What are the guidelines for Human Papillomavirus (HPV) vaccine administration?

HPV Vaccination Guidelines

Routine Vaccination Schedule

Routine HPV vaccination should be initiated at age 11 or 12 years, with the series starting as early as age 9 years, using a 2-dose schedule for those beginning before age 15 and a 3-dose schedule for those starting at age 15 or older. 1, 2

Age-Based Dosing Schedules

For individuals initiating vaccination before age 15:

• 2-dose schedule is recommended with doses administered at 0 and 6-12 months apart 1, 2
• The minimum acceptable interval between doses is 12 weeks (approximately 3 months) 1
• Longer intervals (closer to 12 months) produce stronger immune responses than shorter intervals 1

For individuals initiating vaccination at age 15 through 26 years:

• 3-dose schedule is required with doses at 0,1-2, and 6 months 1, 3
• Minimum interval between first and second doses is 4 weeks 4, 3
• Minimum interval between second and third doses is 12 weeks 4, 3

The rationale for age-based dosing stems from immunologic data: younger adolescents (ages 9-14) mount stronger antibody responses than older individuals receiving 3 doses, making the 2-dose schedule non-inferior in this age group 1.

Catch-Up Vaccination

Catch-up vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. 4, 1

• Females aged 13-26 years who have not been vaccinated or completed the series should receive vaccination 4
• Males aged 13-21 years who have not been vaccinated or completed the series should receive vaccination 4
• Males aged 22-26 years may be vaccinated based on individual clinical decision-making 4
• Providers should inform individuals aged 22-26 years that vaccination at older ages is less effective in lowering cancer risk 4, 3

Special Populations Requiring 3-Dose Schedule

Immunocompromised individuals require a 3-dose schedule regardless of age at initiation. 1, 3

High-Risk Groups with Specific Recommendations:

HIV-infected individuals:

• HPV vaccination is recommended through age 26, regardless of gender 4
• HIV-positive patients aged ≥26 years may also benefit from vaccination 4

Men who have sex with men (MSM):

• Vaccination is recommended through age 26 4
• MSM aged ≥26 years may benefit from vaccination 4

Solid organ or hematopoietic stem cell transplant recipients:

• Vaccination is recommended in female transplant recipients aged 9-26 years 4
• If possible, vaccination should be provided before transplantation 4
• Vaccination is not recommended within 6 months post-transplantation 4
• Patients undergoing HSCT should be vaccinated 6-12 months after transplantation 4

Patients receiving immunosuppressive or biological treatment:

• Vaccination is recommended in women receiving these treatments through age 26, particularly those with systemic lupus erythematosus or juvenile idiopathic arthritis 4

Vaccine Products and Administration

As of 2017, the 9-valent HPV vaccine (Gardasil-9) is the only HPV vaccine available in the United States. 3

• The vaccine protects against HPV types 6,11,16,18,31,33,45,52, and 58 3, 5
• HPV types 16 and 18 are responsible for approximately 70% of HPV-related cancers 3
• The vaccine is approved for use in females and males aged 9 through 45 years 5

Administration details:

• Dose is 0.5 mL administered intramuscularly, preferably in the deltoid muscle 4
• HPV vaccine can be administered at the same visit as other age-appropriate vaccines using a separate syringe at a different anatomic site 4, 1
• Patients should sit or lie down for 15 minutes after administration due to risk of syncope in adolescents 1, 5

Interrupted Schedules

If the vaccination schedule is interrupted, it does not need to be restarted. 4, 3

• If interrupted after the first dose, the second dose should be administered as soon as possible 4
• The second and third doses should be separated by an interval of at least 12 weeks 4
• If only the third dose is delayed, it should be administered as soon as possible 4

Critical Clinical Caveats

No prevaccination testing is recommended:

• Pap testing and screening for HPV DNA or HPV antibody are not needed before vaccination at any age 4, 3

Vaccination does not eliminate the need for cancer screening:

• Cervical cancer screening recommendations have not changed for vaccinated individuals 4, 1, 5
• Recipients should not discontinue anal cancer screening if previously recommended 5
• HPV vaccines protect against approximately 70% of cervical cancers; screening remains essential 4, 3

Limitations of vaccine protection:

• Vaccination does not protect against HPV types to which a person has already been exposed through sexual activity 4, 3, 5
• Vaccination is most effective when administered before potential exposure to HPV through sexual contact 4, 3
• However, sexually active individuals should still be vaccinated according to age-based recommendations, as they may not have been exposed to all vaccine HPV types 4

Pregnancy considerations:

• Vaccination is not recommended during pregnancy 1
• If a woman becomes pregnant during the vaccination series, subsequent doses should be postponed until after delivery 1
• Breastfeeding women can safely receive the HPV vaccine 1
• A pregnancy registry is available at 1-800-986-8999 5

Contraindications:

• History of immediate hypersensitivity to yeast or any vaccine component 1
• Moderate or severe acute illness (defer vaccination) 1

Vaccine Efficacy Context

The vaccine is highly effective in preventing HPV-related diseases when administered before exposure. 6

• Efficacy is remarkably high among young women who were HPV seronegative before vaccination 6
• Vaccine efficacy is lower among women regardless of HPV DNA status when vaccinated and among adult women 6
• The vaccine provides herd protection in addition to direct protection 6
• Two-dose schedules show no difference in seroconversion compared to three-dose schedules in younger adolescents 6