Do I Need to Get Hpv Vaccine Again if Ive Had It Before

Human Papillomavirus (HPV)

Affliction Problems Contraindications and Precautions Vaccine Recommendations Vaccine Safety Scheduling and Administering Vaccines Storage and Handling

Disease Issues

How common is human papillomavirus (HPV) infection?

HPV is the most common sexually transmitted infection in the United states. In the U.s.a., an estimated 79 1000000 persons are infected, and an estimated 14 million new HPV infections occur every year among persons age 15 through 59 years. Approximately half of new infections occur among persons age 15 through 24 years. First HPV infection occurs within a few months to years of condign sexually active.

How serious is disease caused by HPV?

Well-nigh HPV infections are asymptomatic and go abroad completely on their own inside 2 years after infection without causing clinical disease. Some infections are persistent and can lead to precancerous lesions or cancer. HPV infection caused by certain HPV types cause nigh all cases of anogenital warts in women and men and recurrent respiratory papillomatosis.

From 2014 through 2018, approximately 46,143 new cases of HPV-associated cancers* occurred each year in the United states (25,719 among women and xx,424 among men). Cervical cancer, the near widely known HPV-associated cancer, caused an average of 12,200 cases in the U.South. each twelvemonth during that time. HPV is also associated with vulvar, and vaginal cancer in females, penile cancer in males, and anal and oropharyngeal cancer in both females and males. Between 2014 and 2018, oropharyngeal cancers were the most usually occurring HPV-associated cancers, with an boilerplate of 20,236 reported cases each year (16,680 among men and iii,556 among women). See world wide web.cdc.gov/cancer/hpv/statistics/cases.htm for more information on trends in HPV-associated cancer.

*Note: CDC defines HPV-associated cancer as cancers at specific anatomic sites with specific cell types in which HPV Dna is oftentimes found. These parts of the torso include the neck, vagina, vulva, penis, anus, and oropharynx.

Which types of HPV are most likely to cause disease?

In the United States, approximately fourscore% of HPV-related cancers are attributable to HPV 16 or 18 which are included in all three HPV vaccines that have been bachelor in the U.Southward. Approximately 12% are attributable to HPV types 31, 33, 45, 52, and 58 (xvi% of all HPV-attributable cancers for females; 6% for males; approximately 3,800 cases annually), which are included in the 9-valent HPV vaccine. HPV types 16, xviii, 31, 33, 45, 52, or 58 account for about 81% of cervical cancers in the United States. HPV types vi or xi crusade 90% of anogenital warts (condylomata) and virtually cases of recurrent respiratory papillomatosis.

Is there a treatment for HPV infection?

There is no treatment for HPV infection. Only HPV-associated lesions including genital warts, recurrent respiratory papillomatosis, precancers, and cancers are treated. Recommended treatments vary depending on the diagnosis, size, and location of the lesion. Local treatment of lesions might not eradicate all HPV containing cells fully; whether available therapies for HPV-associated lesions reduce infectiousness is unclear.

Are healthcare personnel at chance of occupational infection with HPV?

Occupational infection with HPV is possible. Some HPV-associated conditions (including anogenital and oral warts, anogenital intraepithelial neoplasias, and recurrent respiratory papillomatosis) are treated with laser or electrosurgical procedures that could produce airborne particles. These procedures should exist performed in an accordingly ventilated room using standard precautions and local exhaust ventilation. Workers in HPV research laboratories who handle wild-type viruses or "quasi virions" might be at adventure of acquiring HPV from occupational exposures. In the laboratory setting, proper infection control should be instituted including, at minimum, biosafety level 2. Whether HPV vaccination would be of benefit in these settings is unclear considering no information exist on transmission risk or vaccine efficacy in this state of affairs.

Can human papillomavirus (HPV) exist transmitted by not-sexual manual routes, such equally clothing, undergarments, sex toys, or surfaces?

Nonsexual HPV manual is theoretically possible just has not been definitely demonstrated. This is mainly because HPV can't exist cultured and Dna detection from the environment is difficult and likely prone to imitation negative results.

If a person has been infected with a wild-blazon strain of HPV tin they be reinfected with the same strain?

