What are the guidelines for papilloma vaccination in an adolescent or young adult without a history of Human Papillomavirus (HPV) exposure?

HPV Vaccination Guidelines for Adolescents and Young Adults

All adolescents and young adults through age 26 years without prior HPV vaccination should receive the HPV vaccine series, regardless of sexual activity or presumed HPV exposure. 1

Age-Based Vaccination Schedule

Routine Vaccination (Ages 9-14 Years)

• Routine vaccination is recommended at age 11-12 years, though it can be initiated as early as age 9 years 1, 2
• 2-dose schedule: For individuals initiating vaccination before their 15th birthday, administer 2 doses with the second dose given 6-12 months after the first 1, 2
• The 2-dose schedule is supported by robust immunogenicity data showing younger adolescents (ages 9-14) mount significantly stronger antibody responses than older individuals receiving 3 doses 2
• Longer intervals between doses (closer to 12 months) produce stronger immune responses than shorter intervals 2

Catch-Up Vaccination (Ages 15-26 Years)

• 3-dose schedule: For individuals initiating vaccination at age 15 years or older, administer 3 doses at 0,1-2, and 6 months 1, 3
• Catch-up HPV vaccination is recommended for ALL persons through age 26 years who are not adequately vaccinated 1, 4
• This applies regardless of sexual activity history, prior HPV exposure, history of genital warts, abnormal Pap tests, or positive HPV DNA tests 4, 3

Minimum Dosing Intervals

• Between doses 1 and 2: Minimum 4 weeks 2, 3
• Between doses 2 and 3: Minimum 12 weeks 1, 3
• Between doses 1 and 3: Minimum 24 weeks (6 months) 3

Critical Clinical Principles

No Pre-Vaccination Testing Required

• Do not perform HPV testing, Pap testing, or antibody testing before vaccination 1, 2
• No clinical test can determine immunity or susceptibility to specific HPV types 1, 4

Prior HPV Exposure Is NOT a Contraindication

• A history of genital warts, abnormal Pap tests, or positive HPV DNA tests does NOT preclude vaccination 4, 3
• Most sexually active adults have been exposed to some HPV types, but not necessarily all vaccine-type HPV 1, 4
• The vaccine protects against multiple HPV types (6,11,16,18,31,33,45,52,58), and prior exposure to one type does not confer immunity to others 1, 2

HPV Vaccines Are Prophylactic Only

• HPV vaccines prevent NEW infections but do NOT treat existing infections or HPV-related diseases 1, 4
• The vaccine will not clear existing genital warts, accelerate their resolution, or prevent progression of existing HPV infections to disease 1, 4
• Vaccine efficacy is highest among persons not previously exposed to vaccine-type HPV 1, 4

Vaccination for Ages 27-45 Years

Routine catch-up vaccination is NOT recommended for all adults aged 27-45 years 1, 4

Shared Clinical Decision-Making Approach

For adults aged 27-45 years, consider vaccination based on:

• Risk factors favoring vaccination: Having new sex partners or anticipating new partners in the future 4
• Special populations: Men who have sex with men (MSM) or immunocompromised individuals 4
• Limited benefit: The public health benefit of HPV vaccination in this age range is minimal, with vaccination through age 45 estimated to prevent only an additional 0.5% of cancer cases compared to vaccination through age 26 4
• Prior exposure: Most adults in this age range have already been exposed to multiple HPV types, reducing vaccine effectiveness 1, 4

Important caveat: The American Cancer Society explicitly does NOT endorse the shared clinical decision-making recommendation for ages 27-45 due to low effectiveness and minimal cancer prevention potential 4

Licensing Limits

• HPV vaccines are NOT licensed for use in adults over age 45 years 1, 5

Special Populations

Immunocompromised Individuals

• Always use a 3-dose schedule regardless of age at initiation 4, 2, 3
• This includes persons with HIV, solid organ transplant recipients, and other immunocompromising conditions 4, 3
• Vaccine effectiveness may be lower in immunocompromised individuals 1, 4

Pregnancy and Breastfeeding

• Vaccination should be delayed until after pregnancy 4, 2
• If pregnancy is discovered during the vaccination series, postpone subsequent doses until after delivery 2
• Breastfeeding women can safely receive the HPV vaccine 4, 2

Men Who Have Sex With Men (MSM)

• Routine vaccination is recommended through age 26 years 4, 2
• MSM may especially benefit from prevention of genital warts and anal cancer 4

Managing Interrupted Vaccination Series

Key Principle: Never Restart the Series

• If the vaccination series is interrupted, continue from where you left off—do NOT restart 2, 3
• There is no maximum time interval between doses 2
• Administer the next dose as soon as possible while maintaining minimum intervals 2, 3

Schedule Determination

• The age at first dose determines the total number of doses needed, not the age at subsequent doses 2
• If vaccination was initiated before age 15, only 2 total doses are needed even if the second dose is given after age 15 2
• If vaccination was initiated at age 15 or older, 3 total doses are needed 2, 3

Cervical Cancer Screening

HPV vaccination does NOT change cervical cancer screening recommendations 1, 4, 2

• Continue routine cervical cancer screening according to established guidelines 1, 3
• The vaccine does not protect against all oncogenic HPV types 4, 3

Available Vaccine

Gardasil 9 (9-valent HPV vaccine) is the only HPV vaccine currently distributed in the United States (as of late 2016) 1, 4, 2

• Protects against HPV types 6,11,16,18,31,33,45,52, and 58 1, 2
• Prevents approximately 90% of cervical cancers and 90% of anogenital warts 3
• Also prevents anal, penile, and oropharyngeal cancers 2

Common Pitfalls to Avoid

1. Do NOT delay vaccination waiting for "optimal" timing—approximately 24% of adolescents report sexual intercourse by 9th grade 2
2. Do NOT restart an interrupted series—this results in unnecessary doses 3
3. Do NOT assume sexually active individuals cannot benefit—they should still be vaccinated according to age-based recommendations 1, 3
4. Do NOT skip cervical cancer screening in vaccinated individuals—screening remains essential 4, 3
5. Do NOT perform pre-vaccination HPV testing—it is not recommended and does not guide vaccination decisions 1, 2

Administration Considerations

• Administer via intramuscular injection 2
• Can be given at the same visit as other age-appropriate vaccines using separate syringes at different anatomic sites 2
• Patients should sit or lie down for 15 minutes after vaccination due to syncope risk in adolescents 2
• Most common side effect is injection-site pain, occurring in approximately 60% of recipients 3