What are the Human Papillomavirus (HPV) vaccination recommendations by country, including dosage and age guidelines for vaccines such as Gardasil 9 (9-valent human papillomavirus vaccine) and Cervarix (human papillomavirus bivalent vaccine)?

HPV Vaccination Recommendations by Country

The most effective HPV vaccination strategy is routine vaccination at age 11-12 years with catch-up vaccination through age 26 years, as this approach provides the greatest reduction in HPV-related cancer morbidity and mortality across populations. 1

United States Recommendations

Age-Based Recommendations

• Routine vaccination recommended at age 11 or 12 years; can start as early as age 9 years 1
• Catch-up vaccination recommended for all persons through age 26 years who are not adequately vaccinated 1
• Shared clinical decision-making recommended for adults aged 27-45 years; not routinely recommended for all adults in this age group 1
• American Cancer Society (ACS) does not endorse vaccination for adults older than 26 years due to low effectiveness and low cancer prevention potential 1

Dosing Schedule

• 2-dose schedule for individuals initiating vaccination before their 15th birthday (0,6-12 months) 2, 3
• 3-dose schedule for individuals initiating vaccination at age 15 years or older (0,1-2,6 months) 2, 3
• 3-dose schedule for immunocompromised individuals regardless of age 2, 3

Special Populations

• Vaccination recommended through age 26 years for men who have sex with men (MSM) 1
• Vaccination recommended through age 26 years for immunocompromised persons, including those with HIV infection 1
• HPV vaccination should be delayed until after pregnancy 1, 3

Vaccine Type

• 9-valent HPV vaccine (Gardasil 9) is the only HPV vaccine currently available in the US (since 2016), protecting against HPV types 6,11,16,18,31,33,45,52, and 58 2, 4

Spain Recommendations

High-Risk Populations

• Vaccination recommended for specific high-risk groups including: 1
  • HIV-infected patients
  • Men who have sex with men (MSM)
  • Inflammatory bowel disease patients
  • Women with precancerous cervical lesions
  • Patients with congenital bone marrow failure syndrome or primary immunodeficiency
  • Survivors of childhood neoplasia
  • Solid organ or hematopoietic stem cell transplant recipients
  • Patients on immunosuppressive or biological treatment
  • Patients with recurrent respiratory papillomatosis

Australia and Canada

Special Populations

• Australia recommends vaccination for MSM and immunocompromised individuals 1
• Canada recommends vaccination for individuals with abnormal cervical cytology or history of cervical cancer and/or genital warts, MSM, and immunocompromised individuals 1

Effectiveness Considerations

Age-Related Effectiveness

• HPV vaccination is most effective when given before exposure to HPV through sexual activity 1, 3
• Vaccine effectiveness decreases with age due to prior HPV exposure 1, 5
• The number needed to vaccinate (NNV) to prevent one case of cancer increases dramatically with age: 202 for current program vs. 6,500 for extending to age 45 years 1, 3

Clinical Impact

• Since vaccine introduction, significant decreases in 4vHPV-type prevalence have occurred among females aged 14-19 years (88%) and 20-24 years (81%) 6
• Significant declines among unvaccinated females suggest herd effects 6, 7
• HPV vaccination does not change cervical cancer screening recommendations 1, 3

Important Clinical Considerations

Vaccine Selection

• 9-valent HPV vaccine contains HPV 6,11,16,18,31,33,45,52, and 58 VLPs 4, 8
• HPV types 16 and 18 are responsible for approximately 70% of HPV-related cancers 2, 8
• The additional types in 9vHPV (31,33,45,52, and 58) provide broader protection against HPV-related diseases 8, 9

Practical Implementation

• No prevaccination testing (e.g., Pap or HPV testing) is recommended before vaccination 1, 3
• If vaccination schedule is interrupted, it does not need to be restarted 2
• All women, regardless of vaccination status, should continue to follow cervical cancer screening guidelines 1, 2

Shared Decision-Making for Adults 27-45 Years

• New sex partners at any age increase risk for acquiring new HPV infections 1, 3
• Persons in long-term, mutually monogamous relationships are not likely to acquire new HPV infections 1, 3
• Most sexually active adults have already been exposed to some HPV types 1, 3
• HPV vaccines are prophylactic and do not treat existing infections or diseases 3, 9