Anya and Adriana host an informative episode about the HPV vaccine with pediatrician Dr. Nathan Boonstra. They cover the effectiveness and safety of the vaccine and discuss myths and misinformation.

Here’s a link to a series of stories about HPV-related cancer survivors in Iowa, mentioned in the episode: www.youtube.com/watch?v=lwUPu4vS8…fa0Nx0aQ5Lnz2szGt

Find our previous episodes on Spotify, Apple Podcasts, and SoundCloud.

Anya Morozov:

Hello, everyone, and welcome back to From the Front Row. Human Papillomavirus or HPV is linked to five different types of cancer that cause thousands of deaths each year. The virus is also hard to detect and spreads easily between people. Luckily, we have a vaccine against HPV that can help prevent HPV related cancers and cancer deaths. To help discuss the HPV vaccine and its importance to public health, we have Dr. Nathan Boonstra on the show. Dr. Boonstra is a pediatrician at Blank Children’s Pediatric Clinic in Des Moines, Iowa, and is a longtime advocate for the importance of vaccinations. I’m Anya Morozov, co-hosting with Adriana Kotchkoshki, and if it’s your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they are relevant to anyone, both in and outside the field of public health. Welcome to the show, Dr. Boonstra.

Nathan Boonstra:

Hey, thank you so much. It’s great to be here.

Anya Morozov:

So to start out, can you just tell us a little bit about yourself, your background, and why you’re an advocate for vaccines?

Nathan Boonstra:

Yeah, so I went to the University of Iowa for medical school and at least the idea of vaccine advocacy started to take root when I did some away rotations in some areas of the state that had pretty significant amount of vaccine hesitancy. And I had some experiences as a medical student, a naïve, meek medical student being met with really upset parents. They weren’t even just like, “We don’t want vaccines, but we really hate them and here’s why and don’t you hate these vaccines?” And so I went back with my carpool people and was like, “What is up with this? This doesn’t seem to be a super controversial thing. What information are parents getting that makes them feel this way about vaccines?”

And so that started my interest in just figuring out where do families get information? What’s good information? What’s bad information? How do families that don’t necessarily have backgrounds in these things figure out what’s good information, bad information? This was really before most social media that we’re using today, I’m that old. So at that time it was a lot of just websites and whatnot. And that was really a few years before really some of these sites like Facebook and Twitter started to take hold. And so that landscape has changed over time. And then in residency, I would see the consequences of kids not getting vaccinated, whether that was influenza deaths or pertussis and things like that.

And so when I became an attending, I stayed on here at Blank Children’s Hospital after finishing residency. And since then, that’s really been my special interest is how do families get information? How do we get them good information? How do we do our best to dispel myths that parents might encounter? And when it comes to what vaccines need the most advocacy, really HPV has been one of those vaccines that need it the most. There’s probably some of the worst myths and most unfair myths about the vaccine. And it’s also one of, if not the, most life-saving vaccines that we give in a pediatric clinic. So that’s why I have been doing what I do or had this special interest in that for quite a while now.

Adriana Kotchkoski:

Yeah. Thank you. To you start off, go Hawks. Once a Hawk, always a Hawk.

Nathan Boonstra:

Absolutely.

Adriana Kotchkoski:

And in your own words, why do you think HPV vaccination is so important?

Nathan Boonstra:

Yeah, so really by the numbers, there are not very many vaccines that save as many lives as the HPV vaccine. And when I say that, what I’m thinking of is when we look back historically at some of these vaccines, what the death rates were for the diseases prior to widespread vaccination, I mean, they’re not insignificant, don’t get me wrong. I don’t want to minimize the impact of any vaccine. They’re all hugely important. But we’re looking at, and if we look at reports, there were 500 ish deaths in the United States every year from measles. There’s probably some under-reporting there too, but that’s what was reported there. We’re looking at things like HIB and Pneumococcal in kids, we’re looking in the hundreds to low thousands, I believe, deaths a year. All very important. When we look at HPV vaccine, we’re looking at, if we talk about cervical cancer alone, cervical cancer kills or killed prior to the vaccine, certainly 4,000 in the United States every year. That’s a lot.

