Which HPV Vaccine Should I Administer to Patients?

Anne M. Teitelman, PhD, CRNP, MSN

Disclosures

September 07, 2010

Question:

Which HPV vaccine should I give my patients? Are they the same?

Response from Anne M. Teitelman, PhD, CRNP, MSN
Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Nurse Practitioner, University of Pennsylvania Hospital, Philadelphia, Pennsylvania

Two vaccines for human papillomavirus (HPV) are currently available in the United States. They are the quadrivalent HPV vaccine (HPV4; Gardasil® [human papillomavirus vaccine]) and the bivalent vaccine (HPV2, Cervarix® [human papillomavirus vaccine, bivalent]). Updated recommendations and guidance for these vaccines were recently published in the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report.[1,2]

Current Recommendations and Guidance From the CDC Advisory Committee on Immunization Practices (ACIP)

ACIP currently recommends routine vaccination for girls at age 11 or 12 years with 3 doses of either HPV2 or HPV4 for prevention of cervical cancers and precancers. Catch-up vaccination is recommended for girls and women aged 13-26 years; however, vaccination can begin as early as 9 years. Evidence suggests that both vaccines provide protection for additional oncogenic HPV subtypes, but data are sufficient only to recommend HPV4 for prevention of vulvar and vaginal cancers and precancers. In addition, HPV4 is recommended for protection against genital warts in young women.[1] ACIP also provides guidance that to protect against genital warts, HPV4 vaccine may be given to boys and men aged 9-26 years.[2]

Similarities among HPV2 and HPV4. Both vaccines are highly effective in providing protection from the 2 oncogenic HPV subtypes (16 and 18) that account for 70% of cervical cancers. During 2010, an estimated 12,200 new cases will be diagnosed and approximately 4210 women will die from cervical cancer in the US.[3] HPV 16 is also primarily responsible for some types of anal, penile, and oral cancers in men. Both HPV vaccines are given as a series of 3 injections, (Gardasil® at 0, 2, and 6 months and Cervarix® at 0, 1, and 6 months) and the safety profiles of both vaccines are excellent. Neither HPV vaccine is a live vaccine, therefore co-administration of other vaccines is permitted. If a series is interrupted and more than the recommended interval elapses, it is not necessary to begin the series again. The HPV vaccines are most effective if given prior to the initiation of sexual activity.[1]

Differences between HPV2 and HPV4. Only HPV4 includes protection for 2 nononcogenic HPV subtypes (6 and 11), which are responsible for 90% of genital warts. Approximately half a million cases of genital warts are reported each year in the United States among sexually active men and women, which adversely affect quality of life. Another difference between these 2 vaccines is that they contain different adjuvants.[2]

How long does protection last after completing the HPV vaccine series? We do not yet know if a booster vaccine will be necessary for either HPV vaccine. The duration of protection of the 2 vaccines can vary because they contain different adjuvants.

Should we vaccinate boys and men to reduce transmission of HPV and protect women from cervical cancer? According to mathematical modeling, if 80% or more of female vaccination is achieved, then a female-only vaccination program would be more cost-effective in reducing the overall burden of HPV-associated disorders. However, the most recent data on vaccination rates indicate that 2 years after the HPV4 vaccine was approved, among eligible girls and women, 37% have received the first dose and only 18% have received all 3 doses of HPV4. The mathematical model suggests that if vaccination rates for women are less than 80%, then vaccinating men might be a cost-effective approach.[2]

How much do the HPV vaccines cost? The current HPV2 and HPV4 vaccines are similarly priced at $385-$390 for the 3-dose series. The Vaccines for Children Program (VCP)[4] provides coverage for individuals 18 years or younger who do not have insurance coverage for the vaccine. Girls and young women aged 9-18 years are eligible for both vaccines under the VCP, and boys and young men aged 9-18 years are eligible for the HPV4 vaccine under the VCP. For men and women who are 19-26 years of age who do not have insurance coverage for HPV vaccines, options to receive free or lower-cost HPV vaccines include local health departments, college or university clinics, or local Planned Parenthood clinics. Merck has a Vaccine Patient Assistance Program for HPV4.[5]

Can the HPV vaccine be given during pregnancy and lactation? Giving the HPV vaccine to pregnant women is not recommended. Although no evidence suggests adverse outcomes of HPV vaccination to the mother or developing fetus, data on vaccination during pregnancy are limited. A pregnancy test prior to vaccination is not necessary. However, if a woman becomes pregnant after beginning the series, completion of the series should resume after pregnancy. If a dose was given during pregnancy, no intervention is needed. Lactating women can receive either HPV vaccine.[1]

What if my patient had an abnormal pap smear or genital warts -- suggesting prior exposure to HPV -- should I still give one of the HPV vaccines? Yes, the guidelines should be followed even if the patient has a history of an abnormal pap smear or genital warts, because infection with other HPV strains is possible. The HPV vaccine series can protect against the other HPV subtypes, but the vaccine has no therapeutic benefit for HPV strains already acquired.

After completion of the HPV series, do my patients still need to get regular Pap smears? Yes, women should still get regular Pap smears, even after completing the vaccine series of either HPV4 or HPV2 because not all oncogenic subtypes are covered by these vaccines.

Case example. A 19-year-old patient says she received the first injection of HPV vaccine 6 months ago, but does not remember which HPV vaccine she received and her records are not available. What should you do?

If possible, it is best to give the same vaccine formulation for the entire series. No reports have been published about the interchangeability of the vaccines. However, if a provider cannot determine which vaccine was administered previously, either HPV vaccine can be used to complete the series to provide protection against HPV 16 and 18. However, 3 doses of HPV4 are required to provide the maximum available protection against genital warts and vulvar and vaginal cancers and precancers. Full antibody response is present in both HPV vaccines 1month after completion of either series.[1,6] Patients should also be counseled about other methods, such as condoms or dental dams, to reduce their risk for HPV and other sexually transmitted infections.[7]

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