HPV Vaccination
Full update September 2022
Human papillomavirus (HPV) is the most common sexually transmitted infection in Canada and the US.1-3 Most HPV infections are asymptomatic and resolve without intervention. However, some HPV infections lead to significant morbidity, including precancer and cancer in both females and males.2,4 HPV vaccination rates remain low, with just over half of teenagers fully vaccinated for HPV.3,5 The FAQ below answers questions about HPV vaccination and includes a few talking points to ease concerns and improve vaccination rates.
Question |
Answer/Pertinent Information |
Who should be vaccinated against HPV? |
Gardasil 9 is FDA- and Health Canada-approved in males and females nine to 45 years of age.6-8 Cervarix (Canada only) is Health Canada-approved in females nine to 45 years of age.9 Ideally start the series between the ages of 11 and 12 years (for females and males).10,11
|
How should HPV vaccine doses be given? |
Administer 0.5 mL of the HPV vaccine as an intramuscular injection.2
Patients should be observed for 15 minutes after administration, due to a risk of fainting.2,6 |
When are the two-dose and three-dose series appropriate? |
The two-dose series is recommended for males and females up to 14 years.2,6,10
The three-dose series (doses at 0, 2, and 6 months for Gardasil 9; doses at 0,1, and 6 months for Cervarix [Canada only]) is recommended for:
For the three-dose series, there must be at least one month between the first two doses, at least three months between the second and third doses, and at least six months between the first and third doses.2 It is not necessary to restart the two- or three-dose series if more than the recommended time lapses between doses.2,18 Complete the vaccination series, starting right where the patient left off.18 |
How well is Gardasil 9 tolerated? |
Expect adverse effects to be more common in females compared to males.6 Injection-site pain, redness, and swelling are the most common (~90% of females, ~65% of males) adverse effects, but are usually mild.2,6,13,17 Headache is the next most common adverse effect (~10%).6 Systemic adverse events (e.g., fatigue, myalgia, fever, nausea) have been reported. However, rates do not seem to differ from the control groups.2,6,17
|
What does the HPV vaccine protect against? |
Gardasil 9 covers HPV strains 6, 11, 16, 18, 31, 33, 45, 52, and 58.6,8
Cervarix (Canada only) covers HPV strains 16 and 18.9,21
Note that the now discontinued Gardasil vaccine covered HPV strains 6, 11, 16, and 18.21 |
What are some suggested talking points with patients and parents?
|
Discuss the benefits of vaccination with patients and their parents/caregivers. See our Vaccine Adherence: Addressing Myths and Hesitancy algorithm for additional ways to improve vaccination rates and overcome barriers.
Ask parents/caregivers and/or patients about their concerns.
Recommend vaccination at a young age to ensure immunity before becoming sexually active.23
There is insufficient evidence that HPV vaccination causes:
Avoid use during pregnancy, due to lack of data.26
HPV vaccination can be given while breastfeeding.26 |
How much do the HPV vaccines cost? |
Gardasil 9 costs about $270 (US) or $185 (Canada) per dose.a Cervarix costs about $110 (Canada) per dose.a US: Check with insurers to verify coverage.
Canada: All provinces and territories offer HPV vaccines at no cost as part of school vaccination programs. Some insurance providers may cover HPV vaccines.28 |
Abbreviations: HPV = human papillomavirus, NNT = number to treat.
- Pricing based on wholesale acquisition cost (WAC). US medication pricing by Elsevier, accessed September 2022.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
- CDC. Genital HPV infection – fact sheet. April 12, 2022. https://www.cdc.gov/std/hpv/stdfact-hpv.htm. (Accessed September 7, 2022).
- Government of Canada. Canadian Immunization Guide. Human papillomavirus (HPV). September 23, 2021. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-9-human-papillomavirus-vaccine.html#p4c8a1. (Accessed September 7, 2022).
- Bird Y, Obidiya O, Mahmood R, et al. Human Papillomavirus Vaccination Uptake in Canada: A Systematic Review and Meta-analysis. Int J Prev Med. 2017 Sep 14;8:71.
- CDC. Morbidity and Mortality Weekly Report (MMWR): human papillomavirus-associated cancers – United States, 2008-2012. Updated August 24, 2017. https://www.cdc.gov/mmwr/volumes/65/wr/mm6526a1.htm. (Accessed September 7, 2022).