That’s much higher than a lot of the other annual saw from other vaccine preventable diseases. And that doesn’t even account for all those other cancers that you brought up at the beginning, so just by the numbers. The catch here is that unlike a lot of these other vaccine preventable diseases, these are deaths that will mostly happen down the road. We immunize in adolescents to prevent the adolescent from catching the virus in the next… We’re trying to cover them really for the next adolescents and young adulthood so that then down the line, they don’t develop… So that virus does not cause these cancers down the line. So it’s a little bit of forward-thinking in terms of the lives that we’re saving that we’re not necessarily saving usually the child’s life at the age that they are, but we’re giving them a better future. We’re looking towards when they’re 30, 40, 50, 60 in terms of the development of these cancers.

Anya Morozov:

Yeah, I think there’s a lot of peace of mind that comes with that because the HPV virus is pretty hard to detect, so it’s hard to know if you have it for a very long time and knowing that you’ve been vaccinated and those HPV related cancers are much less likely to happen further down the road is a good piece of [inaudible 00:05:59].

Nathan Boonstra:

It is and it’s very effective. Well, the HPV vaccine, it covers the strains. If we’re talking again just about cervical cancer, it covers the strains of the virus that cause about, I usually say about 85% of all cervical cancers and nearly all cases of cervical cancer are caused by HPV. And the vaccine is nearly a hundred percent effective against the strains that it covers. So it’s really very good at protecting against the vast majority of HPV types that will cause cervical cancers. So one can be pretty darn reassured if they’re immunized that their risk is much, much lower, even though a person may not necessarily know if and when they have HPV.

Adriana Kotchkoski:

Yeah, I remember getting my vaccine, I think at this point over 10 years ago. I remember, I think it was a sequence of three or is it still the same or how does it work now?

Nathan Boonstra:

It’s a little bit different. First of all, I don’t remember the exact year, but 10 years ago, that might have been when we had the Gardasil that covers four types of the virus. And now we have the one that covers nine. I can’t remember exactly off the top of my head when that one was replaced, but also the guidelines have changed a little bit in that if you get your first dose before the age of 15, you only need two. And if you get your first dose on your 15th birthday or later, you need three. And this has to do with the fact that younger we are, even talking about teens the younger you are, the more your immune system is interested in making a robust immune response when it encounters antigens, when it encounters that stimulation. So if you get those vaccines younger, your antibody response is much better than if you get those vaccines in your late teens.

And so that’s a really good reason, one of several reasons why we give the vaccine at the ages that we do. So we usually give the vaccine at age 11 or 12. Usually that’s because teens are coming in or adolescents are coming in for other shots at that time anyway. We want to make sure that they’re covered well before there’s the chance of exposure to HPV. And as best we can tell, they’re probably getting better efficacy if they get it at those ages instead of waiting until later teen years. So you can give it as young as age nine. And there’s certainly discussion about whether or not it’s better to give the vaccine even earlier. But right now it’s pretty common to give it at age 11 or 12.

Anya Morozov:

You mentioned earlier that there’s a lot of misinformation floating around regarding HPV and the HPV vaccine. So can you talk about what you think the biggest piece of misinformation is or maybe some major misconceptions that you hear about HPV or the HPV vaccine?

Nathan Boonstra:

Sure. So I’ll start off by saying the HPV vaccine is probably the most, if not one of the safest vaccines that we have. And by saying that, I mean it probably has some of the largest amount and most robust safety studies amongst the vaccines, in part because when it came out, it’s a relative, I say relatively in quotes, or I guess I say new in quotes, it’s relatively new vaccine, but it’s been out since 2006. But it’s newer than measles vaccine and pertussis vaccine. All these ones have been around for decades. So when it came out, I think it was predicted that yes, because this has to do with a sexually transmitted disease, HPV can actually be transmitted in some other ways, but it has to do with a sexually transmitted disease, there’s going to be stigma around it. It’s going to be unfairly stigmatized.

