The human papillomavirus (HPV) vaccine reduces the incidence of diseases associated with HPV infection, including genital
warts, most cervical cancers and many anogenital and oropharyngeal cancers. Since January, 2017, all females and males
aged nine to 26 years have been eligible to receive subsidised vaccination; previously it was only subsidised for females
until age 20 years. At the same time as subsidised access to the vaccine was widened, protection was extended from four
strains of HPV to nine strains, by changing from Gardasil to Gardasil 9.
Further information on the nonavalent HPV vaccine is available from: www.bpac.org.nz/2016/hpv.aspx
The number of doses varies by age
Table 1 describes the groups of people eligible for subsidised vaccination and the number of doses recommended. School-based
immunisation normally begins at age 11 or 12 years (Year 7 or 8), however, the vaccine can be given early to patients
who are immunocompromised or prior to organ transplant.1 People aged 27 years and older who received at least
one dose of HPV vaccine before turning 27 years can complete the schedule fully subsidised. The vaccine can be administered
unsubsidised to people aged 27 years and over if they are likely to benefit (Table 1).1
Immunocompromised patients can receive the HPV vaccination
HPV vaccination can be safely administered to people who are immunocompromised, e.g. those who have received chemotherapy
or with HIV infection, because the vaccine contains non-replicating, non-infectious viral subunits.1, 3
HPV vaccine can be given during pregnancy or while breast feeding
While it is recommended to wait until after pregnancy to administer the HPV vaccine, there is no evidence that it causes
adverse effects such as congenital abnormalities or spontaneous abortion.4 The HPV vaccine is safe to receive
while breastfeeding.4
Table 1. HPV vaccine schedules adapted from the Ministry of Health (2017)1
|
Number of doses |
Schedule |
Subsidy |
Children aged 9–14 years |
2 |
0 and 6–12 months |
Yes |
People aged 15–26 years |
3 |
0, 2 and 6 months |
Yes |
People aged 9–26 years with:
OR
- Organ or tissue transplant (including stem cells)
|
3 |
0, 2 and 6 months |
Yes |
People aged 9–26 years who are post-chemotherapy |
One additional dose |
≥ 1 month after the last dose |
Yes |
People aged 27 and older† who may benefit, e.g.:
- Those with little previous exposure to HPV
- Men who have sex with men
- Those with HIV infection
|
3 |
0, 2 and 6 months |
No |
† The HPV vaccine is registered for use in females aged 9–45 years and in males aged 9–26 years, however, there are no concerns
that the efficacy or safety in males up to the age of 45 years will differ significantly from females of the same age or younger males.1 The unsubsidised
cost of three doses varies but is approximately $500 as of February 2019.2
How effective has HPV vaccination been in New Zealand?
The number of diagnoses of genital warts has significantly decreased since the introduction of the vaccine: the latest surveillance data reported a 17% decline in diagnoses in sexual health clinics and family planning clinics in all ages from 2014 to 2015.5 Data
collected from the Auckland Sexual Health Service showed an 83% reduction in genital wart diagnoses in young females in
2013 compared with 2008, before the HPV vaccination programme was introduced.6 It is too early to detect any
effects of HPV vaccination on cancer rates in New Zealand as this requires lengthy follow-up periods.
Vaccination rates against HPV in New Zealand are too low
The target for HPV vaccination is 75% coverage across all DHBs, which the Ministry of Health hoped to achieve by December,
2017. This level of coverage is considered to provide more effective “herd immunity” where those unwilling or unable to
receive the vaccine are also protected.7 This target was not met, with latest figures showing only 67% coverage
for females born in 2003.* 8 The lowest rate of vaccination was in European/Others (65%), with higher
rates in Māori (67%), Asian (71%) and Pacific peoples (73%).8
* Data are currently unavailable for females born after 2003 and there are currently no statistics
for coverage in males
Catch-up vaccinations following the supply shortage
There was a supply shortage of HPV vaccines in New Zealand during late 2017 and through most of 2018. This issue has
been resolved and health professionals in primary care are now able to order unrestricted quantities of the vaccine. However,
the Ministry of Health indicates that there are a significant number of eligible people, particularly young males, who
have not completed the full course of vaccinations due to the shortage. The following guidance is provided for health
professionals scheduling “catch-up” vaccinations:
- If a person has started the course of HPV vaccinations they do not need to begin the course again, regardless of the
amount of time that has passed; give the next dose as scheduled
- If the second HPV vaccination is given at age 15 years or older a third dose is recommended and subsidised
- People who turned age 27 years after April 1, 2018, who received their first dose of HPV vaccine before 1 April, 2019,
and international students who turn age 18 years during this period are eligible to receive a subsidised course of HPV
vaccinations*
* A manual claim should be submitted after the first dose. Once this has been accepted the
subsequent doses should be processed automatically.
