HPV Vaccine Recommendations Including Guidance for Ages 27 to 45

SUMMARY:

The most recent evidence-based HPV vaccine recommendations address when to administer the vaccine and dosing.  One area that has elicited more recent guidance focuses on whether to offer the HPV vaccine to individuals over the age of 26.

• The FDA (October 2018) extended approval of HPV vaccine to individuals age 27 to 45 years
• ACIP (June 2019) voted to
  • Expand routine and catch-up HPV vaccination in males through 26 years of age who are inadequately vaccinated
  • Offer HPV vaccine to individuals age 27 to 45 years who have not been adequately vaccinated based on shared clinical decision making
• ACIP published their final recommendations (August 2019) in the CDC’s Morbidity and Mortality Weekly Report

Children and adults aged 9 through 26 years: HPV vaccination is routinely recommended at age 11 or 12 years; vaccination can be given starting at age 9 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated.

Adults aged >26 years: Catch-up HPV vaccination is not recommended for all adults aged >26 years. Instead, shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 through 45 years who are not adequately vaccinated. HPV vaccines are not licensed for use in adults aged >45 years.

These recommendations for children and adults aged 9 through 26 years and for adults aged >26 years apply to all persons, regardless of behavioral or medical risk factors for HPV infection or disease.

For persons who are pregnant, HPV vaccination should be delayed until after pregnancy; however, pregnancy testing is not needed before vaccination.

Persons who are breastfeeding or lactating can receive HPV vaccine. Recommendations regarding HPV vaccination during pregnancy or lactation have not changed.

• ACIP suggests considering the following points for shared-decision making with adults who are 27 to 45 years of age
  • HPV is very common, usually transient and asymptomatic
  • Although typically acquired in young adulthood, some adults are at risk for acquiring new HPV infection
  • A new sex partner is a risk factor, while those in long-term, mutually monogamous partnerships are not likely to acquire a new HPV infection
  • HPV types: Sexually active adults will likely have been exposed to some HPV types, but not all HPV types are vaccine targets
  • There is no antibody test to determine immunity
  • HPV vaccine has high efficacy in young persons not yet exposed to vaccine-type HPV
  • Lower vaccine effectiveness may be expected in those with HPV risk factors
    • Multiple lifetime sex partners | Previous infection with vaccine-type HPV | immunocompromising conditions
  • HPV vaccines are prophylactic only and can’t prevent infection progression, improve time to clearance or treat HPV-related disease
• In summary, the CDC states

For adults aged 27 years and older, clinicians can consider discussing HPV vaccination with people who are most likely to benefit. HPV vaccination does not need to be discussed with most adults over age 26 years

CDC Dosing Schedule 

• <15 years: 2 doses spaced 6 to 12 months apart
• ≥15 years: 3-dose schedule
  • Initial dose
  • Second dose at 1 to 2 months after initial 
  • Third dose at 6 months after initial 

Updated ACOG HPV vaccine recommendations 

• Routine HPV vaccination is recommended for females and males 
• Target age is 11 to 12 years but can be given through age 26
  • Can be given from age of 9 
• Do not test for HPV DNA prior to vaccination
  • Vaccinate even if patient was tested and is HPV DNA positive
•  If not vaccinated between 11 to 12 years
  • Vaccinate between 13 to 26 years (catch up period)
• Women 27 to 45 years and not previously unvaccinated
  • Use shared clinical decision making
• ACOG “does not recommend that an individual who received the quadrivalent HPV vaccine be revaccinated with 9-valent HPV vaccine, including those aged 27–45 years who previously completed some, but not all, of the vaccine series when they were younger”
• Pregnancy
  • HPV vaccine is not recommended during pregnancy
  • Pregnancy testing prior to HPV vaccination not recommended
  • If vaccination schedule is interrupted by pregnancy, resume postpartum with the next dose
  • HPV vaccine can and should be given to breastfeeding women ≤26 who have not been vaccinated
• Counsel to expect mild local discomfort and that this is not a cause for concern
  • Watch adolescents for at least 15 minutes following vaccination due to risk of fainting in this population

AAP  

• The AAP  has also endorsed the CDC HPV recommendations
  • The HPV vaccine should be normalized as a standard of care
  • Recommendation should be clear and unambiguous 
  • AAP provides multiple strategies (see ‘Learn More – Primary Sources’ below) to engaging with patients including focusing on cancer prevention benefits for all children 

ACS

• The ACS endorses ACIP CDC guidance regarding HPV guidance except for the approach to take with individuals who are 27 to 45 years and not adequately vaccinated

The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit

Adjuvant HPV Vaccine to Prevent CIN Recurrence 

• ACOG recommends considering adjuvant HPV vaccine for unvaccinated individuals 27 to 45 years who are undergoing treatment for CIN 2+

Learn More – Primary Sources:

FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices (MMWR)