And so it was very important to do studies that demonstrated its safety and continue to monitor it and make sure that they are large studies and whatnot. And the studies that have been done to date have all been extremely reassuring. There just have not been significant safety concerns with the HPV vaccine, despite what you’ll read online. When you go to anti-vaccine websites, they are all… I mean, prior to Covid, HPV was the vaccine of choice for anti-vaccine websites. There’s websites that claim that it is associated with everything. Whenever there is a teenager who got the vaccine and then had any health issue, people are trying to exploit that person, trying to put that online, make it seem like anything and everything is associated with HPV vaccine, just like people are trying to make anything and everything associated with Covid vaccine these days.

And so there’s absolutely a lot of just emotional anecdotes that are understandably convincing some parents that the vaccine is more dangerous than it is. And we have to understand to some extent that the way the brains work, emotional stories like that work on us, whether we like it or not. Even if we know facts and science, emotional stories like that, however true they are, whether or not there’s a real association or anything, those stories work on us. And it makes it challenging. Makes it challenging to counsel families because if they read stuff like that, then it seems pretty convincing to them. And having all the studies at my fingertips does not necessarily change somebody’s mind when they’ve seen something or read something like that. But as far as the vaccine itself, it’s extremely safe. It does not increase the likelihood of higher risk sexual behavior. If somebody is vaccinated, it works very well. It is not associated with autoimmune diseases. That’s one thing, myth. It has no impact on fertility. These are some of the myths that have floated around it. It is absolutely a good idea to get your adolescent immunized.

Adriana Kotchkoski:

Speaking to that, but on the other side, do you have any stories of people who have been affected by HPV preventable cancer?

Nathan Boonstra:

Yeah. I actually have a friend who is a survivor of HPV neck cancer, and I’ve gotten to meet so many fantastic people over the years that are advocates for the vaccine because of their experience with HPV associated cancers. A lot of cervical cancer survivors. And I know that Iowa Department of Public Health, if we can find a link to it that you can put in whatever, they have a series of stories of Iowans that were affected by HPV associated cancer and did some very nice videos with them and interviews and such. So I would recommend anybody check those out.

Anya Morozov:

I know what the ones you’re talking about, so.

Nathan Boonstra:

You know we’re talking about, [inaudible 00:12:53] yeah. Yep.

Anya Morozov:

But yeah, and I think the interesting thing about head and neck cancers and a lot of other cancers that aren’t cervical cancer is you can detect HPV in the cervix, but you can’t really detect it anywhere else.

Nathan Boonstra:

There’s at least not a screening process for it that is effective at this point. So in order to screen something, it has to be cost-effective, you have to be able to know what you’re going to do if you detect it, et cetera. And so we don’t really have that for head and neck cancers at this point. You can detect it, but you have to have a reason why you’re testing for it, and it’s not a screening thing, so you’re not going to find it in a lot of people because we’re not checking for it in a lot of people. It’s important to talk about head and neck cancers because as much as we talk about HPV vaccine and as fantastic as it is for cervical cancer, and we often immediately associate it with cervical cancer prevention, and it is that. If we’re only viewing it as cervical cancer prevention, we’re missing the fact that it’s not a small amount of head and neck cancers.

And we talk about why should adolescent boys get it. We talk about how significant that prevention of head and neck cancer is. When we look at all of the HPV associated cancers that are prevented by the vaccine, a third of them are in males. It’s not a little tiny amount, and it’s mostly benefit for other genders that we’re talking about, a third of them in males. So we think it’s very important for all genders in adolescents to get immunized against HPV.

Anya Morozov:

Wow, very true. So as a pediatrician, we know you probably spend a lot of time talking about the HPV vaccine to your patients. How do you think folks outside of the clinic, like public health folks or just anyone listening, can help spread awareness about the value of an HPV vaccine outside of the clinical setting?

