Adult HPV Vaccine Age, Guidelines

The HPV vaccine is having a significant effect of decreasing cervical cancer.  More recently HPV is associated with oral cancer and anal cancer.

HPV goes through latex And many of  other sexually transmitted diseases do not.  Many adults don’t know that the “safe sex” procedures they use may not work with HPV.

This recent review of this CDC information says that the vaccine has a low side effect rate in adults.  The CDC data is established up to age 26.  The CDC cannot recommend the vaccines for older adults.  Adults older than 26 years who are sexually active should examine this data and balance that with their HPV risks.

 Gardasil 9 has the broadest range of efficacy.  The Prevents infection by 9 different types of HPV virus.  These 9 types account for 90% of cervical cancers.”                                                                  Bill Chesnut M.D.

Return to New Health News, http://billchesnutmd.com/new-health-news/

  • ·         Why Adults Should Get the HPV Vaccine
  • ·         When Should Adults Get the HPV Vaccine?
  • ·         Are There Any Adults Who Should Not Receive the HPV Vaccine?
  • ·         What Are the HPV Vaccine Ingredients?
  • ·         What Are the Risks and Side Effects of the HPV Vaccine?
    Human papillomavirus (HPV) is the virus that causes cervical cancer in women and genital warts in men and women. The HPV vaccine effectively prevents infection with the HPV types responsible for most cervical cancers and can also prevent genital warts. HPV vaccination is most effective during childhood or adolescence, but adults can also benefit from the HPV vaccine.

Why Adults Should Get the HPV Vaccine

HPV infection is extremely common; most sexually active people will be infected with HPV at some point in life. HPV infection usually causes no symptoms, but can cause genital warts and anal cancer in both women and men. HPV can also cause throat cancer.

In women, HPV infection can cause cells in the cervix to grow abnormally. In a small fraction of women, these HPV-induced changes will develop into cervical cancer. About 12,000 women are diagnosed with cervical cancer each year and about 4,000 women die from the condition.

The HPV vaccine prevents infection by the HPV types responsible for most cervical cancers. There are three available forms of the HPV vaccine:

Cervarix: Prevents infection by HPV-16 and HPV-18. These two HPV types cause 70% of all cervical cancers. It is used for the prevention of cervical cancer and precancers.
Gardasil: Prevents infection by HPV-16, HPV-18, and also HPV-6 and HPV-11, the two HPV types that cause 90% of genital warts. It is used to prevent cancers and precancers of the cervix, vulva, vagina, anus, penis, and throat.
Gardasil 9: Prevents infection by the same HPV types as Gardasil, plus HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58. Collectively, these types are implicated in 90% of cervical cancers.
All HPV vaccines are extremely effective at preventing infection by the HPV types they cover. Getting the HPV vaccine reduces a woman’s risk of cervical cancer and precancerous growths substantially. Men cannot develop cervical cancer, but the HPV vaccine may prevent genital warts, anal cancer, and the spread of HPV to sexual partners. Gardasiland, Gardasil 9 are approved for males ages 9 through 26.

The HPV vaccine does not treat or cure an HPV infection in women or men who are already infected by one of these HPV types.

When Should Adults Get the HPV Vaccine?

The CDC recommends that all women ages 26 years and younger receive three doses of the HPV vaccine. The CDC recommends that all men ages 21 years and younger receive three doses of the HPV vaccine. It is an option for all men, but is recommended for men who have sex with men or who have a compromised immune system (including HIV) who are ages 26 and younger.

CDC guidelines recommend the three doses of the HPV vaccine should be given as follows:

First dose: ideally at ages 11 or 12
Second dose: one to two months after the first dose
Third dose: six months after the first dose
Some adults may have received doses of the HPV vaccine in childhood or adolescence. All three doses should be given to get the most protection from HPV infection. Re-vaccination in adulthood is recommended if the vaccination schedule was not completed.

Are There Any Adults Who Should Not Receive the HPV Vaccine?

Certain people should not get the HPV vaccine or should wait before getting it:

Anyone who has had a life-threatening allergic reaction to a previous dose of the HPV vaccine
Anyone who has had a previous life-threatening allergic reaction to an ingredient in the HPV vaccine
Pregnant women
Anyone with a moderate or severe illness; people who feel mildly ill may still receive the HPV vaccine.
The HPV vaccine is not known to be harmful to pregnant women or their babies. However, until more information is known, pregnant women are advised not to receive the HPV vaccine. Women who are breastfeeding can safely receive the HPV vaccine.