If a person is infected with an HPV strain that does not clear (that is, the person becomes persistently infected) the person cannot be reinfected because they are continuously infected. If a person is infected with an HPV strain that clears, some but not all persons will have a lower chance of reinfection with the same strain. Information suggest that females are more likely than males to develop immunity later on clearance of natural infection. Prior infection with an HPV strain does not lessen the gamble of infection with a unlike HPV strain.

Vaccine Recommendations Back to peak

Please depict the HPV vaccines available in the United States.

Gardasil 9 (9vHPV, Merck) is the only HPV vaccine being distributed in the United States. Bivalent Cervarix (2vHPV, GlaxoSmithKline) and quadrivalent Gardasil (4vHPV, Merck) are no longer being distributed in the United States.

9vHPV is an inactivated 9-valent vaccine licensed past the Food and Drug Administration (FDA) in 2014. It contains 7 oncogenic (cancer-causing) HPV types (16, 18, 31, 33, 45, 52, and 58) and two HPV types that cause most genital warts (6 and 11). The 9vHPV vaccine is licensed for females and males historic period nine through 45 years.

What are the recommendations for employ of HPV vaccine in people age 9 through 26 years?

The ACIP recommends that routine HPV vaccination exist initiated for all children at age 11 or 12 years. Vaccination tin can be started as early as age 9 years. Vaccination is likewise recommended for all people age thirteen through 26 years who have not been vaccinated previously or who have non completed the vaccination series.

Are take hold of-up recommendations for the use of HPV vaccine different for males and females?

No. In June 2019, the Informational Committee on Immunization Practices (ACIP) voted to recommend routine catch-up HPV vaccination of all previously unvaccinated or incompletely vaccinated males historic period 22 through 26, the same every bit the recommendation for females. HPV vaccination recommendations differ past age group. There is ane recommendation for people ix through 26 years of age and another recommendation for people 27 through 45 years of historic period.

The most current ACIP recommendations for HPV vaccine are available at www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6832a3-H.pdf.

What are the recommendations for utilize of HPV vaccine in people historic period 27 through 45 years?

Catch-upwardly HPV vaccination is not recommended for all adults older than 26 years of historic period. Instead, shared clinical controlling regarding HPV vaccination is recommended for some adults aged 27 through 45 years who are not adequately vaccinated.

Ideally, HPV vaccine should be administered earlier potential exposure to HPV through sexual contact.

Why is shared clinical controlling (a discussion between the provider and the patient) recommended to determine whether to provide HPV vaccine to an adult age 27 through 45 years?

Although new HPV infections are most ordinarily acquired in adolescence and young adulthood, at any age, having a new sex partner is a risk factor for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical risk factors for HPV infection or disease, including men who have sex with men, transgender persons, and persons with immunocompromising weather condition. HPV vaccine works to prevent infection amidst persons who accept not been exposed to vaccine-blazon HPV before vaccination. A word with your patient is the best way to determine together how much the patient may do good from HPV vaccination to prevent new HPV infections.

Why is HPV vaccination non routinely recommended for all adults age 27 through 45 years?

Because HPV acquisition generally occurs soon after kickoff sexual practice, vaccine effectiveness will be lower in older historic period groups equally the effect of prior infections. In general, exposure to HPV also decreases amid individuals in older age groups. Evidence suggests that although HPV vaccination is safe for adults 27 through 45 years, population benefit would be minimal; nevertheless, some adults who are unvaccinated or incompletely vaccinated might be at risk for new HPV infection and might benefit from vaccination in this historic period range.

Should I screen my patients age 27 through 45 years for previous HPV infection to determine whether to offer them HPV vaccine?

No. No screening laboratory test can make up one's mind whether a person is already allowed or even so susceptible to whatsoever given HPV type. About sexually agile adults have been exposed to one or more HPV types, although not necessarily all of the HPV types targeted by vaccination. HPV vaccine works to prevent infection with vaccine types to which a person is still susceptible.

I accept a few patients who received their first or second dose of HPV vaccine at historic period 26 years or younger, but did non complete the series. Should I routinely complete their serial after age 26 years, or do I need to employ the shared clinical decision-making arroyo?

Complete the series based on shared clinical controlling involving the patient�south risk and want for protection.

What is the routine schedule for HPV vaccine?

ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who start the vaccination serial earlier the 15th birthday. The two doses should be separated by half dozen to 12 months. The minimum interval between doses is 5 agenda months.

A 3-dose schedule is recommended for all people who start the serial on or after the 15th birthday and for people with certain immunocompromising atmospheric condition (such as cancer, HIV infection, or taking immunosuppressive drugs). The second dose should be given 1 to 2 months after the start dose and the 3rd dose 6 months later on the first dose. The minimum interval between the showtime and second doses of vaccine is 4 weeks. The minimum interval between the second and tertiary doses of vaccine is 12 weeks. The minimum interval between the first and 3rd dose is 5 calendar months. If the vaccination series is interrupted, the series does not need to be restarted.

I read that HPV vaccination rates are notwithstanding low. What can we practice as providers to ameliorate these rates?

Coverage levels for HPV vaccine are improving but are nevertheless inadequate. Results from the Centers for Disease Control and Prevention's 2020 National Immunization Survey-Teen (NIS-Teen) indicate that 77.ane% of girls age 13 through 17 years had started the serial that they should have completed by age 13 years and 61.iv% had completed the series. In 2020, 73.1% of boys age 13 through 17 years had received ane dose but simply 56% had received all recommended doses. A summary of the 2020 NIS-Teen survey is available at www.cdc.gov/mmwr/volumes/70/wr/mm7035a1.htm.

Providers can amend uptake of this life-saving vaccine in two master ways. First, studies have shown that missed opportunities are occurring. Upwardly to ninety% (depending on yr of birth) of girls unvaccinated for HPV had a healthcare visit where they received another vaccine such as Tdap, but not HPV. If HPV vaccine had been administered at the same visit, vaccination coverage for ane or more than doses could be xc% instead of 70%. Second, enquiry has shown that non receiving a healthcare provider's recommendation for HPV vaccine was 1 of the primary reasons parents reported for not vaccinating their adolescent children.

CDC urges healthcare providers to increase the consistency and strength of their recommendation of HPV vaccine, particularly when patients are age xi or 12 years. CDC's "Talking to Parents about HPV Vaccine," available at www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf tin aid providers with these conversations. For more detailed information about HPV vaccination strategies for providers, visit www.cdc.gov/hpv/hcp/index.html.

Some parents resist HPV vaccination of their 11- and 12-twelvemonth-olds because they are not sexually agile. How should I counter this position?

Explain to the parent that vaccination starting at 11 or 12 years will provide the all-time protection possible long earlier the first of any kind of sexual activity. It is standard exercise to vaccinate people before they are exposed to an infection, as is the case with measles and the other recommended babyhood vaccines. Similarly, we want to vaccinate children before they get exposed to HPV. Studies of HPV vaccine indicate that younger adolescents respond meliorate to the vaccine than older adolescents and young adults. Salubrious children vaccinated at this age volition need simply 2 doses of vaccine rather than 3 doses if vaccinated at an older age. Finally, numerous research studies take shown that getting the HPV vaccine does not make kids more likely to exist sexually active or start having sex at a younger age.

Nosotros have several males in our college health service whose records indicate that they received doses of Cervarix. Tin can we count these doses every bit valid?

No. Cervarix was not approved or recommended for utilize in males. Doses of Cervarix administered to males should not be counted and need to be repeated using 9vHPV.

Are additional 9vHPV doses recommended for a person who started a 3-dose series with 2vHPV or 4vHPV and completed the series with ane or 2 doses of 9vHPV?

There is no ACIP recommendation for additional doses of 9vHPV for persons who started the 3-dose series with 2vHPV or 4vHPV and completed the series with 9vHPV.

Does ACIP recommend revaccination with 9vHPV for patients who previously received a three-dose series of 2vHPV or 4vHPV?

ACIP has not recommended routine revaccination with 9vHPV for persons who have completed a 3-dose series of another HPV vaccine. There are data that indicate revaccination with 9vHPV after a 3-dose series of 4vHPV is safe. Clinicians should decide if the benefit of immunity against 5 boosted oncogenic strains of HPV (which cause 12% of HPV-owing cancers) is justified for their patients.

Is apply of HPV vaccine covered under the Vaccines For Children (VFC) plan?