Nathan Boonstra:

I think normalizing it is the most important thing. I think any chance you get, whether it’s HPV vaccine or any vaccine to talk about that you got vaccinated or you got your child vaccinated, we know that people make decisions about vaccinating their family, that they are impacted by their social networks. And whether we’re talking about online social networks or their actual IRL social networks, the more positive information and normalization of immunizing that they see around them, the more likely people are to immunize. So you don’t have to be like me who loves to go out and dispel myths and know all the things and know all the myths and how to counter them. That’s something I like to do, but I do not think that most people need to do that. The best thing that people can do is post or talk about positive experiences with vaccination.

If you get somebody who is confronting you about that or telling you things, it’s okay to say, “You know what? I hear you. I can tell why you’re concerned about that. As best I can tell, virtually every expert says that this is a good idea to do. I think you should talk with your own doctor about that.” That’s really all you got to say. You don’t have to get into the nitty-gritty. If you’re just mentioning and normalizing presenting good information, the people who are your friends, they like you for a reason, they look up to you for a reason. That’s an impact. And I think the more that we can do that, the more we improve the culture around immunizations in general.

Adriana Kotchkoski:

I feel a lot of people’s perceptions in general is really related to their social network and what their families say, what their friends say, and what people in their community say. What do you think of the new Education Bills being proposed that want to remove the requirement to teach about acquired immunity deficiency syndrome, HPV, and the HPV vaccine in Iowa schools?

Nathan Boonstra:

Super concerned. So focusing mostly on the HPV aspect of it, it’s super important that teenagers are aware of HPV itself and that they’re aware of the fact that there’s a vaccine that is available to them. Obviously, those medical decisions are always made between that person and their medical care provider, but if a teen does not know that it’s there, that it’s available to them, not every teen’s coming in for well child checks. Not every teen is in a situation where they may be paying attention to that thing in the clinic, just going, because that’s what they’re told to do. But I think it’s super important that they learn about these things that impact them directly in school. We as pediatricians, of course, we’re educating every teenager on HPV vaccination. We’re having those conversations, but we can only do so much in the limited time that we have in a clinic and learning about things like HPV, HIV, vaccines in the context of the science classes that they have or the health classes that they have, that’s valuable.

And so I don’t see any reason why they shouldn’t be learning about these things in school when it impacts them directly. And the reality is that the bill right now in Iowa, or at least prior to the bill, I’m forgetting exactly what the status is right now of the bill, but prior to the bill, it was an Iowa code that they were supposed to learn about HPV and the HPV vaccine. And so really what the bill is doing is it can only go down from there. So it’s not like the bill prohibits the education. Teachers can still choose to, or districts can still choose to, but some are just not going to do that. And that doesn’t make any sense. That can only bring down the level of awareness of a life-saving vaccine.

Anya Morozov:

Yeah, very true. I was looking into it, and it looks like it’s been an Iowa code since the vaccine came out pretty much in I believe, 2007 when I was looking into it.

Nathan Boonstra:

One of the things that makes me sad is having done this for a while and been interested in both vaccination advocacy, but also legislative issues around vaccines, I really feel like there was a time when things like this that were public health issues, really weren’t that partisan. I had the opportunity almost a decade ago to meet with Governor Branstad with some other advocates and mothers of people who passed away from meningitis. And we met with him, and this was when it was being discussed whether or not the meningitis vaccine should be added to the requirement for schools. And he actually said at the time, he said, “There are people in my party who are not going to like this, but I really think this is the right thing to do.” And it was just like this almost West Wing moment like, “Holy cow. People have come together and worked together towards a common good and protect kids and whatnot.” And now it’s sad that things about vaccines are becoming partisan. They really should not be.

Anya Morozov:

Yeah. Yeah. It’s really just about saving lives and improving the health of Iowans, which I agree, should not really be a partisan thing, especially with how much data we have backing up, how important vaccines are and how really helpful they are.

Nathan Boonstra:

Yeah. The thing that is frustrating is this has been a building thing. So I’ve followed the anti-vaccine movement for… I started getting really interested in, I want to say 2009 or such when I started getting interested in online anti-vaccine websites and looking at what they do. And this has been building up. The anti-vaccine movement has been building up connections, allying with different groups, and then this pandemic hits, and it’s all snowballed into what we are seeing today, but it didn’t come out of nowhere. It was with a lot of long-term planning well before the pandemic, and so we’re reaping what was sown then.

Anya Morozov:

To wrap up on a little bit lighter, more educational note, for folks who do want to get themselves or their children vaccinated. I know we talked a little bit about the timing, but can you just give your general spiel about when the best time is to get vaccinated or where people can get more information about the HPV vaccine?

Nathan Boonstra:

Yeah, so as I mentioned, people can get vaccinated starting at age nine. Teens, adolescents, they can get vaccinated if they haven’t started their HPV vaccine series, they can start it at any time. No, there’s not really too late when it comes to teenagers anyway. And really the first place is the office of their healthcare provider. They can give them a call and check on their vaccination status. Parents should check and make sure that their children got their vaccines as well. We have laws in the state of Iowa that allow teenagers to make decisions when it comes to things regarding sexual health, and HPV vaccine falls under that. So it is okay as a teenager to call your doctor and find out if you got the HPV vaccine and have that discussion. So really just anytime people can get immunized. So I would recommend doing that. And oh, I think that answers your question.

Anya Morozov:

I think so.

Adriana Kotchkoski:

Thank you. And just to wrap this up, what was one thing you thought you knew but were later wrong about?

Nathan Boonstra:

Regarding this or just anything?

Adriana Kotchkoski:

Anything.

Nathan Boonstra:

Okay. I should have thought of this in advance. So now I have to take a little time to think because so rarely am I wrong? No. I’m trying to think of a… I’ve been wrong about plenty of things. Trying to think of a really good example. I’ll give you the example of how science evolves over time, because initially as pediatricians, we recommended, when I started practice, we recommended that kids avoid peanuts, peanut products, peanut butter, whatever, until two or later of age because the evidence at the time indicated that delaying it may reduce the risk of peanut allergy. And that changed quite a while ago now. It became evident that actually the reverse is probably true. As newer studies came out, it became evident that with exceptions for certain high risk situations, kids under the age of one should get exposed to peanut protein in some way, whether it’s those little peanut puffs or peanut butter that that actually decreased the risk of peanut allergy if they were regularly exposed to peanuts.

And it’s not because we had it totally wrong or did wrong things, it’s because the evidence that we had that was the best at the time, it changed and we changed with it, like we made new recommendations. That’s true about a lot of the stuff that we do. And that’s true about vaccines as well. The evidence is pretty darn clear that it’s far safer to be immunized than not immunized. It would take a lot of evidence at this point, because it’s not small like what peanut allergy evidence we had two decades ago, right? It’s a huge amount of evidence.

But when new evidence, when new things come to light, we change our minds. We change our policies. We find out that a vaccine is not good for this group of people, we change that policy, but it’s not done on a whim because lives are at stake. If you make a major change or you say don’t immunize or something like that, people will die. So you cannot just suddenly stop a vaccine until the evidence is perfect. Now, the evidence that we have for all the vaccines that we give, it’s extremely, extremely strong. But to think that there is something that keeps us recommending the vaccine or that anybody would recommend the vaccine if it wasn’t in the best interest of the child, it’s just wrong. It’s just not how we work. It’s not how science works.

Anya Morozov:

Well, thank you. I think you really captured the essence of why we asked that question, just to show that we’re making evidence-based decisions based on the best evidence we have at the time, but also continuing to learn as evidence changes. So thank you for that. Thank you for just talking about the HPV vaccine, it’s importance, it’s safety, and yeah, I guess we can wrap up there.

Nathan Boonstra:

No, this is absolutely my pleasure. Thank you.

Anya Morozov:

That’s it for our episode this week. Big thanks to Dr. Nathan Boonstra for joining us today. This episode was hosted and written by Anya Morozov and Adriana Kotchkoski and edited and produced by Anya Morozov. You can learn more about the University of Iowa College of Public Health on Facebook, and our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.