Disease- and Population-specific Immunizations

Human Papillomavirus Vaccine (HPV)

Despite the 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

Data suggest that physicians are not giving strong recommendations for HPV vaccine. Yet, a physician’s recommendation is the single best predictor of vaccination.

Prevention of HPV-associated Disease by Vaccination

 Currently, three vaccines are available: bivalent (2vHPV), quadrivalent (4vHPV) and 9-valent (9vHPV). All three vaccines protect against HPV types 16 and 18, which cause close to 70% of cervical cancers, as well as some anogenital and oropharyngeal cancers.

 Both 4vHPV and 9vHPV vaccines also provide protection against HPV types 6 and 11, which cause 90% of genital warts and most cases of recurrent respiratory papillomatosis. These two vaccines are licensed for males, as well as females. Finally, 9vHPV offers protection against five additional, cancer-causing HPV types.

The Advisory Committee on Immunizations Practices (ACIP) recommends:

Vaccination with any of the three vaccines for routine vaccination of females aged 11 or 12 years and females through age 26 years who have not been vaccinated previously or who have not completed the 3-dose series.
 Vaccination with 4vHPV or 9vHPV in males aged 11 or 12 years or males through age 21 years who have not been vaccinated previously or who have not completed the 3-dose series.
 Vaccination with 4vHPV or 9vHPV for men who have sex with men and immunocompromised persons (including those with HIV infection) through age 26 years if not vaccinated previously.
 HPV vaccination can begin at age 9 for either gender.

AAFP & ACIP Recommendations


2vHPV Vaccine


HPV Type
16, 18

Females
Age 11-12
Range 9 through 26 years


4vHPV Vaccine


HPV Type
16, 18, 6, 11

Females
Age 11-12
Range 9 through 26 years

Males
Age 11-12
Range 9 through 21 years

MSM/Immunocompromised
Through age 26


9vHPV Vaccine


HPV Type
16, 18, 6, 11, 31, 33, 45, 52, 58

Females
Age 11-12
Range 9 through 26 years

Males
Age 11-12
Range 9 through 21 years

MSM/Immunocompromised
Through age 26


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

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Safety of HPV Vaccines

More than 175 million doses of HPV vaccine have been distributed worldwide and 57 million have been distributed in the United States.

More than nine 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.

Safety of 9vHPV was evaluated in approximately 15,000 subjects and the vaccine was well tolerated, with the exception of more injection-site swelling and tenderness compared to 4vHPV.

Syncope can occur among adolescents who revive any vaccines, including the HPV vaccines.  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 precancers caused by HPV16 and HPV18.

In males, 4vHPV demonstrated 90% efficacy in preventing genital warts and 75% efficacy in preventing anal precancers 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 precancers caused by the five additional HPV types covered in HPV 9 was 96.7%.

The additional five serotypes in 9vHPV account for a higher proportion of HPV-associated cancers in females compared with males, so females are more likely to receive direct protective benefit from 9vHPV than males.


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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