COMMENTARY

5 Things to Know: HPV Vaccination of Adults Aged 27 Through 45 Years

Lauri E. Markowitz, MD

Disclosures

August 20, 2021

Editorial Collaboration

Medscape &

Should adults aged 27 through 45 years get the human papillomavirus (HPV) vaccine? The answer comes down to shared clinical decision-making between you and your patient.

HPV is so common that nearly all men and women will get infected at some point in their lives. Most sexually active adults have already been exposed to HPV, although not necessarily to all of the HPV types targeted by vaccination. While most HPV infections clear or become undetectable, some do not and can cause some precancers and cancers, as well as anogenital warts.

Cervical cancer is the most common HPV-associated cancer among women, and oropharyngeal cancers (cancers of the back of the throat, including the base of the tongue and tonsils) are the most common among men. HPV can also cause cancers of the anus, vulva, vagina, and penis, as well as anal, vaginal, cervical, and vulvar precancers. Although there is screening for cervical cancer, there are no routine screenings for other types of cancers caused by HPV, so they often are not detected until they cause serious health problems. HPV vaccination can prevent more than 90% of cancers caused by HPV.

Here are five things you should know about the current HPV vaccination recommendations:

1. HPV vaccination is not routinely recommended for persons older than 26 years.

CDC recommends shared clinical decision-making (SCDM) regarding potential HPV vaccination of adults aged 27 through 45 years who are not already vaccinated. Some of these adults aged 27 through 45 years may decide to get vaccinated after discussion with their healthcare provider. HPV vaccination of adults in this age range provides less benefit compared to vaccination of younger people, as more have been already exposed to HPV.


 

CDC does not recommend vaccination for all adults aged 27 through 45 years, but recognizes that some persons in this age range who are not adequately vaccinated might be at risk for new HPV infection and might benefit from vaccination. Since there is no clinical antibody test that can determine whether a person is already immune or still susceptible to any given HPV type, identifying who could benefit from HPV vaccination is not always straightforward. Some considerations are mentioned in the next section.

2. SCDM recommendations should be informed by the characteristics, values, and preferences of the patient and the clinical discretion of the healthcare provider.

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

HPV vaccine effectiveness is highest in people who have never had sex. HPV vaccine effectiveness might be lower among people with more risk factors for HPV, such as having had sex with more than one person or having certain immunocompromising conditions. At any age, having a new sex partner is a risk factor for getting a new HPV infection. However, this is only one possible consideration for SCDM.

Adults with more HPV risk factors (for example, multiple previous sex partners or certain immunocompromising conditions) might have been infected with HPV in the past, and so might have a lower chance of getting a new HPV infection in the future.

Adults with fewer HPV risk factors (for example, few or no previous sex partners), who might not have been infected with HPV in the past, could have a higher chance of getting HPV infection from a new sex partner. People who are already in a long-term, mutually monogamous relationship are not likely to get a new HPV infection.

Therefore, use your clinical judgment based on information the patient has shared with you to assess if they might benefit from HPV vaccination at their current age.

3. Routine recommendations for HPV vaccination of adolescents remain the same.

HPV vaccination provides the most benefit when given before a person is exposed to any HPV. That's why CDC recommends HPV vaccination at age 11 or 12 years; the series can be started at age 9 years. HPV vaccination is also recommended through age 26 years for everyone who is not adequately vaccinated. HPV vaccination is given as a series of either two or three doses, depending on age at initial vaccination.

4. HPV vaccination prevents new HPV infections but does not treat existing infections or diseases.

HPV vaccines are prophylactic (ie, they prevent new HPV infections). They do not prevent progression of HPV infection to disease, decrease time to clearance of HPV infection, or treat HPV-related disease.

5. If adults aged 27 through 45 years are vaccinated, they need three doses of HPV vaccine.

If you and your previously unvaccinated adult patient decide to proceed with HPV vaccination, offer a three-dose series of HPV vaccine at 0, 2, and 6 months. If your patient is pregnant, HPV vaccination can be given after pregnancy. HPV vaccination is considered very safe unless a patient had a severe allergic reaction after a previous dose or to a vaccine component. Eligible patients should also get recommended cervical cancer screening.

Resources

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

ACIP HPV Vaccine Recommendations | CDC

ACIP Shared Clinical Decision-Making Recommendations | CDC

HPV Vaccine Schedule and Dosing | CDC

Adult Immunization Schedule by Vaccine and Age Group | CDC

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