Primary prevention
Human papillomavirus (HPV) vaccination can prevent HPV infections and HPV-associated diseases.[52][53][54][55][56][57][58][59]
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Studies in countries with established HPV vaccination programs report a substantially reduced incidence of cervical cancer.[15][16][17][18] The studies highlight the importance of early vaccination in reducing risk. Vaccinating boys in the same schedule may contribute to indirect protection for unvaccinated women and increase immunity in the population overall.[20]
The majority of HPV-associated cancers are caused by HPV types 16 or 18 (approximately 70%), both of which are targeted by HPV vaccines.[25][60] HPV vaccines are characterized by valency:[61]
Bivalent (protects against HPV types 16 and 18)
Quadrivalent (protects against HPV types 6, 11, 16, and 18)
9-valent (protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58).
HPV vaccines are licensed for use in two- or three-dose schedules; however, evidence from long-term studies suggests that a single dose offers protection comparable to two doses.[62][63][64] The World Health Organization recommends a one- or two-dose schedule for girls ages 9 to 20 years and a two-dose schedule for women over 21 years.[65]
US vaccination schedule
In the US, the Centers for Disease Control and Prevention (CDC) recommends routine vaccination against HPV for girls and boys ages 11 or 12 years, but early vaccination from the age of 9 years onwards may be considered.[66] The American Academy of Pediatrics recommends routine HPV vaccination between the ages of 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series.[67]
The recommended schedule is:[66]
Two intramuscular injections at 0 and 6-12 months where vaccination is initiated before age 15 years, or
Three intramuscular injections at 0, 1-2, and 6 months where vaccination is initiated at age 15 years or older.
People with HIV or other immunocompromising conditions should receive three doses of HPV vaccine, even if vaccination is initiated between ages 9 and 14 years, because their response to vaccination may be attenuated.[68] Children with a history of sexual abuse or assault should be given the HPV vaccine as early as possible (starting at age 9 years).[69]
Catch-up vaccination is recommended for people through age 26 years (and may be considered with shared decision-making for those ages 27 years and over) who were not adequately vaccinated when younger.[66]
HPV vaccination is not recommended during pregnancy (although no intervention is needed if vaccination is given inadvertently during pregnancy).[66][69][70] The American College of Obstetricians and Gynecologists (ACOG) recommends HPV vaccination in breastfeeding women ages 26 years and younger who have not previously been vaccinated.[69]
Barrier contraception and intrauterine devices
HPV is spread by skin-to-skin sexual contact; therefore, safe sexual health and effective barrier contraception may play a role in primary prevention.[71] However, the issue is complex.[72][73]
Use of an intrauterine device may reduce the risk of cervical cancer.[74][75][76]
The table that follows summarizes recommendations on HPV vaccination from the CDC.[66][70] The table outlines preventive measures for girls and women; the same CDC recommendations on HPV vaccination apply as listed here for boys and men.
Note that an individual patient may fall into more than one group, and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Girl ages 9-12 years; not yet vaccinated against HPV
Without immunocompromise
Intervention
HPV vaccination; 2-dose series
HPV vaccination is routinely recommended at ages 11-12 years, but can start at age 9 years.
HPV vaccination is recommended to start at the age of 9 years for those with history of sexual abuse or assault.
A 2-dose series (given at 0 months and 6-12 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages 9–14 years at initial vaccination who have received 2 doses at least 5 months apart.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
With immunocompromise
Intervention
HPV vaccination; 3-dose series
HPV vaccination is routinely recommended at ages 11-12 years, but can start at age 9 years.
HPV vaccination is recommended to start at the age of 9 years for those with a history of sexual abuse or assault.
For those with immunocompromising conditions, including HIV infection, a 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those with immunocompromise of any age who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Pregnant
Intervention
Delay HPV vaccination until after pregnancy
HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.
Goal
Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy
Girl ages 12-14 years; not yet vaccinated against HPV, or not adequately vaccinated
Without immunocompromise
Intervention
Catchup HPV vaccination; 2-dose series
A 2-dose series (given at 0 months and 6-12 months) is recommended.
A minimum interval of 5 months is required between doses; give the second dose if this has not yet been given, or repeat the second dose if this was administered too soon.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages 9–14 years at initial vaccination who have received 2 doses at least 5 months apart.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
With immunocompromise
Intervention
Catchup HPV vaccination; 3-dose series
For those with immunocompromising conditions, including HIV infection, a 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those with immunocompromise of any age who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Pregnant
Intervention
Delay HPV vaccination until after pregnancy
HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.
Goal
Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy
Female ages 15-26 years; not yet vaccinated against HPV, or incompletely vaccinated
No doses of HPV vaccine received
Intervention
Catchup HPV vaccination; 3-dose series
For those vaccinated against HPV at ages 15 years or older at initial vaccination, a 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages ≥ 15 years who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Incompletely vaccinated; ages 9-14 years at initial vaccination
Intervention
Catchup HPV vaccination; give one additional dose
Those who were ages 9–14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart require 1 additional dose of HPV vaccine.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages 9–14 years at initial vaccination who have received 2 doses at least 5 months apart.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Incompletely vaccinated; ages ≥ 15 years at initial vaccination
Intervention
Catchup HPV vaccination; give one or two additional doses
Those who began HPV vaccination at ages ≥ 15 years are considered to be incompletely vaccinated if they have received less than 3 doses, or if subsequent doses were administered too soon.
For those ages 15 years or older at initial vaccination, a 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages ≥ 15 years who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Pregnant
Intervention
Delay HPV vaccination until after pregnancy
HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.
Goal
Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy
Woman ages 27-45 years; not yet vaccinated against HPV, or incompletely vaccinated
No doses of HPV vaccine received
Intervention
Consider catchup HPV vaccination; 3-dose series
Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.
For those vaccinated against HPV at ages 15 years or older at initial vaccination, a 3-dose series is recommended.
A 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages ≥ 15 years who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Incompletely vaccinated; ages 9-14 years at initial vaccination
Intervention
Consider catchup HPV vaccination with administration of one additional dose
Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.
One additional dose of HPV vaccine may be considered for those ages 9–14 years at initial vaccination who received only 1 dose, or 2 doses less than 5 months apart.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages 9–14 years at initial vaccination who have received 2 doses at least 5 months apart.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Incompletely vaccinated; ages ≥ 15 years at initial vaccination
Intervention
Consider catchup HPV vaccination with one or two additional doses
Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.
Those who began HPV vaccination at ages ≥ 15 years are considered to be incompletely vaccinated if they have received less than 3 doses, or if subsequent doses were administered too soon. In this scenario, consider catchup vaccination using shared decision making.
A 3-dose series (given at 0 month, 1-2 months, and 6 months) is recommended.
Goal
Prevention of HPV and HPV-associated disease, including cervical cancer
The HPV vaccination series is complete, with no additional dose needed, for those ages ≥ 15 years who have received 3 doses given at 0, 1-2, and 6 months.
The following minimum intervals apply:
dose 1 to dose 2: 4 weeks
dose 2 to dose 3: 12 weeks
dose 1 to dose 3: 5 months.
No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.
Pregnant
Intervention
Consider HPV vaccination after pregnancy
HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.
Following pregnancy, decisions about HPV vaccination should be made using shared clinical decision making following discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.
Goal
Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy
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