528379

National Cancer Institute. HPV and Cancer. (2018). Retrieved from https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer

Melville, Catriona. Sexual and Reproductive Health at a Glance. Wiley Blackwell, 2015.

Other Sexually Transmitted Diseases - 2018 Sexually Transmitted Diseases Surveillance. (2019, October 7). Retrieved from https://www.cdc.gov/std/stats18/other.htm#hpv

Sairiya, M., Unger, E., Thompson, T., Lynch, C., Hernandez, B., Lyu, C., Steinau, M., Watson, M., Wilkinson, E., Hopenhayn, C., Copeland, G., Cozen, W., Peters, E., Huang, Y., Saber, M., Altekruse, S., & Goodman, M. (2015). US Assessment of HPV Types in Cancers: Implications for Current and 9-Valent HPV Vaccines. Journal of National Cancer Institute, 107(6), 1-12.

The HPV Vaccine: Why Parents Really Choose to Refuse. (2020). Johns Hopkins Medicine Newsroom. Retrieved on Feb 18, 2020 from https://www.hopkinsmedicine.org/news/newsroom/news-releases/the-hpv-vaccine-why-parents-really-choose-to-refuse

Workowski, K. A. (2015). Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clinical Infectious Diseases, 61(suppl 8). doi: 10.1093/cid/civ771

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