HPV infection is spread via close skin-to-skin contact which can occur during penetrative and non-penetrative sexual
contact, e.g. oral sex.9 In very rare cases, HPV can be transmitted from mother to fetus perinatally.1 Approximately
80% of sexually active adults will be infected by at least one strain of HPV during their lifetime, with the risk of infection
increasing in proportion to the number of sexual partners.9
The natural history of HPV infection, i.e. without vaccination, is often transient and asymptomatic, with a loss of
detectable HPV occurring after 6–12 months.9 However, in some individuals the repeated division of infected
cells will result in the development of anogenital warts, often weeks or months after acquiring the infection.9 In
10–20% of people the infection will persist latently over years, strongly increasing their risk of developing a neoplasia,
which may eventually progress to invasive cancer.10 The reasons why some people have persistent infections
with HPV are not completely understood but may involve genetics and environmental factors such as alcohol consumption
and tobacco smoking.10 Consistent use of condoms only reduces the rate of transmission by 30–60% as they
may not cover all areas of infection.9
Vaccination protects against nine strains of HPV
The current HPV vaccine prevents infection from nine strains of HPV, including two low-risk strains (6 and 11) that
cause approximately 90% of genital warts and seven high-risk strains (16, 18, 31, 33, 45, 52 and 58) that cause the majority
of cervical cancers; strains 16 and 18 are associated with approximately 70% of invasive cervical cancers.9
HPV vaccination prevents more than 97% of genital intraepithelial neoplasias and anogenital warts among females aged
16–26 years who have tested negative for prior infection with HPV (see: “Routine cervical screening
is still required“).1,
11 Less data are available regarding the vaccine’s efficacy in males, but there is evidence that more than 90%
of external genital lesions, including warts and genital intraepithelial neoplasias, are prevented in males aged 16–26
years.12 N.B. Genital intraepithelial neoplasias are rare among young males and females.
Long-term immune responses occur in almost all people
One month after completing the HPV vaccination schedule, 99.6% – 100% of people aged 9–26 years will have antibodies
present against all nine strains covered by the vaccine.11 It is unclear how long protection lasts as studies
are ongoing, however, it is known to persist for at least ten years with no decrease in efficacy, therefore booster vaccinations
are not considered necessary if the full schedule has been completed.11
Vaccination at an early age is associated with greater protection
Vaccination against HPV is associated with a stronger immune response in younger people.13 For this reason,
only two doses of the vaccine are required for those aged under 14 years, compared with three in older groups. It is important
that young people and caregivers understand that the reason why vaccination is recommended at age 11–12 years is to maximise
the recipient’s immune response and avoid the need for additional doses, rather than it being a predictor of imminent
sexual activity.
Vaccination is also beneficial for people who are sexually active
People who are sexually active, including those who have already been infected with HPV and those who have developed
HPV-related conditions, may also benefit from vaccination. Most significantly, the vaccine will provide these people with
protection against strains of HPV they have not encountered. It may also prevent reinfection with a strain they have been
previously exposed to if they cleared the infection without producing antibodies against that strain. Many people who
are infected with HPV do not develop immunity as seroconversion is poor.9 Immunity from vaccination is more
effective than immunity post-exposure to the wild virus. There are no safety concerns associated with vaccination in people
who are already infected with HPV or who have developed an HPV-related condition.1
Conditions associated with HPV infection
HPV infects human epithelial cells and there are more than 100 subtypes with differing propensities to infect mucosal
or cutaneous tissue.9 There are more than 40 types of HPV that infect the anogenital area and throat, the majority
of which are sexually transmitted.9 It has been reported that high-risk HPV strains cause 5% of all cancers
worldwide.14
Anogenital warts: Anogenital warts typically occur within weeks or months of infection with HPV.9 Strains
6 and 11 account for approximately 90% of all cases of anogenital warts.15 These warts do not lead to cancer
but they can cause physical discomfort, anxiety and social stigma.
