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same reason why we give tetanus shots. I understand concerns that the vaccine doesn't provide lifelong protection, but I don't understand using that as an excuse not to vaccinate." Dr. Harper questions the appropriateness of routine early vaccination and pushes for an individualized approach to vaccine administration. "The argument that someone should get the vaccine at age 11 because by the time they're 18, they'll have a 50 percent chance of having had sex and the vaccine won't work, is true at face value," Dr. Harper says. "But it may very well be that the age at which a person decides to get vaccinated is very personally determined. It's much more appropriate to decide what the risk is as a family or as a person." benefits of Vaccination Although preventing cervical cancer is the primary goal of HPV vaccination, people can benefit from the vaccine in other ways. Dr. Harper co-authored a rev iew paper published by the Internationa l Scholarly Research Network, in which she notes that the most beneficial results of vaccination are reductions in abnormal pap test results, colposcopies and excisional treatments. "The importance of the vaccine is not [solely] one of cancer protection, but one of health economics in reducing the number of procedures a young person with HPV is likely to get in his or her lifetime," Dr. Harper says. methods of approach In the Pediatrics study, which was published in March 2013, Dr. Darden shows that between 2008 and 2010, a little more than half of surveyed physicians recommended HPV vaccination to their teenage fema le patients. Dr. Darden explains that physicians have a duty to provide clearly stated recommendations to their patients. "Sometimes, as physicians, we feel we've stated our recommendations, but to the other party, they remain unstated," Dr. Darden says. "This can increase their uncertainty. Parents or patients can still refuse the vaccination, but the reason they're coming to you is for your expert opinion, and I don't think it's fair to them not to give it." Dr. Harper agrees that, while physicia ns should clea rly state their r e c om m e n d a t ion s , t h e y s h o u ld not conform to messages sent by the CDC's Advisory Committee on Immunization Practices. " T he messa ge physicia ns have received ... is that you have to push the vaccine," Dr. Harper says. "That's absolutely the wrong way to present these vaccinations. What physicians need to be saying is that the vaccine is available, and it's useful." ■ SPecIal clInIcal SecTIon: peDiatRics major reasons for declining the vaccine for their children. This dichotomy leads Dia ne Harper, MD, MPH, MS, Professor of Medicine at the University of Missouri School of Medicine, who participated in early trials of the vaccines at the behest of their makers, GlaxoSmithKline and Merck & Co., to suggest that vaccination be based upon individual risk factors because studies have not shown how long the vaccines protect against HPV. Dr. Harper sees merit in waiting until patients themselves determine the appropriateness of vaccination. "I provide a balanced picture to my patients and their families and am not at all upset if they refuse the vaccine, especially at younger ages," Dr. Harper says. "I think it may be more appropriate for some people to decide they want to be vaccinated at age 16, 18 or 20 — whichever age makes the most sense for them to have protection from infection." On the other hand, Dr. Darden notes that sexual activity doesn't always happen as planned, and because of prevalent teenage sexual activity, Dr. Darden encourages vaccination before children enter high school. "If you vaccinate after the patient is infected, the vaccine won't help at all," Dr. Darden notes. "The vaccine may not provide the protection we hope for, but it's better than nothing — it's the aRe SaFeTy conceRnS Well-Founded? Authors of "Reasons for Not vaccinating Adolescents: National immunization survey of Teens, 2008-2010," published in Pediatrics, volume 131, number 4, found that, in three years, parents citing safety concerns as a reason not to vaccinate their children against human papillomavirus (hPv) increased from 4.5 percent to 16.4 percent. Randomized clinical trials of hPv vaccines showed no increase in adverse events that would lead to safety concerns about the vaccines, according to Diane harper, MD, MPh, Ms, Professor of Medicine at the university of Missouri school of Medicine, who worked with Merck, & Co. and GlaxosmithKline to develop the hPv vaccines. "looking at the internet, you can see websites dedicated to people who had very serious, lifealtering events after Gardasil vaccination," Dr. harper says. "The diffi culty with this is that there's no way to prove that Gardasil actually caused those adverse events, but there's no way to prove that it didn't because these events are so rare." mDnews.com ■ MD News Twin Cities | 15

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