- American Cancer Society. Half of US teens getting HPV vaccinations. August 29, 2019. https://www.cancer.org/latest-news/half-of-us-teens-getting-hpv-vaccinations.html. (Accessed September 7, 2022).
- Product information for Gardasil 9. Merck & Co. Whitehouse Station, NJ 08889. June 2020.
- FDA. FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old. October 5, 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm. (Accessed September 7, 2022).
- Product monograph for Gardasil 9. Merck Canada. Kirkland, QC H9H 4M7. April 2022.
- Product monograph for Cervarix. GlaxoSmithKline. Mississauga, ON L5N 6L4. February 2019.
- CDC. CDC recommends only two HPV shots for younger adolescents. October 20, 2016. https://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html. (Accessed September 7, 2022).
- CDC. Catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind. February 17, 2022. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html. (Accessed September 7, 2022).
- Meites E, Szilagyi PG, Chesson HW, et al. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):698-702.
- Salvadori MI. Human papillomavirus vaccine for children and adolescents. Paediatr Child Health. 2018 Jul;23(4):262-265.
- Government of Canada. Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada. July 2022. https://www.canada.ca/en/public-health/services/provincial-territorial-immunization-information/provincial-territorial-routine-vaccination-programs-infants-children.html. (Accessed September 7, 2022).
- Government of Canada. Not just for kids: an adult guide to vaccination. May 3, 2022. https://www.canada.ca/en/public-health/services/publications/healthy-living/just-kids-adult-guide-vaccination.html. (Accessed September 7, 2022).
- Petrosky E, Bocchini JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep. 2015 Mar 27;64(11):300-4.
- Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015 Feb 19;372(8):711-23.
- Immunization Action Coalition. Ask the experts: human papillomavirus (HPV). January 18, 2022. http://www.immunize.org/askexperts/experts_hpv.asp. (Accessed September 7, 2022).
- CDC. Fainting (syncope). August 25, 2020. http://www.cdc.gov/vaccinesafety/concerns/fainting.html. (Accessed September 7, 2022).
- CDC. Cancers caused by HPV are preventable. November 1, 2021. https://www.cdc.gov/hpv/hcp/protecting-patients.html. (Accessed September 7, 2022).
- Canada Communicable Disease Report. Tunis MC, Deeks, SL. Summary of the National Advisory Committee on Immunization’s updated recommendations on human papillomavirus (HPV) vaccines: nine-valent HPV vaccine and clarification of minimum interval between doses in the HPV immunization schedule. July 7, 2016. https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2016-42/ccdr-volume-42-7-july-7-2016/ccdr-volume-42-7-july-7-2016-we-stop-measles-2.html. (Accessed September 7, 2022).
- Castellsague X, Munoz N, Pitisuttithum P, et al. End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24-45 years of age. Br J Cancer. 2011 Jun 28;105(1):28-37.
- CDC. Human papillomavirus (HPV): answering parents’ questions about HPV vaccination. November 1, 2021. https://www.cdc.gov/hpv/hcp/answering-questions.html. (Accessed September 7, 2022).
- Bednarczyk RA, Davis R, Ault K, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics. 2012 Nov;130(5):798-805.
- World Health Organization. Safety of HPV vaccines. https://www.who.int/groups/global-advisory-committee-on-vaccine-safety/topics/human-papillomavirus-vaccines/safety. (Accessed September 7, 2022).
- CDC. Questions about HPV vaccine safety. July 15, 2020. https://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html#A2. (Accessed September 7, 2022).
- BlueCross BlueShield of North Carolina. Blue Cross NC expands age range coverage for Gardasil. August 16, 2019. https://www.bluecrossnc.com/provider-news/blue-cross-nc-expands-age-range-coverage-gardasil. (Accessed September 7, 2022).
- Government of Canada. Update on the recommended Human Papillomavirus (HPV) vaccine immunization schedule. March 10, 2016. https://www.canada.ca/en/public-health/services/publications/healthy-living/update-recommended-human-papillomavirus-vaccine-immunization-schedule.html. (Accessed September 7, 2022).
Cite this document as follows: Clinical Resource, HPV Vaccination. Pharmacist’s Letter/Prescriber’s Letter. September 2022. [380927]