Disease- and Population-specific Immunizations

Human Papillomavirus Vaccine (HPV)

Despite overwhelming evidence of the safety and effectiveness of the human papillomavirus (HPV) vaccine, vaccination rates remain low. The American Academy of Family Physicians (AAFP) urges physicians to strongly recommend the HPV vaccine to their patients.

What you say, and how you say it, matters

Physicians give consistent, strong recommendations for the HPV vaccine. A physician’s recommendation is the single best predictor of vaccination. It is recommended that physicians “bundle,” and not single out the HPV vaccine in discussions with patients on the importance of receiving vaccinations. The bundling approach has been shown to normalize and increase acceptance of the HPV vaccine, and demonstrate the importance of the HPV vaccine. The current HPV immunization schedule is provider and patient friendly, and is consistent with adolescent well visits. More talking points can be found on the CDC website(www.cdc.gov).

Prevention of HPV-associated Disease by Vaccination

The currently available HPV vaccine is the 9-valent human papillomavirus (9vHPV) vaccine. This vaccine protects against the most common HPV types, which cause 90% of cervical, vaginal, vulvar, anal, and penile cancers. Additionally, this vaccine prevents HPV types that cause genital warts in both males and females.

ACIP and AAFP Recommendations

9vHPV Vaccine

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HPV Type16, 18, 6, 11, 31, 33, 45, 52, 58
Recommended Ages11 through 12
    Female  Age 9 through 26
    Male
Age 9 through 21
    MSM/Immunocompromised  Through Age 26

The 9vHPV vaccine is routinely recommended for both males and females, routinely given at age 11 or 12. Specifically, the 9vHPV vaccine is recommended from ages 9 through 26 for females and ages 9 through 21 for males. The 9vHPV vaccine is also recommended for high-risk males ages 22 through 26 years. High risk in this context is defined as men who have sex with men or men with immunocompromising conditions including HIV infection. Non-high-risk males ages 22 through 26 may also be vaccinated.

The 9vHPV vaccine is a two-dose series if the first dose is given prior to the 15th birthday. The second dose should be 6 through 12 months after the first dose (0, 6-12 month schedule). If the second dose in the two-dose series is given at least five months after the first dose, the series is considered complete.

If the first dose is given on or after the 15th birthday, two additional doses should be administered to complete the series (0, 1-2 months, and 6 months).

A three-dose series is recommended for persons who have 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.

Patients who began a series with 4vHPV may complete the series with 9vHPV. Repeat vaccination with 9vHPV is not recommended in patients who have completed three-dose courses of 2vHPV or 4vHPV vaccines.

Special Populations

It is recommended by the Advisory Committee on Immunization Practices (ACIP) and the AAFP that children with a history of sexual abuse or assault get routine HPV vaccination beginning at age 9.

Men who have sex with men are recommended to get routine HPV vaccination through age 26 for those who were not adequately vac­cinated previously.

ACIP and AAFP recommend that transgender persons get routine HPV vaccination through age 26 for those who were not adequately vaccinated previously.

Safety of HPV Vaccines

More than 205 million doses of the HPV vaccine have been distributed worldwide and nearly 90 million doses of HPV vaccines have been distributed in the United States from June 2006 through March 2016. More than 10 years of post-licensure vaccine monitoring in the U.S. provide evidence of the safety of 4vHPV. Data available from post-licensee monitoring in other countries for 2vHPV and 4vHPV provide additional evidence of the safety of these vaccines. Gardasil 9 (a 9-valent HPV vaccine) was studied in more than 15,000 females and males. These clinical trials showed HPV vaccines to be safe and effective. Each vaccine continues to be monitored for any safety problems. Syncope can occur among adolescents who receive any vaccine, including the HPV vaccines. The ACIP recommends that clinicians consider observing patients for 15 minutes after vaccination.

Efficacy of HPV Vaccines

Among women who have not been previously infected with a targeted HPV type, 2vHPV, and 4vHPV have over 95% efficacy in preventing cervical pre-cancers caused by HPV16 and HPV18.

In males, 4vHPV demonstrated 90% efficacy in preventing genital warts, and 75% efficacy in preventing anal pre- cancers in men caused by HPV16 and HPV18.

The 9vHPV was compared to the 4vHPV. Few cases of disease caused by HPV types 6, 11, 16, and 18 were seen in either group. The immunogenicity of HPV 9 was comparable to HPV4, which inferred efficacy for HPV types 6, 11, 16, and 18. In subjects who were not infected at the start of the study and received all three doses (per protocol), efficacy for prevention of genital pre-cancers caused by the five additional HPV types covered in HPV 9 was 96.7%.


Sources

Ylitalo KR, Lee H, Mehta NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US National Immunization Survey. Am J Public Health. 2013;103(1):164-169.

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. 2015;64(11):300-304.

 

 

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