Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)
- Joel M Palefsky, MD
Joel M Palefsky, MD
- University of California San Francisco
- Immediate Past President, International Papillomavirus Society
- Immediate Past President, International Anal Neoplasia Society
- J Thomas Cox, MD
J Thomas Cox, MD
- American Society for Colposcopy and Cervical Pathology (ASCCP)
HPV VACCINE OVERVIEW
Human papillomavirus (HPV) is a virus that causes cervical cancer and genital warts. Persistent infection with certain types of HPV can lead to cancer of the cervix, which affects more than 10,000 American women every year. HPV can also cause cancers of the vulva and vagina in women, although these cancers are much less common than cervical cancer. HPV also causes cancers of the anus and of the oral cavity and throat, in both men and women.
Three vaccines (Gardasil, Gardasil-9, and Cervarix) are available to prevent infection with types of HPV known to cause cervical cancer. It is clear that these vaccines significantly reduce the number of women who develop cervical pre-cancer. It is expected that this will result in substantial reduction in the number women who develop cervical cancer.
This article discusses human papillomavirus and the human papillomavirus vaccine. Articles that discuss cervical cancer, cervical cancer screening (Pap smears), and genital warts are also available (see "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)" and "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Genital warts in women (Beyond the Basics)"). An article that discusses vaccines recommended for adults is also available. (See "Patient education: Adult vaccines (Beyond the Basics)".)
More detailed information about human papillomavirus vaccines is available by subscription. (See "Recommendations for the use of human papillomavirus vaccines".)
WHAT IS HPV?
Human papillomavirus (HPV) is a virus that is spread by skin-to-skin contact, including sexual intercourse (vaginal sex), oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). Condoms do not provide complete protection from HPV infection because condoms do not cover all exposed genital skin. People do not become infected with HPV by touching an object, such as a toilet seat.
The risk of HPV exposure increases with the number of sexual partners you have and the number of partners your partner has. It has been estimated that 75 to 80 percent of sexually active adults will acquire HPV infection before the age of 50. A majority of women and men become infected with HPV for the first time between ages 15 and 25 years. Most people who are infected with HPV have no signs or symptoms, and in most cases, never develop any problems caused by HPV.
In 10 to 20 percent of women, however, HPV infection persists. In this situation, there is a greater chance of developing cervical pre-cancer and then cancer. However, it usually takes on average 20 to 25 years for a new HPV infection to cause cervical cancer. Thus, regular testing is important in detecting cervical abnormalities early, before cancer develops. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)
Over 100 different types of HPV have been identified; more than 40 of these are known to infect the cervix and approximately 15 are known to cause cervical cancer. Researchers have labeled the HPV types as being high or low risk for causing cervical cancer.
●HPV types 6 and 11 can cause about 90 percent of genital warts. These types are low-risk because they do not cause cervical cancer. (See "Patient education: Genital warts in women (Beyond the Basics)".)
●Types 16 and 18 are the high-risk types that cause most (about 70 percent) cases of cervical cancer. HPV types 31, 33, 45, 52, and 58 are also high-risk types, causing about 19 percent of cervical cancers.
There are three US Food and Drug-approved HPV vaccines available. Talk to your health care provider to determine which vaccine is best for you. The three vaccines protect against different types of HPV:
●Gardasil-9 helps to prevent infection with nine HPV types (6, 11, 16, 18, 31, 33, 45, 52, and 58).
●Gardasil helps to prevent infection with four HPV types (6, 11, 16, and 18).
●Cervarix helps to prevent infection with HPV types 16 and 18.
HPV VACCINE TIMING AND DOSE
All of the HPV vaccines are given by injection. Dosing depends on your age:
●If you are younger than 15, you should get two injections at least six months apart, regardless of which vaccine you are getting.
●If you are 15 years or older, you should get three injections:
•For Gardasil and Gardasil-9, the second and third doses are given two and six months after the first, respectively.
•For Cervarix, the second and third doses are given one and six months after the first.
It is best to try to get all the recommended doses. If you miss a dose, talk to your health care provider about how many more doses you need.
Who should be vaccinated? — In the United States, HPV vaccination with any vaccine is recommended for all girls and women who are between ages 9 and 26 years . HPV vaccination with either Gardasil or Gardasil-9 is recommended for boys and men who are between ages 9 and 21 years. It can be given up to 26 years of age if they are men who have sex with men or have infection with the human immunodeficiency virus.
With any HPV vaccine, you will have the greatest protection from HPV if you are vaccinated BEFORE becoming sexually active. The vaccine does not help to get rid of HPV infection or any cervical abnormality after it has occurred. However, if you are less than 26 years old and you have been sexually active, had genital warts, a positive HPV test, or an abnormal Pap smear, you may still obtain some (albeit smaller) benefit from the HPV vaccine.