Yes.

Are Pap smears still necessary for women who receive HPV vaccine?

Yes. Vaccinated women even so demand to see their healthcare provider for periodic cervical cancer screening. The vaccine does not provide protection confronting all types of HPV that cause cervical cancer, so even vaccinated women will still be at risk for some cancers from HPV.

Do women and men whose sexual orientation is same-sex need HPV vaccine?

Yep. HPV vaccine is recommended for females and males regardless of their sexual orientation.

Should transgender persons receive HPV vaccine?

Yep. ACIP recommends routine HPV vaccination for transgender persons as for all adolescents and young adults through age 26 years. Clinicians should hash out the risks of HPV disease and benefits of HPV vaccination with unvaccinated or incompletely vaccinated transgender persons historic period 27 through 45 years.

What immunocompromising conditions are an indication for a three-dose HPV schedule?

ACIP recommends vaccination with 3 doses of HPV vaccine for females and males age 9 through 26 years with main or secondary immunocompromising conditions that might reduce jail cell-mediated or humoral immunity. Examples include B lymphocyte antibiotic deficiency, T lymphocyte complete or partial defects, HIV infection, cancerous tumour, transplantation, autoimmune disease, or immunosuppressive therapy.

Is asplenia considered to be an indication for a 3-dose HPV schedule?

No. The recommendation for a 3-dose HPV schedule also does not utilize to children 9 through 14 years with asthma, chronic granulomatous affliction, chronic liver disease, chronic renal disease, central nervous organisation anatomic barrier defects (such as a cochlear implant), complement deficiency, diabetes, centre disease or sickle jail cell disease unless the person is receiving immunosuppressive therapy for the condition.

If a patient has been sexually agile for a number of years, is it nonetheless recommended to requite HPV vaccine or to consummate the HPV vaccine series?

Yes. HPV vaccine should be administered to people who are already sexually active. Ideally, patients should be vaccinated before onset of sex; yet, people who have already been infected with one or more HPV types will even so exist protected from other HPV types in the vaccine that have not been acquired.

I have a patient who was diagnosed with HPV types sixteen and 18. The patient received a properly spaced Gardasil series in 2006 when she was 25 years erstwhile. Did the HPV vaccine she received in 2006 fail to protect her?

In clinical trials, HPV vaccines were shown to be highly constructive (more than 95%) for prevention of HPV vaccine-type infection and disease among persons without prior infection with the HPV types included in the vaccine. The about probable caption for this situation is that the patient was exposed to at to the lowest degree HPV types sixteen and 18 prior to vaccination. The HPV vaccine is non effective in preventing infection from HPV types a person has been exposed to prior to vaccination. The vaccine also cannot foreclose progression of HPV infection or HPV-related illness. The 9vHPV vaccine protects against 9 dissimilar types of HPV.

Will patients who have already had genital warts do good from receiving HPV vaccine?

A history of genital warts or clinically evident genital warts indicates previous infection with HPV, nearly often type half-dozen or eleven which cause 90% of genital warts. All the same, people with this history might not have been infected with both HPV 6 and 11 or with the other HPV types included in HPV vaccine. Vaccination will provide protection against infection with HPV serotypes the patient has not already caused. Providers should advise their patients/clients that the vaccine will not take a therapeutic event on existing HPV infection or genital warts. It is important, however, that patients receive a total age-advisable series of HPV vaccine to get total protection from genital warts, in addition to the cancer-causing HPV types in the vaccine.

Scheduling and Administering Vaccines Back to top

What is the recommended schedule for administering HPV vaccine?

ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who showtime the vaccination serial before the 15th altogether. The two doses should be separated by 6 to 12 months. The minimum interval between doses is 5 agenda months.

A 3-dose schedule is recommended for people who start the series on or after the 15th altogether and for people with sure immunocompromising weather condition (such every bit cancer, HIV infection, or taking immunosuppressive drugs). The second dose should exist given 1 to ii months after the first dose and the third dose half dozen months afterward the first dose. The minimum interval between the outset and 2nd doses of vaccine is four weeks. The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the starting time and 3rd doses is 5 calendar months. If the vaccination series is interrupted, the series does non need to be restarted.