The HPV vaccine’s safety and effectiveness have not yet been studied in adults older than age 26. Until that information is available, the HPV vaccine is not recommended for adults older than age 26.

What Are the HPV Vaccine Ingredients?

The HPV vaccine contains no viruses and is not made from human papillomavirus. The active ingredients in the HPV vaccine are proteins that are similar to those found in the human papillomavirus. Genetically modified bacteria produce the proteins, which are then purified and mixed into a sterile, water-based solution.

What Are the Risks and Side Effects of the HPV Vaccine?

In clinical trials and in real-world use, the HPV vaccine appears to be very safe. More than 40 million doses of the vaccine — mostly Gardasil, which was approved in 2006 — have been given in the U.S. Cervarix was approved in 2009 and Gardasil 9 was approved in 2014.

From 2006 to 2014, there were about 25,000 reports to the government of HPV vaccine side effects. Over 90% of these were classified as nonserious. The most common side effects of the HPV vaccine are minor:

About one in 10 people will have a mild fever after the injection.
About one person in 30 will get itching at the injection site.
About one in 60 people will experience a moderate fever.
These symptoms go away quickly without treatment. Other mild-to-moderate side effects resulting from the HPV vaccine include:

Nausea
Fainting
Headache
Arm pain

Severe side effects, or adverse events, are uncommonly reported and have included:

Blood clots
Seizures
Guillain-Barre syndrome
Chronic inflammatory demyelinating polyneuropathy
Systemic exertion intolerance disease (formerly called chronic fatigue syndrome)
Death
Government, academic, and other public health investigators could not identify the HPV vaccine as the cause of any severe adverse event. There were 117 deaths as of September 2015, none of which could be directly tied to the HPV vaccine. The conclusion of public health investigators was that the HPV vaccine was unlikely to be the cause of these events. Such events occur at a certain rate in any group of tens of millions of people. The vaccination before each adverse event seemed to be a simple coincidence.

 

HPV infections falling among young women

“Great news here that needs to be widely disseminated in my view. We should encourage the use of the HPV vaccine in children 11-12 years of age. This post is from AMA News and links to the original article. I  posted the original article abstract below for your information. As parents, it is easy to forget this information. Secondly it may be difficult to explain to the child it a necessity to prevent cancers in young adults. Important.” Bill Chesnut, MD

 HPV infections falling among young women, study shows

USA Today (2/22, Painter) reports a study published in Pediatrics suggests that “thanks to a vaccination program that began a decade ago, fewer U.S. women are entering adulthood infected with” HPV. This study “is the first to show falling levels of dangerous strains of the” virus “among women in their early 20s.”

The Pittsburgh Post-Gazette (2/22, Sostek) reports that the study found “girls between 14 and 19 years old saw infection rates on the four types of HPV covered by the Gardasil vaccine fall 64 percent from the rate prior to the vaccine’s introduction — from 11.5 percent in 2003-2006 to 4.3 percent between 2009 and 2012.” Meanwhile, “in women ages 20 to 24, prevalence of the infection declined 34 percent in those years, from 18.5 percent to 12.1 percent.”

Pediatrics ___________________________________

March 2016

Prevalence of HPV After Introduction of the Vaccination Program in the United States

Lauri E. Markowitz, Gui Liu, Susan Hariri, Martin Steinau, Eileen F. Dunne, Elizabeth R. Unger

BACKGROUND: Since mid-2006, human papillomavirus (HPV) vaccination has been recommended for females aged 11 to 12 years and through 26 years if not previously vaccinated.

METHODS: HPV DNA prevalence was analyzed in cervicovaginal specimens from females aged 14 to 34 years in NHANES in the prevaccine era (2003–2006) and 4 years of the vaccine era (2009–2012) according to age group. Prevalence of quadrivalent HPV vaccine (4vHPV) types (HPV-6, -11, -16, and -18) and other HPV type categories were compared between eras. Prevalence among sexually active females aged 14 to 24 years was also analyzed according to vaccination history.

