What are the current recommendations for HPV vaccination with Gardasil 9 (nonavalent recombinant vaccine), including age eligibility, dosing schedule, contraindications, and considerations for immunocompromised or pregnant patients?

HPV Vaccination with Gardasil 9: Current Recommendations

All children should receive routine HPV vaccination at age 11-12 years using a 2-dose schedule, with the vaccine series starting as early as age 9 years, and catch-up vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. 1

Age-Based Vaccination Schedule

Routine Vaccination (Ages 9-14)

• Initiate vaccination at age 11-12 years (can start as early as age 9 years) 1
• 2-dose schedule for those starting before their 15th birthday 1, 2
  • Second dose administered 6-12 months after the first dose 1, 2
  • Minimum acceptable interval is 12 weeks, though longer intervals produce stronger immune responses 2
• The 2-dose schedule is based on robust immunogenicity data showing younger adolescents mount stronger antibody responses than older individuals receiving 3 doses 2

Catch-Up Vaccination (Ages 15-26)

• 3-dose schedule required for those initiating vaccination at age 15 or older 1, 2
  • Doses administered at 0,1-2, and 6 months 1, 2
  • Minimum intervals: 4 weeks between doses 1 and 2; 12 weeks between doses 2 and 3 2
• Universal recommendation through age 26 years for all persons not adequately vaccinated 1
• Providers should inform unvaccinated individuals aged 22-26 years that vaccination may not be effective in lowering their cancer risk 1

Adults Ages 27-45 Years

• Catch-up vaccination is NOT routinely recommended for all adults over age 26 1
• Shared clinical decision-making is recommended for some adults aged 27-45 years who are not adequately vaccinated 1
• The American Cancer Society does not endorse vaccination for adults aged 27-45 years due to low effectiveness and minimal cancer prevention potential 3
• Vaccination effectiveness decreases dramatically by age 18 years, with modeling studies showing that extending vaccination to age 45 would prevent only an additional 0.5% of cancer cases 3

Not Licensed

• HPV vaccines are not licensed for use in adults over age 45 1, 3

Special Populations

Immunocompromised Individuals

• 3-dose schedule required regardless of age at initiation 1, 2
• This includes persons with HIV, solid organ transplant recipients, and other immunocompromising conditions 2, 4
• Seroconversion rates are lower in transplant recipients (53-68% per HPV type) compared to immunocompetent individuals 2

Pregnancy

• HPV vaccination should be delayed until after pregnancy 1
• If a woman becomes pregnant during the vaccination series, subsequent doses should be postponed until after delivery 2
• Pregnancy testing is not needed before vaccination 1
• This is a precautionary measure, not based on evidence of harm 1

Breastfeeding

• Persons who are breastfeeding or lactating can receive HPV vaccine 1, 2

Men Who Have Sex with Men (MSM)

• Routine vaccination recommended through age 26 years 1, 4
• This population has a higher burden of HPV infection and HPV-related cancers 4

Administration Guidelines

Dosing Intervals and Interrupted Series

• The vaccine series does not need to be restarted regardless of how long the interruption lasts 2
• If interrupted after the first dose, administer the next dose as soon as possible 2
• The critical determining factor is the age when the first dose was given, not when subsequent doses are administered 2
• A patient who initiated vaccination at age 14 qualifies for the 2-dose schedule regardless of extended intervals 2

Co-Administration

• HPV vaccine can be administered at the same visit as other age-appropriate vaccines (such as Tdap and MCV4) 2, 4
• Use separate syringes at different anatomic sites 2, 4

Post-Vaccination Monitoring

• Patients should sit or lie down for 15 minutes after HPV vaccine administration due to risk of syncope in adolescents 2, 4

Contraindications and Precautions

Absolute Contraindications

• History of immediate hypersensitivity to yeast or any vaccine component 2

Precautions

• Defer vaccination for people with moderate or severe acute illness 2

Important Clinical Considerations

No Prevaccination Testing Required

• No prevaccination testing (Pap testing, HPV DNA testing, or antibody testing) is recommended before vaccination 1, 2
• History of genital warts, abnormal Pap tests, or positive HPV DNA tests are not contraindications to vaccination 2

Continued Screening Necessary

• Cervical cancer screening guidelines remain unchanged for vaccinated individuals 1
• The vaccine does not protect against all oncogenic HPV types, making continued screening essential 2, 3
• The 9-valent vaccine prevents approximately 92% of HPV-attributable cancers, but not all 1

Sexually Active Individuals

• Sexually active persons should still be vaccinated according to age-based recommendations 1
• They are unlikely to have been infected with all vaccine HPV types 2
• The vaccine protects against HPV types not yet acquired 2
• Vaccination does not protect against HPV types already present at the time of vaccination 2

Cancer Prevention Benefits

The 9-valent HPV vaccine protects against HPV types responsible for:

• Cervical cancer: 92% of cases attributable to vaccine types 1
• Oropharyngeal cancer: 70% of cases 1
• Anal cancer: 90% of cases 1
• Vaginal, vulvar, and penile cancers: 60-70% of cases 1
• Genital warts: 90% caused by HPV types 6 and 11 1, 4

Common Pitfalls to Avoid

• Do not delay vaccination waiting for "optimal" timing, as approximately 24% of adolescents report sexual intercourse by 9th grade 2
• Do not restart the series if interrupted—continue from where you left off while maintaining minimum intervals 2
• Do not assume sexually active individuals don't benefit from vaccination—they likely haven't been exposed to all vaccine types 2
• Do not skip cervical cancer screening in vaccinated women—the vaccine doesn't eliminate all cancer risk 2, 3