ACOG Updates Recommendations to Include 9-Valent HPV Vaccine

Tara Haelle

June 29, 2015

A key role of obstetrician/gynecologists and other healthcare providers is to provide patients and their parents with information on the benefits and safety of the human papillomavirus (HPV) vaccine and to encourage adolescents to receive the HPV immunization, according to updated recommendations published online June 26 by the American College of Obstetricians and Gynecologists.

"Current vaccination rates are unacceptably low," write ACOG's Committee on Adolescent Health Care and Immunization Expert Work Group. "Studies have shown that physicians' recommendations play a crucial role in the acceptance of HPV vaccination by patients and parents of patients."

The committees updated the March 2014 recommendations to include the new 9-valent HPV vaccine, also recommended by the Centers for Disease Control and Prevention (CDC) for girls and boys aged 11 to 12 years. Those who do not receive the HPV vaccine during the target age range should undergo catch-up vaccination until age 26 years.

The US Food and Drug Administration licensed the new formulation, Gardasil 9 (Merck), in December 2014. The new vaccine protects against the original four strains in the quadrivalent vaccine, as well as five additional strains, all of which are responsible for cervical, vulvar, vaginal, penile, and anal cancers. Another earlier bivalent vaccine protects against strains 16 and 18, which are responsible for the majority of cervical cancers. The 9-strain vaccine is more than 99% effective in reducing HPV disease from strains 6, 11, 16, and 18, and it is 96.7% effective in reducing disease from strains 31, 33, 45, 52, and 58.

Despite existing recommendations for HPV vaccination in adolescents, only about 50% of US girls between the ages 13 and 17 years have received at least one dose, and 33% have received all three doses. The CDC estimates that an immunization rate of at least 80% would prevent an additional 53,000 cases of cervical cancer during the lifetimes of those currently younger than 12 years.

Neither the CDC's Advisory Committee on Immunization Practices nor ACOG routinely recommends anyone receive the 9-strain vaccine if he or she received all three doses of the previous vaccine. However, providers can use the 9-strain vaccine to complete any series for males or females who received one or two doses of the earlier vaccines.

The safety profile of the 9-strain vaccine resembles that of the quadrivalent vaccine, with the exception of greater redness and swelling at the injection site in the newer vaccine. After more than 60 million doses of HPV vaccine administered, "there are no data to suggest that there are any severe adverse effects or adverse reactions linked to vaccination," the committee writes. "Obstetrician–gynecologists or other providers should counsel patients to expect discomfort after vaccination and that such discomfort is not a cause for concern," they write, although anyone with a previous life-threatening reaction to the HPV vaccine or its components, including yeast, should not receive the vaccine.

The committee does not recommend routine pregnancy testing or routine HPV testing before a patient receives the vaccine, and those in the target age range who may already have a positive HPV DNA test should still receive the vaccine. Despite reassuring safety data for HPV vaccination during pregnancy, ACOG recommends that women do not receive the vaccine while pregnant. Lactating women may receive it.

The committee opinion did not list external funding or disclosures.

"Committee Opinion: Human Papillomavirus Vaccination." ACOG. Published online June 26, 2015. Full text


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