RESULTS: Between the prevacccine and vaccine eras, 4vHPV type prevalence declined from 11.5% to 4.3% (adjusted prevalence ratio [aPR]: 0.36 [95% confidence interval (CI): 0.21–0.61]) among females aged 14 to 19 years and from 18.5% to 12.1% (aPR: 0.66 [95% CI: 0.47–0.93]) among females aged 20 to 24 years. There was no decrease in 4vHPV type prevalence in older age groups. Within the vaccine era, among sexually active females aged 14 to 24 years, 4vHPV type prevalence was lower in vaccinated (≥1 dose) compared with unvaccinated females: 2.1% vs 16.9% (aPR: 0.11 [95% CI: 0.05–0.24]). There were no statistically significant changes in other HPV type categories that indicate cross-protection.

CONCLUSIONS: Within 6 years of vaccine introduction, there was a 64% decrease in 4vHPV type prevalence among females aged 14 to 19 years and a 34% decrease among those aged 20 to 24 years. This finding extends previous observations of population impact in the United States and demonstrates the first national evidence of impact among females in their 20s.

  • Accepted October 30, 2015.

 

Study finds physicians may be hesitant to recommend HPV vaccine for young adults

“This is so important to protect our youth. Do everything you can.” Bill Chesnut, MD.

Study finds physicians may be hesitant to recommend HPV vaccine for young adults

NPR (10/23) reports in its “Shots” blog that vaccination rates for human papillomavirus (HPV) “have remained far lower than rates for other routine childhood and teen immunizations.” A study found the reason for the low rates may be that primary care physicians “treat the HPV vaccine differently from other routinely recommended immunizations, hesitating to recommend it fully and on time and approaching their discussions with parents differently. In the actual NPR newsletter the title is Doctors, Not Parents, Are The Biggest Obstacle To The HPV Vaccine.

“The single biggest barrier to increasing HPV vaccination is not receiving a health care provider’s recommendation,” said lead study author Melissa Gilkey, an assistant professor of population medicine at Harvard Medical School. That’s more of an issue, she says, than parents’ decisions to refuse or delay HPV vaccination.

“Discomfort talking about sex appears to be a more salient factor” than safety concerns about the vaccine.

Nearly all cervical cancers result from HPV infections, which can also cause vaginal, vulvar, anal, penile or head and neck cancers. Although most strains of HPV infections go away on their own, a three-dose series of the vaccine protects against the strains responsible for an estimated 90 percent of HPV-related cancers.

The Centers for Disease Control and Prevention recommends it for all girls and boys ages 11 and 12 because it’s most effective prior to first engaging in sexual activity.”

Read the entire report here: http://www.npr.org/sections/health-shots/2015/10/22/450827102/doctors-not-parents-are-the-biggest-obstacle-to-the-hpv-vaccine

 

 

Ultimate cause of Alzheimer’s may be fungal, cadaver study suggests

“This new finding is remarkable in many ways. Has anyone heard about this work in the media? Pub Med includes a 2014 article in J. Alzheimers Disease of fungus  in Alzheimer’s brains. The abstract says:

To our knowledge, these findings represent the first evidence that fungal infection is detectable in brain samples from Alzheimer’s disease patients. The possibility that this may represent a risk factor or may contribute to the etiological cause of Alzheimer’s disease is discussed.  http://www.ncbi.nlm.nih.gov/pubmed/24614898

A Google review today finds the study in GIZMODO October 26, 2015.  http://gizmodo.com/new-study-suggests-alzheimers-is-associated-with-brain-1738788855

Clearly this is astoundingly good news by opening a possible treatment for Alzheimer’s. I am eager to follow this topic.” Bill Chesnut, MD

 Ultimate cause of Alzheimer’s may be fungal, cadaver study suggests

 The Economist (10/23) reports that a study published online Oct. 15 in the journal Scientific Reports suggests that “the ultimate cause of Alzheimer’s is fungal.” Researchers arrived at this conclusion after examining “brain tissue from 25 cadavers, 14 of which belonged to people who had had Alzheimer’s disease when alive.” The study authors now “think a clinical trial of anti-fungal drugs is the next logical step.

