An Update on Human Papillomavirus Vaccination in the United States

Abstract

ABSTRACT Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States in adults, and although most cases are transient, 10%–20% of infections can persist and progress to various forms of cancer. The HPV vaccine prevents more than 90% of HPV infections and HPV-associated cancers. The vaccine is most effective at preventing all types of HPV-related dysplasia in patients with no prior exposure to HPV. Reasons for decreased compliance include parent-specific factors such as education, safety concerns, absence of professional recommendation, and apprehension about supporting sexual behavior, whereas professional-level barriers include lack of time to discuss vaccination, knowledge gaps, vaccine access, and financial concerns. This clinical expert series highlights the evidence supporting the HPV vaccine as a safe and effective way to prevent cervical cancer. Most HPV infections are acquired in individuals aged 14–24 years with increasing prevalence with each year. Shared decision-making should be used for patients aged 27–45 years, in whom the vaccine has been demonstrated to be safe and effective, but the population advantage of vaccination is expected to be limited. Unvaccinated health care workers exposed to the virus in their practices should be vaccinated between the ages of 27 and 45 years. A previous HPV infection should not be a reason to not receive the vaccine, and it is not necessary to screen individual patients before vaccination. The vaccine is efficacious against other HPV types regardless of which HPV strain an individual may be positive for at the time of vaccination. Regarding women with HPV-related dysplasia such as high-grade squamous intraepithelial lesions that undergo excisional procedures, up to 15% will experience persistent or recurrent disease, and these women are at higher risk of developing a new HPV-associated lesion. Therefore, vaccination may provide a significant reduction in future disease in this patient population. The World Health Organization Strategic Advisory Group of Experts on Immunization recently evaluated the current scheduling regimens for the HPV vaccine and concluded that a single dose may provide enough protection in individuals younger than age 21; however, the Centers for Disease Control and Prevention is yet to comment. An ongoing large randomized, controlled, double-blinded, noninferiority trial (ESCUDDO) is currently evaluating a single-dose versus 2-dose regimen that will help elucidate whether vaccine scheduling in the United States may change to a single-dose paradigm. The strongest predictor of vaccine uptake is health care professional recommendation, and patients with prior infection or excision should still be offered the vaccine. Finally, although vaccination national guidelines are in place for individuals aged 9–26 years, certain patient populations older than 26 years may benefit from the vaccine.