Is the Human Papillomavirus (HPV) vaccine recommended for a 45-year-old?

HPV Vaccination at Age 45

The HPV vaccine is not routinely recommended for a 45-year-old, and the American Cancer Society explicitly does not endorse vaccination in this age group due to minimal cancer prevention benefit and dramatically reduced effectiveness. 1

Regulatory and Guideline Framework

HPV vaccines are not licensed by the FDA for use in adults over age 45 years, creating an absolute regulatory barrier to vaccination at this age. 1, 2

The Advisory Committee on Immunization Practices (ACIP) framework for HPV vaccination is clear and age-stratified:

• Routine vaccination is recommended at ages 11-12 years (can start at age 9), when the vaccine is most effective 1
• Catch-up vaccination is recommended for all persons through age 26 years who are not adequately vaccinated 1
• For ages 27-45 years, ACIP recommends shared clinical decision-making for some adults, but explicitly does not recommend routine catch-up vaccination for all adults in this age range 1
• No vaccination is approved or recommended for adults over age 45 years 1, 2

Why the American Cancer Society Opposes Vaccination at This Age

The American Cancer Society takes a stronger stance than ACIP, explicitly not endorsing the shared clinical decision-making recommendation for ages 27-45 due to several critical factors 1:

• Minimal cancer prevention potential: Vaccinating adults through age 45 would prevent only an additional 0.5% of cancer cases, 0.4% of cervical precancer cases, and 0.3% of genital warts cases over the next 100 years compared to vaccination through age 26 1, 2
• Dramatically reduced effectiveness: HPV vaccine effectiveness decreases dramatically by age 18 years, with minimal benefit noted by age 20-21 years 1, 2
• Burden of decision-making on patients and clinicians without sufficient guidance on patient selection 1
• The number needed to vaccinate increases from 202 in routine programs to 6,500 when extending to age 45 3, 2

Why Effectiveness Is So Low at Age 45

The biological and epidemiological rationale against vaccination at age 45 is compelling:

• HPV vaccines are prophylactic only—they prevent new infections but do not treat existing infections or HPV-related diseases 1, 3, 2
• Most sexually active adults have already been exposed to multiple HPV types by age 45, limiting the vaccine's protective potential 1, 2
• HPV acquisition generally occurs soon after first sexual activity, with the highest rates of new infections in adolescents and young adults 1, 3
• Most new HPV infections occur in adolescents and young adults, not in middle-aged adults 3

Clinical Approach for a 45-Year-Old

For a 45-year-old patient inquiring about HPV vaccination:

Do not offer the vaccine, as it is not FDA-approved for this age and provides negligible cancer prevention benefit. 1, 2

Instead, focus on evidence-based cancer prevention strategies:

• Ensure appropriate cervical cancer screening (for females) continues according to current guidelines, as screening remains the primary prevention strategy 1, 3, 2
• For males, implement risk-based screening for HPV-related cancers (e.g., anal cancer screening for men who have sex with men) 2
• Counsel that HPV vaccination does not replace screening, as vaccines do not protect against all oncogenic HPV types 3, 4

Common Pitfall to Avoid

Do not confuse the ACIP's "shared clinical decision-making" recommendation for ages 27-45 with a recommendation to vaccinate. This language represents a compromise position that:

• Acknowledges some individuals in this age range might theoretically benefit (e.g., those with new sexual partners) 1, 3
• However, the American Cancer Society explicitly rejected this approach due to concerns it would shift focus from cancer prevention back to sexual behavior discussions and potentially undermine efforts to vaccinate adolescents at the optimal age 1
• At age 45, even this limited recommendation does not apply, as the vaccine is not licensed beyond age 45 1, 2