Technically Speaking: Why HPV Vaccination Before Age 11 Years Is a Good Idea
Published on
Vaccine Update for Healthcare ProvidersPublished on
Vaccine Update for Healthcare ProvidersIn the United States, vaccination recommendations for children and adolescents are developed through collaboration of two groups of experts: the American Academy of Pediatrics (AAP) Committee on Infectious Diseases (COID) and the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). While the recommendations are usually “harmonized,” meaning the same or nearly so, the recommendations about human papillomavirus (HPV) vaccine differ in an important way.
During this Cervical Health Awareness Month, we asked Dr. Sean O’Leary, Chair of AAP’s COID, to explain the “what” and “why” related to this recommendation difference.
In short, AAP emphasizes series initiation at an earlier age, as the 2018-2021 AAP Red Book first spelled out:
“The AAP and the ACIP on behalf of CDC recommend routine HPV vaccination for females and males. The AAP recommends starting the series between 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series. The ACIP recommends starting the series at age 11 or 12 years and states that vaccination can be administered starting at 9 years.”
Absolutely! CDC and AAP both see HPV vaccine as an important routine vaccination because the vaccine is safe and effective, preventing most cases of HPV infection if given before exposure to the virus. HPV infection prevention, in turn, leads to prevention of cervical dysplasia and cancer; the data on the impact on cervical cancer grow stronger every year. Healthcare personnel often do not realize that in the U.S., HPV-related mortality far surpasses the mortality from tetanus, diphtheria, pertussis and meningococcal disease combined. Each year, about 4,000 deaths are the result of cervical cancer; most are preventable through pre-exposure vaccination. We expect vaccination to prevent other HPV-associated cancers, such as oropharyngeal cancer, too. Further, we also are thrilled with the evidence that HPV vaccination prevents anogenital warts and respiratory papillomatosis.
In short, we see recommending HPV vaccine at 9 or 10 years of age to increase vaccination coverage. We are aware that, despite the vaccine’s remarkable record of safety and efficacy, HPV vaccination coverage is well below national goals. As detailed in the September 2022 “Technically Speaking” column, the most recent National Immunization Survey-Teen showed uptake of tetanus diphtheria acellular pertussis (Tdap) vaccine was 90.1% and the first dose of quadrivalent meningococcal (MenACWY) was 89.3%, whereas HPV initiation was 75.1% and completion was 58.6%.
Four considerations were critical to this decision:
Two main changes to the practice of medicine and HPV vaccination offer reasons to abandon the 11- to 12-year-old “adolescent platform” when it comes to HPV vaccination:
Observational studies support earlier initiation. For example, a retrospective study showed that adolescents who started the HPV vaccine series at age 9 or 10 were 22 times more likely to complete the two-dose series by age 15 compared with those who initiated the series at age 11 or 12. Likewise, reports from quality improvement initiatives have shown rapid uptake of HPV vaccine prior to age 11.
A randomized trial comparing series initiation at 9 or 10 years versus 11 or 12 years, in which I am involved, is currently ongoing. Results are expected in the next few years.
The AAP and CDC share the goal of preventing HPV-related cancers and other diseases by optimizing coverage with HPV vaccine. HPV vaccination at 9 or 10 years of age is just one of many strategies to increase HPV vaccine uptake (e.g., reminder/recall, standing orders, presumptive recommendations). However, preliminary evidence suggests that it may be effective; therefore, it offers another important tool in the box as we seek to position our patients for healthy futures.
Editor’s note: Sean O’Leary, MD, MPH, FAAP, practices in the Department of Pediatrics at the University of Colorado Anschutz Medical Campus and the Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS) at the University of Colorado School of Medicine/Children’s Hospital Colorado in Aurora, Colorado. Dr. O’Leary indicated that he has no financial conflicts of interest. He is a co-investigator on an NIH-funded clinical trial comparing introduction of HPV vaccine at age 9 or 10 to introduction at 11 or 12, as mentioned in the commentary (Kempe, Szilagyi, multi-PI’s, 5R01 CA240649-03).
Contributed by: Sharon G. Humiston, MD, MPH, FAAP
Categories: Vaccine Update January 2023, Technically Speaking
Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.
You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.