From the abstract of the study: The possibility that Alzheimer’s disease (AD) has a microbial aetiology has been proposed by several researchers. Here, we provide evidence that tissue from the central nervous system (CNS) of AD patients contain fungal cells and hyphae. Fungal material can be detected both intra- and extracellularly using specific antibodies against several fungi. Different brain regions including external frontal cortex, cerebellar hemisphere, entorhinal cortex/hippocampus and choroid plexus contain fungal material, which is absent in brain tissue from control individuals. Analysis of brain sections from ten additional AD patients reveals that all are infected with fungi. Fungal infection is also observed in blood vessels, which may explain the vascular pathology frequently detected in AD patients. Sequencing of fungal DNA extracted from frozen CNS samples identifies several fungal species. Collectively, our findings provide compelling evidence for the existence of fungal infection in the CNS from AD patients, but not in control individuals.

Pisa, D. et al. Different Brain Regions are Infected with Fungi in Alzheimer’s Disease. Sci. Rep. 5, 15015; doi: 10.1038/srep15015 (2015).

 

Have you touched an electronic screen recently?

“Cleaning surfaces used by others is worth talking about every day. We know about public telephone and TV remote controls in hotel rooms. Public bathroom door handles are considered a possible culprit by most of us.  It is easy to overlook computer touch screens. These are becoming more important because they are omnipresent in modern urban living. When getting your boarding pass, you may touch the kiosk at the airline check in. Here is advice from the Cleveland Clinic Wellness newsletter.” Bill Chesnut, MD

Have you touched an electronic screen recently? Wash your hands to prevent the spread of germs and stay healthy! 

You knew that communal keyboards were germy — well, that iPad in your doctor’s office or grandchild’s classroom may be just as bad. Researchers have found that shared computer keyboards (such as an airport check-in kiosk), ATM machines, and other public touch screens are all pretty icky when it comes to germs (think methicillin-resistant Staphylococcus aureus, aka MRSA). Companies are at work developing antimicrobial touch screens to help minimize this problem, and you can always wipe things down with rubbing alcohol to kill bacteria, but this is a reminder that there’s no substitute for regular, thorough hand washing. 

The Centers for Disease Control and Prevention recommend washing hands vigorously for at least 20 seconds at these times to prevent the spread of illness:

  • Before, during and after preparing food
  • Before eating food
  • Before and after caring for someone who is sick
  • Before and after treating a cut or wound
  • After using the toilet
  • After changing diapers or cleaning up a child who has used the toilet
  • After blowing your nose, coughing or sneezing
  • After touching animals, animal feed or animal waste
  • After touching garbage

And we’d add to that list: After using a communal keyboard or touch screen. 

Keeping a small bottle of hand sanitizer (containing at least 60% alcohol) in your pocket for personal use is a great way to be ready for anything and fend off illness at the same time. 

http://www.clevelandclinicwellness.com/DailyDose/archive/2014/01/08/Daily-Wellness-Tip-01-08-14.aspx?utm_source=EmailMarketing&utm_medium=email&utm_campaign=DailyTip&CS_003=3699740

FDA approves new hepatitis C medication

Zepatier, a new hep C treatment is $54,000. For a 12-week treatment course. The Associated Press reports that the approval is “good news for patients because the growing competition should crimp the sky-high prices for hepatitis C drugs!” Bill Chesnut, MD

 FDA approves new hepatitis C medication

The Wall Street Journal (1/28, Loftus, Subscription Publication) reports that the Food and Drug Administration has approved Merck & Co.’s Zepatier (elbasvir and grazoprevir), a once-daily, single-tablet combination therapy for hepatitis C. The drug is approved for patients with the most common type of hepatitis C in the US, genotype 1, as well as genotype 4. Zepatier has a list price of $54,000 for a 12-week course of treatment.

The AP (1/29, Johnson) reports that the approval is “good news for patients, because the growing competition should crimp the sky-high prices for hepatitis C drugs, and the additional option means there’s one that will work for nearly every subgroup of people with hepatitis C.”

AMA Wire newsletter January, 2016.

CDC urges people at high risk of HIV infection to use PrEP

“This is a wonderful medical advance. I hope Truvada can be disseminated throughout the poorest countries who are most ravaged by HIV.” Bill Chesnut, MD

CDC urges people at high risk of HIV infection to use PrEP

The Washington Post (11/25, Cha) reports that the Centers for Disease Control and Prevention is making a “big push” to get more people at “substantial” risk of getting HIV to start on pre-exposure prophylaxis (PrEP). The therapy “involves taking a daily pill – Truvada [tenofovir/emtricitabine] – that makes it more difficult for the virus to establish a permanent infection when a person is exposed to” the virus “through sexual contact or injectable drug use.” Research has shown that the therapy can reduce risk of infection “by 70 to more than 90 percent.”