How long am I protected? — Scientists do not know exactly how long the vaccine protects against HPV infection. Clinical trials show that it provides protection for at least eight years .
Do I still need a Pap smear? — You do not need to have a pelvic exam or test for cervical cancer (eg, Pap smear) before you have the HPV vaccine. Cervical cancer screening (Pap smear) is recommended to start at age 21 .
However, getting the HPV vaccine does not mean that you can skip cervical cancer screening in the future, since the vaccine does not treat infections that might have occurred before you got the vaccine. Other types of high-risk HPV, which are not prevented by the vaccine, can also cause cervical cancer. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)
HPV VACCINE SIDE EFFECTS AND PRECAUTIONS
The HPV vaccine may cause mild redness, tenderness, or swelling near the injection site. There is no thimerosal (a mercury derivative used as a preservative) in the HPV vaccine. There may be an increased risk of passing out after an injection of HPV vaccine, so it is a good idea not to stand up too soon after getting the vaccine.
The vaccine is not currently recommended during pregnancy, although there are no known risks to a fetus if the vaccine is given.
Despite concerns about safety based on anecdotal reports, large studies have not confirmed major health risks of these vaccines. Most experts believe that the benefits of the vaccine outweigh its risks [4,5].
DOES THE VACCINE REALLY WORK?
Results from vaccine studies show that the HPV vaccine in women is very effective in preventing HPV infections and cervical pre-cancers caused by HPV types targeted by the vaccine [6-9]. HPV vaccination of women has been shown to reduce the risk of genital warts in their male sexual partners . Studies also show that the HPV vaccine in men reduces the risk of developing genital warts and persistent penile HPV infection, which may decrease the spread of HPV to sexual partners. HPV vaccination also reduces the risk of anal cancer in both men and women.
OTHER SEXUALLY TRANSMITTED INFECTIONS
The HPV vaccine is not 100 percent protective, but it is still highly effective. The HPV vaccine does not prevent other sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), herpes, chlamydia, and gonorrhea.
It is important to practice safer sex to reduce the risk of all STIs. This includes using a male or female condom with every sexual act. (See "Patient education: Barrier methods of birth control (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your specific medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Human papillomavirus (HPV) vaccine (The Basics)
Patient education: Vaccines (The Basics)
Patient education: Cervical cancer (The Basics)
Patient education: Vaccines for adults (The Basics)
Patient education: Screening for sexually transmitted infections (The Basics)
Patient education: Urethritis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Adult vaccines (Beyond the Basics)
Patient education: Barrier methods of birth control (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment
Carcinoma of the penis: Epidemiology, risk factors, and pathology
Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention
Cervical intraepithelial neoplasia: Management of low-grade and high-grade lesions
Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis
Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in men
Epidemiology of human papillomavirus infections
Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis
Recommendations for the use of human papillomavirus vaccines
Treatment of vulvar and vaginal warts
Virology of human papillomavirus infections and the link to cancer
The following organizations also provide reliable health information.
●National Cancer Institute
●Centers for Disease Control and Prevention, National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
Telephone: 800-CDC-INFO (800-232-4636)
●Center for Disease Control and Prevention
●American Social Health Association
- Petrosky E, Bocchini JA Jr, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2015; 64:300.
- Ferris D, Samakoses R, Block SL, et al. Long-term study of a quadrivalent human papillomavirus vaccine. Pediatrics 2014; 134:e657.
- Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62:147.
- www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm179549.htm (Accessed on October 14, 2011).
- http://www.who.int/vaccine_safety/committee/topics/hpv/dec_2013/en/ (Accessed on October 12, 2015).
- Garland SM, Hernandez-Avila M, Wheeler CM, et al. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med 2007; 356:1928.
- Villa LL, Costa RL, Petta CA, et al. High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up. Br J Cancer 2006; 95:1459.
- Paavonen J, Jenkins D, Bosch FX, et al. Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial. Lancet 2007; 369:2161.
- Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med 2015; 372:711.
- Donovan B, Franklin N, Guy R, et al. Quadrivalent human papillomavirus vaccination and trends in genital warts in Australia: analysis of national sentinel surveillance data. Lancet Infect Dis 2011; 11:39.
- Olsson SE, Villa LL, Costa RL, et al. Induction of immune memory following administration of a prophylactic quadrivalent human papillomavirus (HPV) types 6/11/16/18 L1 virus-like particle (VLP) vaccine. Vaccine 2007; 25:4931.
- Joura EA, Leodolter S, Hernandez-Avila M, et al. Efficacy of a quadrivalent prophylactic human papillomavirus (types 6, 11, 16, and 18) L1 virus-like-particle vaccine against high-grade vulval and vaginal lesions: a combined analysis of three randomised clinical trials. Lancet 2007; 369:1693.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.