Common Questions About 9-Valent HPV Vaccine

Lauri Markowitz, MD


June 22, 2015

Editorial Collaboration

Medscape &

This feature requires the newest version of Flash. You can download it here.

Hello. I'm Dr Lauri Markowitz, a medical epidemiologistat the Centers for Disease Control and Prevention (CDC). I'm pleased to speak with you today as part of the CDC Expert Commentary series on Medscape.

On February 26, 2015, the Advisory Committee on Immunization Practices (ACIP) recommended that the 9-valent HPV vaccine (Gardasil® 9) be included as one of three vaccines that can be used for routine vaccination of females and males in the United States.[1] The other vaccines available are the bivalent vaccine, licensed and recommended for females; and the quadrivalent vaccine, licensed and recommended for females and males.

All three HPV vaccines protect against HPV types 16 and 18, the types that cause the majority of HPV-associated cancers. The quadrivalent and 9-valent vaccines also protect against HPV types 6 and 11, the types that cause the majority of genital warts. The 9-valent vaccine protects against the same four HPV types in the quadrivalent vaccine and five additional types. These additional types cause about 10% of HPV-associated cancers, including about 15% of cervical cancers.

ACIP recommends routine vaccination of girls and boys aged 11 and 12 years. ACIP also recommends vaccination of females aged 13 through 26, and males aged 13 through 21 years who have not been vaccinated previously or who have not completed the HPV vaccine series.

With new recommendations there are always questions, and with this vaccine it is no different. For that reason, I'm going to take this opportunity to address some of the common questions about this recommendation.

One of the questions that comes up most often deals with the idea of delaying vaccination. Should I delay giving my patients HPV vaccine until the 9-valent version is available? No. ACIP recommends that those who are eligible for vaccination start the HPV vaccine series with whatever vaccine is available from their healthcare professional.

A second common question is about completing the vaccination series with a different HPV vaccine. For example, if a patient has started the HPV vaccine series with quadrivalent vaccine but has not completed the series, can the 9-valent HPV vaccine be used to complete the series? For females, any HPV vaccine may be used to complete the series. For males, either quadrivalent or 9-valent HPV vaccine may be used to complete the series.

As with all recently recommended vaccines, both parents and clinicians may have questions about safety. In the prelicensure studies, the 9-valent vaccine was studied in more than 15,000 females and males. In some studies, the 9-valent vaccine was compared with the quadrivalent vaccine. The 9-valent vaccine caused slightly more reactions—primarily swelling and redness—where the injection was given. As with the quadrivalent vaccine, side effects were generally mild. The benefits of HPV vaccination far outweigh any potential risks for side effects from the vaccine.

Along with safety, questions about vaccine effectiveness tend to come up when dealing with recent recommendations. How long will protection from 9-valent HPV vaccine last? In the 9-valent HPV vaccine trials, study participants have been followed for about 4 years after receiving the vaccine and will continue to be monitored to assess how long the vaccine protects against HPV. On the basis of data available for the bivalent and quadrivalent vaccines, the scientific community believes that the 9-valent vaccine will offer long-lasting protection. Studies for quadrivalent and bivalent vaccines have followed study participants for 8-10 years to date and have found no evidence of waning protection.[2,3]

Another question that might be raised is whether to give the 9-valent HPV vaccine to people who have already completed an HPV vaccination series. ACIP probably will address this in future meetings.

CDC encourages healthcare professionals to recommend the HPV vaccine series the same way and on the same day that you recommend the Tdap and meningococcal conjugate vaccines.

We invite you to visit CDC's HPV vaccine portal for clinicians. This site includes materials designed specifically for your needs as well as multimedia products that can be downloaded for use in your practice.

Web Resources

Lauri Markowitz, MD, is the Team Lead for Epidemiology Research in the Division of STD Prevention, CDC. She received her medical degree from Albert Einstein College of Medicine and completed her residency training in internal medicine at the University of Pennsylvania. Dr Markowitz has worked on epidemiologic research and policy for a variety of vaccine-preventable diseases and sexually transmitted infections. She worked on childhood vaccine-preventable diseases in the National Immunization Program, CDC, from 1985 through 1993. From 1993 through 1999, she worked in Bangkok, Thailand, on some of the first HIV vaccine trials. In her current position, she has coordinated the HPV Vaccine Workgroup of the Advisory Committee on Immunization Practices (ACIP) and spearheaded the development of recommendations for use of HPV vaccine in the United States. Dr Markowitz has provided consultation related to HPV vaccine to a variety of national and international groups.