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成人注射宫颈癌疫苗 — 哪些人需要?

发表在JAMA (美国医学学会期刊)最新的一个科研报告显示,HPV 病毒在美国每一年会导致44,000 个癌症病例。宫颈癌疫苗可以有效的预防HPV的危害。

  •     第6 和 11 型HPV造成 90% 的尖锐湿疣
  •     第 16 和 18 型造成 64% 宫颈癌病例
  •     第 31,33,45,52,58型造成 10% 的宫颈癌的病例。

宫颈癌疫苗是预防性的疫苗,所以效果最好是在尚未感染到病毒前就注射。目前建议男性/女性在11-12岁就注射,甚至可以提早到9岁。

  • 15岁以下开始注射:2 剂 —注射之后6-12个月注射第二针。
  • 15岁以后才注射:3剂 — 第一针后,1-2个月打第二针,第六个月打第三针。

早期,美国药监局是核准年龄上限是26岁。在2018 年10 月,又将上限延长到45岁。然而并不是每个超过26岁的人都需要接种疫苗。那么,什么人需要呢?

“凡是有可能还会传染到HPV”的人,都建议接种,至于是否属于高危人群,这决定需要自己和医生一起讨论决定。


HPV Vaccine for Adults: Who Needs It? Who Doesn't?

A new study was published in JAMA Network. HPV, the human papilloma virus, causes cancer—as many as 44,000 cancers in the United States each year. An HPV vaccine is available and protects against nine virus types:

  • Types 6 and 11 cause 90% of all anogenital warts;
  • High-risk types 16 and 18 cause 64% of HPV-related cancers;
  • High-risk types 31, 33, 45, 52, and 58 cause another 10% of HPV-related cancers.

The HPV vaccine is a prophylactic vaccine. It works best when given before exposure to the virus. The HPV vaccination series is recommended for all boys and girls at age 11-12. It can be given as early as age 9. The number of doses needed depends on the age when starting the series:

  • First dose < age 15: two doses (0 and 6-12 months)
  • First dose ≥ age 15: three doses (0, 1-2, and 6 months)

Three doses are also needed for those with HIV or other immunocompromising conditions. Catch-up vaccination is recommended for all patients through age 26.

In October 2018, the US Food and Drug Administration extended the upper age indication for HPV vaccine from 26 up to 45. But not everyone in this older age group needs it. Who does? Those at risk for new HPV infection. ACIP's new buzzword for this decision process is "shared clinical decision-making," which is coded blue on the new adult schedule, meaning that you and your patient have to decide.

Here's what to consider. The HPV vaccine doesn't treat HPV-related disease. It doesn't help clear HPV infection; it prevents it. Unfortunately, there's no clinical antibody test and no antibody titer that can predict immunity. Many adults aged 27-45 have already been exposed to HPV early in life. Those in a long-term mutually monogamous relationship are not likely to get a new HPV infection. Those with multiple prior sex partners are more likely to have already been exposed to vaccine serotypes. For them, the vaccine will be less effective.

However, those with fewer prior sex partners, who are now at risk for exposure to a new HPV infection from a new sex partner, are most likely to benefit from HPV vaccination. With shared clinical decision-making, your patients need to understand the potential value of the vaccine for their circumstances. Then you and your patient have to decide.

Frequently Asked Questions

If you start the series with the 4-valent HPV vaccine, is it okay to complete the series with the 9-valent HPV vaccine?

Answer: Yes, and that's your only choice. The 9-valent version is the only one now available in the United States.

If a patient has completed a 4-valent vaccine series, should they now get a booster with the 9-valent vaccine? Will insurance pay for it?

Answer: Here's what ACIP says: "There is no ACIP recommendation for additional 9v HPV doses for persons who previously completed a series of 4v HPV or 2v HPV. " That's the official guidance. But remember, "no recommendation" doesn't mean "not recommended." Safety is not an issue. But most of the benefit of including the five extra HPV types is for females in preventing cervical cancer. There's not much additional cancer protection for males. More details can be found in the guidance section on the ACIP website.

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