CDC: HPV Vaccination Schedules & Recommendations

ACOG Committee Opinion 809: Human Papillomavirus Vaccination

ACOG Practice Advisory: Adjuvant Human Papillomavirus Vaccination for Patients Undergoing Treatment for Cervical Intraepithelial Neoplasia 2+

AAP: How Pediatricians Can Recommend HPV Vaccination to Parents and Caregivers

CDC Frequently Asked Questions about HPV Vaccine Safety

CDC: HPV Educational Materials For Clinicians

ACS: Human papillomavirus vaccination 2020 guideline update

Gardasil Now FDA Approved for Individuals 27 to 45 Years Old

SUMMARY:

According to the CDC

The 9-valent HPV vaccine protects against nine HPV types, including seven types that can cause cancer. Of the 32,500 cancers that HPV has caused every year, 30,000 are caused by strains that could have been prevented by the 9-valent HPV vaccine.

• Previously, Gardasil 9 was approved for males and females ages 9 to 26
• Based on current research, the FDA has now extended approval to include individuals ages 27 to 45
  • The Gardasil 9 age extension was approved using ‘priority review status’, which is an expedited review of medical products that address a serious or life-threatening condition
• ACOG has responded with a Practice Advisory (October 2019) that addresses the following considerations
  • Further review of data, including cost-effectiveness is still necessary
  • CDC and ACIP are reviewing the data, in conjunction with ACOG
  • Current guidelines “remain in effect” and ObGyns and other health professionals are “encouraged” to discuss the vaccine with women who are >26 years and are interested in vaccination
  • In women 27 to 45 years, decisions regarding vaccination should
    • Be individualized
    • Involve shared decision making
    • Include clinical judgement

KEY POINTS:

• The original Gardasil vaccine was approved in 2006 and covered 4 HPV types but is no longer distributed in the US
• Gardasil 9 (Human Papillomavirus (HPV) 9-valent Vaccine, Recombinant) was approved in 2014 and includes the original 4 HPV types plus another 5 pathogenic types

Effectiveness

• Gardasil studies were considered ‘relevant’ for Gardasil 9 review because both vaccines are manufactured similarly and cover 4 common HPV types
• In one study, 3,200 women 27 through 45 years of age were followed for an average of 3.5 years
  • Gardasil was 88 percent effective in the prevention of a combined endpoint of HPV related lesions and cancer (persistent infection, genital warts, vulvar and vaginal precancerous lesions, cervical precancerous lesions, and cervical cancer)
  • “The FDA’s approval of Gardasil 9 in women 27 through 45 years of age is based on these results and new data on long term follow-up from this study”
• Males age 27 through 45 years
  • Effectiveness: ‘Inferred’ from the above data
  • Efficacy: Derived from Gardasil data in males age 16 through 26 years
  • Immunogenicity: Derived from a clinical trial in which 150 men, 27 through 45 years of age, received a 3-dose regimen of Gardasil over 6 months

Safety

• Gardasil 9 was evaluated in approximately 13,000 males and females
• Most common reported adverse reactions
  • Injection site pain
  • Swelling
  • Redness
  • Headaches

Learn More – Primary Sources:

FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old

CDC: HPV Vaccination Schedules & Recommendations

HPV Vaccine and Maternal and Infant Outcomes

BACKGROUND AND PURPOSE:

• Lipkind et al. (Obstet Gynecol., 2017) evaluated the impact of administering quadrivalent human papillomavirus vaccine (4vHPV) during the periconception and perinatal time periods on maternal and fetal outcomes

METHODS:

• Retrospective, observational cohort study (2007-2013)
• Pregnancy Cohort
  • Periconception (2 weeks before and 2 weeks after after LMP)
  • During pregnancy
  • Both of the above
• Control Cohort
  • 4-18 months before their last menstrual period
• Outcomes were
  • Gestational diabetes
  • Hypertensive disorders of pregnancy
  • Chorioamnionitis
  • Preterm birth
  • Small-for-gestational-age birth
  • Major structural birth defects in offspring

RESULTS:

• 720 received vaccine during periconceptional period, 698 received vaccine during pregnancy and 8196 controls received vaccine
• 4vHPV administered during pregnancy was not associated with increased risk for adverse obstetric events or birth outcomes
• When comparing vaccine exposure during pregnancy to controls
  • There was no evidence of increased preterm birth (adjusted relative risk [aRR] 0.97; 95% CI 0.72-1.3)
  • There was no evidence of increased major structural birth defects (2.0% vs 1.8%)
• Results were similar for 4vHPV exposure during periconceptional period

CONCLUSION:

• Administering 4vHPV during pregnancy or periconceptional period was not associated with adverse pregnancy or birth outcomes

Learn More – Primary Sources:

Maternal and Infant Outcomes After Human Papillomavirus Vaccination in the Periconceptional Period or During Pregnancy