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Issue 1479: February 24, 2020

Ask the Experts: IAC Experts Answer Your Questions

As a thank-you to our loyal IAC Express readers, we periodically publish extra editions such as this one, with new and updated "Ask the Experts" Q&As answered by experts from the Immunization Action Coalition (IAC). The Q&As in this issue all relate to human papillomavirus (HPV) vaccination.

IAC wishes to recognize its team of experts: Kelly L. Moore, MD, MPH (team lead); Carolyn Bridges, MD, FACP; William Atkinson, MD, MPH; and Deborah Wexler, MD.

To access answers to many more questions on the use of HPV vaccine,visit IAC's Ask the Experts: HPV web page ([link removed]) on immunize.org.

Human Papillomavirus (HPV) Vaccine
* Q: Please describe the HPV vaccines available in the United States.
* Q: What are the recommendations for use of HPV vaccine in people age 9 through 26 years?
* Q: Are catch-up recommendations for the use of HPV vaccine different for males and females?
* Q: What are the recommendations for use of HPV vaccine in people age 27 through 45 years?
* Q: Why is shared clinical decision-making (a discussion between the provider and the patient) recommended to determine whether to provide HPV vaccine to an adult age 27 through 45 years?
* Q: Why is HPV vaccination not routinely recommended for all adults age 27 through 45 years?
* Q: Should I screen my patients age 27 through 45 years for previous HPV infection to determine whether to offer them HPV vaccine?
* Q: I have a few patients who received their first or second dose of HPV vaccine at age 26 years or younger, but did not complete the series. Should I routinely complete their series after age 26 years, or do I need to use the shared clinical decision-making approach?
* Q: What is the routine schedule for HPV vaccine? Did ACIP change it in 2019?
* Q: Should transgender persons receive HPV vaccine?
* Q. I read that HPV vaccination rates are still low. What can we do as providers to improve these rates?

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Human Papillomavirus (HPV) Vaccine
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Q: PLEASE DESCRIBE THE HPV VACCINES AVAILABLE IN THE UNITED STATES.

A: Gardasil 9 (9vHPV, Merck) is the only HPV vaccine being distributed in the United States. Bivalent Cervarix (2vHPV, GlaxoSmithKline) and quadrivalent Gardasil (4vHPV, Merck) are no longer being distributed in the United States.

9vHPV is an inactivated 9-valent vaccine licensed by the Food and Drug Administration (FDA) in 2014. It contains 7 oncogenic (cancer-causing) HPV types (16, 18, 31, 33, 45, 52 and 58) and two HPV types that cause most genital warts (6 and 11). The 9vHPV vaccine is licensed for females and males age 9 through 45 years.

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Q: WHAT ARE THE RECOMMENDATIONS FOR USE OF HPV VACCINE IN PEOPLE AGE 9 THROUGH 26 YEARS?

A: The ACIP recommends that routine HPV vaccination be initiated for all children at age 11 or 12 years. Vaccination can be started as early as age 9 years. Vaccination is also recommended for all people age 13 through 26 years who have not been vaccinated previously or who have not completed the vaccination series.

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Q: ARE CATCH-UP RECOMMENDATIONS FOR THE USE OF HPV VACCINE DIFFERENT FOR MALES AND FEMALES?

A: No. In June 2019, the Advisory Committee on Immunization Practices (ACIP) voted to recommend routine catch-up HPV vaccination of all previously unvaccinated or incompletely vaccinated males age 22 through 26, the same as the recommendation for females. HPV vaccination recommendations differ by age group. There is one recommendation for people 9 through 26 years of age and another recommendation for people 27 through 45 years of age.

The most current ACIP recommendations for HPV vaccine are available at [link removed].

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Q: WHAT ARE THE RECOMMENDATIONS FOR USE OF HPV VACCINE IN PEOPLE AGE 27 THROUGH 45 YEARS?

A: Catch-up HPV vaccination is not recommended for all adults older than 26 years of age. Instead, shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 through 45 years who are not adequately vaccinated.

Ideally, HPV vaccine should be administered before potential exposure to HPV through sexual contact.

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Q: WHY IS SHARED CLINICAL DECISION-MAKING (A DISCUSSION BETWEEN THE PROVIDER AND THE PATIENT) RECOMMENDED TO DETERMINE WHETHER TO PROVIDE HPV VACCINE TO AN ADULT AGE 27 THROUGH 45 YEARS?

A: Although new HPV infections are most commonly acquired in adolescence and young adulthood, at any age, having a new sex partner is a risk factor for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical risk factors for HPV infection or disease, including men who have sex with men, transgender persons and persons with immunocompromising conditions. HPV vaccine works to prevent infection among persons who have not been exposed to vaccine-type HPV before vaccination. A discussion with your patient is the best way to decide together how much the patient may benefit from HPV vaccination to prevent new HPV infections.

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Q: WHY IS HPV VACCINATION NOT ROUTINELY RECOMMENDED FOR ALL ADULTS AGE 27 THROUGH 45 YEARS?

