Three vaccines protect against HPV:

• A human papillomavirus nonavalent (9vHPV) vaccine that protects against HPV types 6 and 11 (which cause > 90% of visible genital warts), types 16 and 18 (which cause approximately 70% of cervical cancers and 90% of anal cancers), and types 31, 33, 45, 52, and 58 (which together cause 10 to 20% of cervical cancers [1])

• A human papillomavirus quadrivalent vaccine (4vHPV) that protects against types 6, 11, 16, and 18

• A human papillomavirus bivalent vaccine (2vHPV) that protects against types 16 and 18

Only the 9-valent vaccine is available in the United States.

Recombinant DNA technology is used to prepare HPV vaccines from the major capsid (L1) protein of HPV. The L1 proteins self-assemble into noninfectious, nononcogenic virus-like particles (VLPs).

The HPV vaccine is a routine childhood vaccination. The 9-valent vaccine has been expanded to include adults age 27 through 45 years for the prevention of certain HPV-related cancers and diseases.

The recommendations from the Advisory Committee on Immunization Practices (ACIP) are the following (1–3):

• For patients up to age 26 years: HPV vaccine is recommended at age 11 or 12 years (can start at age 9 years; recommended to start at age 9 if there is a history of sexual abuse or assault) and for previously unvaccinated or not adequately vaccinated patients up through age 26 years.

• For adults 27 to 45 years: Clinicians should engage in a shared decision-making discussion with patients to determine whether they should be vaccinated.

The American Academy of Pediatrics (AAP) recommends HPV vaccination between the ages of 9 and 12 years, at an age the pediatric health care professional deems optimal for acceptance and completion of the vaccination series, and for previously unvaccinated or not adequately vaccinated patients up through age 18 (4, 5).

Alternatively (for consideration outside the United States), the following may be used:

• 4vHPV or 2vHPV for females

• 4vHPV for males, including those who have sex with men

Contraindications for HPV vaccine include:

• A severe allergic reaction (eg, anaphylaxis) after a previous dose or to a vaccine component

• Hypersensitivity to yeast

• Pregnancy

Although HPV vaccines are not recommended for pregnant patients, pregnancy testing is not needed before vaccination. If pregnancy is diagnosed after the vaccination series has been started, no intervention is needed, but the remaining doses of the series should be delayed until pregnancy is completed.

The main precaution with HPV vaccine is:

• Moderate or severe acute illness with or without fever (vaccination is postponed until the illness resolves)

The HPV vaccine dose is 0.5 mL IM, administered in a 3-dose or 2-dose series depending on age at initial HPV vaccination.

• Initial dose at age 9 to 14 years: A 2-dose series is administered at 0 and 6 to 12 months. Minimum interval between doses is 5 months. If a dose is administered too soon (in < 5 months), 1 additional dose should be administered.

• Initial dose at age ≥ 15 years: A 3-dose series is administered at 0, 1 to 2 months, and 6 months. Minimum intervals are 4 weeks between the first and second dose, 12 weeks between the second and third doses, and 5 months between the first and third doses. If the second or third dose is administered too soon it should be repeated.

• Some adults aged 27 to 45 years: Based on a shared clinical decision-making discussion, adults in this age group may complete the 2-dose series (if initiated at age 9 to 14 years) or 3-dose series (if initiated at ≥ 15 years) (see CDC: Shared Clinical Decision-Making: HPV Vaccination for Adults Aged 27-45 Years).

• People with immunocompromising conditions, including HIV infection: Immunocompromised patients are given the 3-dose series as above, regardless of age at initial vaccination.

Common adverse reactions include the following:

• Injection site reactions such as pain, swelling, erythema, pruritis, and bruising

• Fever

• Nausea

• Dizziness

For more information about adverse effects of these vaccines, refer to the prescribing information.

The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.

1. Advisory Committee on Immunization Practices (ACIP): ACIP Recommendations: Human Papillomavirus (HPV) Vaccine

2. Centers for Disease Control and Prevention (CDC): HPV (Human Papillomavirus)

3. American Academy of Pediatrics (AAP): Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger

4. European Centre for Disease Prevention and Control (ECDC): Human Papillomavirus Infection: Recommended vaccinations