USA Today (11/24, Szabo) reports that a national survey not yet published shows that though the “Food and Drug Administration approved Truvada in 2012, one-third of primary care doctors have never heard of PrEP.” The drug, manufactured by Gilead Sciences Inc., “costs about $10,000 a year, according to the CDC.” However, according to Carlos del Rio, co-director of the Emory Center for AIDS Research in Atlanta, many insurance plans cover the drug and those who are uninsured can get Truvada for free through Gilead’s patient assistance program.

Vox (11/24, Lopez) says the CDC report suggests PrEP is crucial for individuals who engage in risky behavior, such “sex with an HIV-positive partner, sex with multiple partners, anal sex without a condom, and sharing needles to inject drugs.”

 

New blood test may help determine if a patient with a respiratory illness is suffering from a virus or bacterial infection

This is a pivot of research investigation in the effort to see if a respiratory illness is viral and will not respond to antibiotics, versus bacterial and needing antibiotics. “The test…flips bacteria and virus testing on its head.” Rather than “searching for hallmark signs of specific bugs, it scans the infected person’s genetic reaction to the microbe.” Bill Chesnut, MD

New blood test may help determine if a patient with a respiratory illness is suffering from a virus or bacterial infection

CBS News (1/20, Marcus) reports that “a new blood test is in the works that could help” physicians determine whether “a patient with a respiratory illness is suffering from a virus or a bacterial infection, or even a non-infectious condition with similar symptoms.” This “test could help cut back on the serious problem of antibiotic overuse, say the” researchers “who developed it.”

TIME (1/20, Park) reports that “the test…flips bacteria and virus testing on its head.” Rather than “searching for hallmark signs of specific bugs, it scans the infected person’s genetic reaction to the microbe.” The test “takes advantage of the fact that our bodies react differently to bacteria and viruses by activating different genes that are part of the immune system.” Research on the test was published in Science Translational Medicine.

HealthDay (1/20, Dotinga) reports that the researchers “tried the test out on 273 people with respiratory infections and 44 healthy people.” Altogether, “the test was accurate 87 percent of the time in distinguishing between bacterial and viral infections, and infections caused by something else.”

AMA Morning Rounds 1.21.16

Severe influenza may double the risk of developing Parkinson’s disease

“The Cleveland Clinic Wellness newsletter wrote this post about an article in Motion Disorders. I include this for your interest because Parkinson’s Disease is complicated. Research of exceptional breadth and depth is being done in the US to try to find causes so better treatments can be fashioned. This effort is a reason to be proud of US medical research. If PD is your interest, please read this statement from the National Institutes of Health dated November 2015. http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_research.htm#pathology

Among known associations is that a high Vitamin D blood level is associated with lower incidence of PD. “In some cases, environmental factors may also have a protective effect. Population-based studies have suggested, for example, that people with high levels of vitamin D in their blood have a much lower risk of developing PD compared with people with very low concentrations of vitamin D. Further research is need to determine if vitamin D deficiency puts people at higher risk for PD, but such findings suggest the possibility that vitamin D supplements may have a beneficial effect. However, there may be genetic factors that cause people with low vitamin D levels to have higher rates of PD in which case vitamin D supplements would not be helpful.”

The NIH has worded this so the public won’t take Vitamin D supplements only to lower the risk of PD. However low Vitamin D, i.e.,hypovitaminosis D, is common in my practice experience. Low vitamin D is easy and inexpensive to treat. Get your Vit D blood level done at least once to be sure you’re in the middle of the normal range, about 50 ng/DL. Bill Chesnut, MD

____________________________________________

Here’s another reason to get your annual flu shot: Severe influenza may double the risk of developing Parkinson’s disease later in life.