Cervical cancer: It is well established that persistent infections with HPV cause cervical cancer and
the association is present in virtually all cases worldwide.16 Most females infected with HPV, however, do
not develop cervical cancer.9 The progression from cervical intraepithelial neoplasia to cervical cancer usually
occurs over 15–20 years, but a compromised immune system may accelerate this.9 There were 180 cases of cervical
cancer registered in New Zealand in 2016.17
Other cancers: Infection with HPV is associated with approximately 75% of oropharyngeal cancers.18 The
incidence of HPV-related oropharyngeal cancer is increasing in New Zealand and is four- to five-times higher in males
than females (3.01 and 0.65 cases per 100,000 population, respectively).18 Infection with high-risk HPV is
also associated with over 90% of anal, 70% of vulval and vaginal, and 50% of penile cancers.9 These cancers
are relatively rare but their prevalence in New Zealand is increasing.9
Other conditions: Low-risk HPV can also cause benign growths in the respiratory tract which may present
as hoarseness or airway compromise.1 Although rare, this can be seen in newborns who acquire the virus from
the birth canal.
Routine cervical screening is still required
Females who have received the HPV vaccine still need to participate in the National Cervical Screening Programme as the vaccine
does not provide protection against every strain of HPV that can cause cervical cancer.1
Changes to the screening programme are coming:19, 20
- During 2019 – The frequency of cervical screening will change from every three years to every five years, and the age
at which screening begins will be increased to 25 years, from 20 years
- During 2021 – Instead of initially using liquid-based cytology to identify pre-cancerous or cancerous changes in cells
from the cervix, HPV primary screening will instead be the first test; samples containing high-risk HPV strains will subsequently
undergo cytology analysis. Cells will be taken from the cervix via the same method used for liquid-based cytology, although
in the future self-sampling methods may be available.
Some people in New Zealand are unaware they are entitled to fully subsidised HPV vaccinations or were not eligible at
the time and have therefore not participated in the school-based programme. General practices should identify any eligible
enrolled patients who have not received HPV vaccination.
A routine recall at age 14 years is recommended. For example:
- Schedule an automatic reminder to occur when a patient turns 14 years and send a recall letter if appropriate
- Establish a monthly recall for all people who have turned 14 in the previous month
People aged 15–26 years who have not received the full schedule of HPV vaccines (or any at all) can
be flagged in the patient management system to be offered the vaccine at their next consultation. Patients who do not
regularly attend primary care may require a recall offering them subsidised vaccination.
Best practice tip: use the recall as an opportunity to also check for completion of two
measles, mumps and rubella (MMR) vaccines, tetanus-diptheria-pertussis (Tdap) vaccination (usually given in a school-based
programme at age 11 years), and a history of varicella or varicella vaccination.
The ASK approach to vaccination discussions
Health professionals sometimes meet resistance when discussing vaccination. The ASK approach is one option clinicians
can use when discussing potentially emotive issues:
- Acknowledging the person’s concerns
- Steering the conversation
- Knowing the facts
Not every person will express the same concerns, so acknowledging differing viewpoints and being non-judgemental is
important when discussing vaccination.
Setting the story straight about safety
More than 100 million doses of the HPV vaccine have been administered worldwide, and it has been well-tolerated in females
and males across all age groups.2 The risks associated with the HPV vaccine are similar to other vaccines.
The most common adverse effect is mild-to-moderate injection-site pain which occurs in 83% of people within five days.11 Other
possible adverse effects are generally transient, including swelling, erythema, pruritus and bruising around the injection
site, as well as headaches and pyrexia.2 The risk of anaphylactic reaction after administering the vaccine
is approximately three cases per million doses.1
There is no evidence linking the HPV vaccine to rare adverse effects
There have been case reports describing an association between administration of the HPV vaccine and the development
of some rare conditions, e.g. autoimmune disorders, complex regional pain syndrome (CRPS) and postural orthostatic tachycardia
syndrome (POTS). However, as vaccination is widespread and these conditions are relatively rare it is not possible to
analyse the potential relationship between the two without performing large epidemiological studies.
A large Canadian cohort study of more than 290,000 females aged 12–17 years found no increased risk of autoimmune disorders
following vaccination with the quadrivalent HPV vaccine.21 An extensive review of the evidence by the European
Medicines Agency (EMA) found no evidence that the HPV vaccine causes CRPS or POTS.22 The prevalence of both
conditions in the general population is approximately 150 cases per million people each year, and the occurrence of CRPS
and POTS in young females who had been vaccinated was no higher than would be expected.22
Patient information on HPV and the HPV vaccine are available from:
