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Why AAP recommends initiating HPV vaccination as early as age 9 :

October 4, 2019

For almost every childhood and adolescent vaccine, AAP policy mirrors the recommendation of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP). AAP representatives have worked with ACIP for decades to harmonize recommendations to prevent confusion among providers.

In rare cases, however, recommendations may differ. One notable example is a subtle difference in the wording of the AAP and ACIP recommendations regarding HPV vaccination.

ACIP’s recommendation is as follows: “ACIP recommends that routine HPV vaccination be initiated at age 11 or 12 years. The vaccination series can be started beginning at age 9 years.”

The AAP recommendation, which was introduced in the 2018-2021 Red Book, is as follows: “The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention 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.”

Why the difference?

Data continue to show the vaccine is safe and effective. It prevents HPV infection, anogenital warts, respiratory papillomatosis, cervical neoplasia and cancer (although the full extent of the impact on cancer likely will not be seen for another decade or two). Data recently presented to ACIP show that vaccinating only 202 people will prevent one case of HPV-related cancer.

Despite its effectiveness, HPV vaccination remains well below national goals and other vaccines that are part of the adolescent platform. The most recent National Immunization Survey-Teen showed uptake of Tdap vaccine was 89% and the first dose of MenACWY was 87%. HPV rates remain significantly behind these vaccines, with initiation at 68% and completion at 51%.

The burden of HPV-related mortality in the U.S. far surpasses the mortality from tetanus, diphtheria, pertussis and meningococcal disease combined. In the U.S., there are roughly 4,000 deaths per year from cervical cancer, not to mention the burden from the other types of HPV-related cancer. The vast majority of these deaths are preventable with the 9-valent HPV vaccine.

Because of this, the AAP considered policy options that could increase HPV uptake and ultimately decided to recommend starting the series between 9 and 12 years.

Giving the vaccination earlier offers providers more flexibility in introducing the vaccine. In addition, initiating the vaccine at age 9 or 10 also may be preferable for parents or adolescents who do not want to receive three or four (in influenza season) concomitant vaccines at age 11 or 12. If a vaccine is delayed at the 11- or 12-year visit, it almost always is the HPV vaccine. Offering the HPV vaccine earlier also offers the opportunity to complete the series before the other vaccines in the adolescent platform are due.

Additionally, there is no known downside to earlier initiation. The immune response is robust at younger ages, and there is no evidence of significant waning protection after antibody levels plateau approximately 18 to 24 months after series completion.

Finally, some providers have reported that initiating the vaccine earlier makes it easier to disentangle the HPV recommendation from the “sex talk” they have with patients at age 11 or 12. For example, few providers likely discuss risk factors for hepatitis B virus acquisition when they administer hepatitis B vaccine in the infant series.

While no randomized trials have compared introduction at 9 or 10 years to introduction at 11 or 12 years, there is some evidence supporting earlier initiation. 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 than those who initiated the series at age 11 or 12 (St. Sauver JL, et al. Prev Med. 2016;89:327-333). In addition, there are anecdotal reports of increased uptake when providers introduce HPV vaccine at age 9-10.

A quality improvement initiative performed in the Nationwide Children’s Hospital system utilizing electronic medical record alerts showed rapid uptake of HPV vaccine prior to age 11, suggesting a willingness by parents and providers to initiate the vaccine earlier than previously recommended (Goleman MJ, et al. Acad Pediatr. 2018;18:769-775). 

The AAP policy aims to encourage pediatricians to introduce the HPV vaccine at an earlier age to achieve higher completion rates. One strategy practices could consider is changing their electronic medical record to prompt an alert at age 9 or 10. The change could result not only in improved vaccine uptake but also fewer cancer deaths.

Drs. O’Leary and Nyquist are members of the AAP Committee on Infectious Diseases.

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