Getting your annual flu shot is always a good idea, but new research finds a particularly convincing reason to inoculate yourself against the virus. According to a study published in the journal Movement Disorders, people who contract a severe case of the flu may double their risk of developing Parkinson’s disease later in life. Parkinson’s is an incurable nervous system disorder that causes shaking, stiffness and, in later stages, loss of balance. Cases of the flu are considered severe when there are complications involved or when they require medical treatment, especially hospitalization. Most people get better on their own within a week or two. While anyone at any age can suffer serious flu complications, those at greatest risk include: people over the age of 50, children between 6 months and 2 years, women who are more than 3 months pregnant during flu season, anyone living in a long-term care facility, and anyone with chronic heart, lung or kidney conditions, diabetes, or a weakened immune system.

Drop in hospital-acquired conditions prevented 87,000 deaths

The AMA newsletter published the mortality effects of the decrease in hospital complications in just 48 months.” Bill Chesnut, MD

Drop in hospital-acquired conditions prevented 87,000 deaths, report shows

USA Today (12/2, O’Donnell) reports that infections and other conditions “caused by hospitals dropped 17% from 2010 to 2014, which prevented 87,000 deaths and saved $20 billion in health care costs, federal health officials said Tuesday.” The hospital-acquired conditions detailed in the report from the Agency for Healthcare Research and Quality include “adverse drug events, catheter-associated urinary tract infections, central line-associated bloodstream infections, pressure ulcers, and surgical site infections.”

The Washington Post (12/2, Sun) says a “number of public and private health-care initiatives have been put in place in the past four years that reward or penalize hospitals based on how they perform on a variety of patient quality and safety measures.”

The Huffington Post (12/2, Cohn) reports that for every 1,000 patients “admitted to and then discharged from a hospital, the agency found, roughly 121 of them developed such a condition.”

Kaiser Health News (12/2, Rau) reports Dr. Richard Kronick, director of the AHRQ, said, “We are still trying to understand all the factors involved, but I think the improvements we saw from 2010 to 2013 were very likely the low-hanging fruit, the easy problems to solve

 

Scratchy throat? Try these easy, at-home soothers

“These work. The gargle is quick and feels good. Honey and lemon tea are hard to beat.” Bill Chesnut, MD

Cleveland Clinic Newsletter, December 3, 2015
Scratchy throat? Try these easy, at-home soothers.
Whether your throat is scratchy due to dry air or because you’re fighting off a cold, here are four of our favorite things you can do to ease the discomfort:

  1. Gargle with a salt-water solution to reduce inflammation, loosen mucus, and flush out irritants that contribute to a sore throat. To make a salt-water gargle, dissolve half a teaspoon of salt in a cup of warm water and gargle a mouthful of the solution for 30 to 60 seconds, three times a day. Spit it out, don’t swallow it.
  2. Sip honey and lemon tea. Mix one tablespoon of honey with a squeeze of lemon juice and some warm water. Sip away.
  3. Try a neti-pot with a salt water nasal rinse morning and night or, if that fails, try a corticosteroid nasal spray, available over the counter without a prescription. Nasal sprays — both salt water alone, and corticosteroid — reduce postnasal drip, which can contribute to a sore throat.
  4. Run a vaporizer in your bedroom through the night. Breathing either warm or cool mist, especially while you sleep, will reduce swelling in air passages, improve mucus membrane function, and soothe an irritated throat.

If your sore throat lasts for more than a week, or if it’s difficult to swallow, see your doctor to rule out a more serious condition.

 

Common Cold Virus and Sleep.

“People who get less than seven hours of sleep a night are three times as likely to get sick after being exposed to a cold virus as people who snooze for eight hours or more. Three times!! That is worth turning off the screens and turning in earlier.Bill Chesnut, MD

Feeling run-down? Don’t sacrifice sleep. Getting less shut-eye is linked to a lower resistance to colds.   by Cleveland Clinic Wellness Editors

The sun is shining, the weather is perfect and you’re feeling miserable. Though we usually associate colds with the winter, you can come in contact with one of the 200 viruses that cause the common cold year-round. One place where you’re likely to be exposed: long-haul flights. The more people on the plane and the more time you spend in their presence, the greater your risk of infection. According to research in the Archives of Internal Medicine, you can reduce your risk of illness by getting enough shut-eye. People who get less than seven hours of sleep a night are three times as likely to get sick after being exposed to a cold virus as people who snooze for eight hours or more. If they slept poorly, they were five times as likely to get sick. According to the researchers, a good goal to aim for is between seven and eight hours each night.