What are the recommendations for administering the Human Papillomavirus (HPV) vaccine, including dosage and schedule, to adolescents and young adults?

HPV Vaccine Recommendations

Routine HPV vaccination should be administered at age 11-12 years using a 2-dose schedule (0 and 6-12 months), with catch-up vaccination recommended for all persons through age 26 years who are not adequately vaccinated. 1

Age-Based Dosing Schedules

Children and Young Adolescents (Ages 9-14)

• 2-dose schedule is recommended when vaccination is initiated before the 15th birthday 1
• Doses administered at 0 and 6-12 months apart 1
• The minimum acceptable interval between doses is 12 weeks, though longer intervals (closer to 12 months) produce stronger immune responses 1
• Vaccination can begin as early as age 9 years 1
• Younger adolescents mount significantly stronger antibody responses than older individuals, with geometric mean titers 1.89-3.35 times higher than 16-26 year-olds depending on HPV type 2

Adolescents and Adults (Age 15-26 Years)

• 3-dose schedule is required when vaccination is initiated at age 15 or older 3, 1
• Doses administered at 0,1-2, and 6 months 3, 1
• Minimum intervals: 4 weeks between doses 1 and 2, and 12 weeks between doses 2 and 3 1
• Minimum interval of 24 weeks must be maintained between doses 1 and 3 3
• Catch-up vaccination is strongly recommended for all persons through age 26 years who have not completed the series 3, 1

Adults (Ages 27-45 Years)

• Routine vaccination is NOT recommended for all adults in this age group 4
• Shared clinical decision-making may be considered for select individuals, though the American Cancer Society explicitly does not endorse this approach due to minimal benefit 4
• Vaccination of adults through age 45 prevents only an additional 0.5% of cancer cases compared to vaccination through age 26 4
• If vaccination is pursued, a 3-dose schedule is required 3

Critical Scheduling Principles

Interrupted Series Management

• Never restart the series regardless of how long the interruption lasts 3, 1
• Continue from where you left off, ensuring minimum intervals are maintained 3, 1
• The age at first dose determines the schedule (2 vs 3 doses), not the age when subsequent doses are given 1

Determining Factor for Schedule

• The critical factor is age when the FIRST dose was given 1
• A patient who initiated vaccination at age 14 qualifies for the 2-dose schedule even if the second dose is given after age 15 1
• If the first dose is given at age 14, only one more dose is needed at least 6 months later 1

Special Populations

Immunocompromised Individuals

• Always require a 3-dose schedule regardless of age at initiation 3, 1
• This includes HIV-positive individuals, solid organ transplant recipients, and others with immunocompromising conditions 3, 1
• Seroconversion rates are lower (53-68% per HPV type) compared to immunocompetent individuals 1
• Vaccine efficacy may be reduced 1

Sexually Active Individuals

• Vaccination is still strongly recommended even for sexually active persons 3, 1
• Most sexually active individuals have not been exposed to all vaccine HPV types 1, 4
• The vaccine is most effective before HPV exposure, but sexually active women should still receive vaccination according to age-based recommendations 3
• Approximately 24% of adolescents report sexual intercourse by 9th grade, emphasizing the importance of early vaccination 1

Prior HPV Exposure or Disease

• A history of genital warts, abnormal Pap test, or positive HPV DNA test is NOT a contraindication 3, 4
• Vaccination is still recommended as these do not indicate infection with all vaccine HPV types 3, 4
• The vaccine does not treat existing infections but protects against vaccine types not yet acquired 3, 4

Pregnancy and Breastfeeding

• Vaccination is not recommended during pregnancy 3, 1
• If pregnancy occurs during the series, postpone subsequent doses until after delivery 1
• Breastfeeding women can safely receive the vaccine 3, 1

Vaccine Type and Protection

• The 9-valent HPV vaccine (Gardasil 9) is the only HPV vaccine currently distributed in the United States 4
• Protects against HPV types 6,11,16,18,31,33,45,52, and 58 3, 4
• Provides protection against approximately 90% of cervical cancers and 90% of anogenital warts 3

Co-Administration with Other Vaccines

• HPV vaccine can be administered at the same visit as other age-appropriate vaccines (such as Tdap and MCV4) 1
• Use separate syringes at different anatomic sites 1
• Co-administration increases likelihood of completing all recommended adolescent vaccinations on schedule 1

Safety and Adverse Events

• Local injection-site reactions (pain, redness, swelling) occur in approximately 60% of recipients and are mild and self-limited 3
• Serious adverse events are rare 3
• Patients should sit or lie down for 15 minutes after vaccination as syncope can occur in adolescents following injections 1

Critical Pitfalls to Avoid

• Do not delay vaccination waiting for "optimal" timing - administer as soon as the patient is eligible 3, 1
• Do not restart an interrupted series - this results in unnecessary doses 3, 1
• Do not assume prior HPV exposure means no benefit - even sexually active individuals benefit from protection against vaccine types they haven't acquired 3, 1
• Cervical cancer screening must continue despite vaccination - the vaccine does not protect against all oncogenic HPV types 3, 1
• No prevaccination testing is recommended before vaccination 1

Contraindications

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