A: Because HPV acquisition generally occurs soon after first sexual activity, vaccine effectiveness will be lower in older age groups as the result of prior infections. In general, exposure to HPV also decreases among individuals in older age groups. Evidence suggests that although HPV vaccination is safe for adults 27 through 45 years, population benefit would be minimal; nevertheless, some adults who are unvaccinated or incompletely vaccinated might be at risk for new HPV infection and might benefit from vaccination in this age range.

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Q: SHOULD I SCREEN MY PATIENTS AGE 27 THROUGH 45 YEARS FOR PREVIOUS HPV INFECTION TO DETERMINE WHETHER TO OFFER THEM HPV VACCINE?

A: No. No screening laboratory test can determine whether a person is already immune or still susceptible to any given HPV type. Most sexually active adults have been exposed to one or more HPV types, although not necessarily all of the HPV types targeted by vaccination. HPV vaccine works to prevent infection with vaccine-types to which a person is still susceptible.

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Q: I HAVE A FEW PATIENTS WHO RECEIVED THEIR FIRST OR SECOND DOSE OF HPV VACCINE AT AGE 26 YEARS OR YOUNGER, BUT DID NOT COMPLETE THE SERIES. SHOULD I ROUTINELY COMPLETE THEIR SERIES AFTER AGE 26 YEARS, OR DO I NEED TO USE THE SHARED CLINICAL DECISION-MAKING APPROACH?

A: Complete the series based on shared clinical decision-making involving the patient’s risk and desire for protection.

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Q: WHAT IS THE ROUTINE SCHEDULE FOR HPV VACCINE? DID ACIP CHANGE IT IN 2019?

A: The routine schedule did not change in 2019. ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who start the vaccination series before the 15th birthday. The two doses should be separated by 6 to 12 months. The minimum interval between doses is 5 calendar months.

A 3-dose schedule is recommended for all people who start the series on or after the 15th birthday and for people with certain immunocompromising conditions (such as cancer, HIV infection, or taking immunosuppressive drugs). The second dose should be given 1 to 2 months after the first dose and the third dose 6 months after the first dose. The minimum interval between the first and second doses of vaccine is 4 weeks. The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the first and third doses is 5 calendar months. If the vaccination series is interrupted, the series does not need to be restarted.

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Q: SHOULD TRANSGENDER PERSONS RECEIVE HPV VACCINE?

A: Yes. ACIP recommends routine HPV vaccination for transgender persons as for all adolescents and young adults through age 26 years. Clinicians should discuss the risks of HPV disease and benefits of HPV vaccination with unvaccinated or incompletely vaccinated transgender persons age 27 through 45 years.

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Q. I READ THAT HPV VACCINATION RATES ARE STILL LOW. WHAT CAN WE DO AS PROVIDERS TO IMPROVE THESE RATES?

A: Coverage levels for HPV vaccine are improving but are still inadequate. Results from the Centers for Disease Control and Prevention's 2018 National Immunization Survey–Teen (NIS-Teen) indicate that 70% of girls age 13 through 17 years had started the series that they should have completed by age 13 years and 54% had completed the series. In 2018, 66% of boys age 13 through 17 years had received one dose but only 49% had received all three recommended doses. A summary of the 2018 NIS-Teen survey is available at [link removed].

Providers can improve uptake of this life-saving vaccine in two main ways. First, studies have shown that missed opportunities are occurring. Up to 90% (depending on year of birth) of girls unvaccinated for HPV had a healthcare visit where they received another vaccine such as Tdap, but not HPV. If HPV vaccine had been administered at the same visit, vaccination coverage for one or more doses could be 90% instead of 70%. Second, research has shown that not receiving a healthcare provider's recommendation for HPV vaccine was one of the main reasons parents reported for not vaccinating their adolescent children.

CDC urges healthcare providers to increase the consistency and strength of their recommendation of HPV vaccine, especially when patients are age 11 or 12 years. The following resources can help providers with these conversations.
* CDC's "Talking to Parents about HPV Vaccine," available at www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf
* IAC's "Human Papillomavirus HPV: A Parent's Guide to Preteen and Teen HPV Vaccination," available at www.immunize.org/catg.d/p4250.pdf.

For more detailed information about HPV vaccination strategies for providers, visit www.cdc.gov/hpv/hcp/index.html.

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If you have a question that you think may be of interest to our readers, please email us your suggestion at [email protected]. We will consider it for inclusion in a future update of the "Ask the Experts" feature.

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Editorial Information

Editor
Deborah L. Wexler, MD ([email protected])

Associate Editors
Carolyn Bridges, MD, MPH ([email protected])
Sharon Humiston, MD, MPH ([email protected])

Consulting Editors
Taryn Chapman, MS ([email protected])
Marian Deegan, JD ([email protected])
Courtnay Londo, MA ([email protected])
Jane Myers, MA, EdM ([email protected])

Technical Editor
Liv Augusta Anderson, MPP ([email protected])

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About IAC Express
We encourage you to reprint any of these Q&As in your own newsletters. When you do so, please add a note that the Immunization Action Coalition is the source of the material and provide a link to this issue ([link removed]).

IAC Express is supported in part by Grant No. 6NH23IP922550 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC.

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