Has ACIP expressed a preference for the 2-dose over the 3-dose schedule for adolescents 9 through 14 years of age?

Yeah. ACIP recommends the two-dose schedule for people starting the HPV vaccination series earlier the 15th birthday, every bit long as they are immunocompetent.

If a dose of HPV vaccine is significantly delayed, do I need to beginning the series over?

No, do non restart the series. You should continue where the patient left off and complete the series.

Tin the 4-day "grace period" exist practical to the minimum intervals for HPV vaccine?

Yes.

A 16 year old received the third dose of HPV vaccine 12 weeks after the second dose but only 4 months later the first dose. Should the third dose exist repeated?

Yep. If an HPV vaccine dose is administered at less than the recommended minimum interval then the dose should be repeated. The repeat third dose should be repeated 5 months subsequently the outset dose or 12 weeks after the invalid third dose, whichever is afterward.

Does the 2-dose HPV vaccine schedule need to be completed with the same vaccine, or can it include different vaccines (such as bivalent or quadrivalent vaccine)?

The 2-dose schedule tin can be completed with whatsoever combination of HPV vaccine brands every bit long as dose #1 was given before historic period 15 years. Dose #2 should be administered 6–12 months after dose #ane.

If dose #one of HPV vaccine was given before the 15th birthday and it has been more than a yr since that dose was given, would the series exist consummate with just i additional dose?

Aye. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one boosted dose of HPV vaccine.

We accept adolescents in our practice who accept received the first 2 doses of the HPV serial 1 or 2 months apart according to the three-dose schedule. Tin can we consider their HPV vaccine series to be consummate or do we need to give these patients a tertiary dose?

People who take received ii doses of HPV vaccine separated by less than 5 months should receive a third dose half dozen�12 months after dose #1 and at least 12 weeks after dose #2.

Is the ii-dose recommendation retroactive for children and teens vaccinated prior to 2016?

Yep. Whatever person who ever received 2 doses of any combination of HPV vaccines tin be considered fully vaccinated if dose #1 was given earlier the 15th altogether and the ii doses were separated by at to the lowest degree 5 months.

I work with university students and many of them miss coming in on time for their next dose of HPV vaccine. What'southward the longest interval allowed earlier nosotros need to commencement the series over?

No vaccine serial needs to be restarted because of an interval that is longer than recommended (with the exception of oral typhoid vaccine in certain circumstances). You should continue the serial where it was interrupted.

I take read that HPV vaccine should non be administered during pregnancy. Do nosotros need to perform a pregnancy test prior to administering this vaccine to our patients? Currently, we ask about pregnancy prior to providing the vaccine.

HPV vaccine is not recommended for use during pregnancy. HPV vaccines have not been associated causally with adverse outcomes of pregnancy or adverse events in the developing fetus. However, if a person is found to be pregnant after initiating the vaccination series, the residue of the series should be delayed until completion of pregnancy. Pregnancy testing is not needed before vaccination.

If a vaccine dose has been administered during pregnancy, no intervention is needed.

We inadvertently gave HPV vaccine to a woman who didn't know she was pregnant at the time. How should we complete the schedule?

Y'all should withhold farther HPV vaccine until she is no longer meaning. Afterwards the pregnancy is completed, administer the remaining doses of the series using the usual 2- or iii-dose schedule (depending on the age at initiation of the serial).

Tin can HPV vaccine be administered at the same time as other vaccines?

Yep, administration of a different inactivated or live vaccine, either at the same visit or at whatever time before or after HPV vaccine, is acceptable because HPV is not a live vaccine.

If HPV vaccine is given subcutaneously instead of intramuscularly, does the dose need to be repeated?

Yes. No data be on the efficacy or safety of HPV vaccine given by the subcutaneous route. All information on efficacy and duration of protection are based on a vaccine series administered by the intramuscular route. In the absence of data on subcutaneous administration, CDC and the manufacturer recommend that a dose of HPV vaccine given by whatever route other than intramuscular should be repeated. There is no minimum interval between the invalid (subcutaneous) dose and the repeat dose.

Contraindications and Precautions Back to top

What are the contraindications and precautions to HPV vaccine?

Contraindications are the following: HPV vaccine is contraindicated for persons with a history of firsthand hypersensitivity to any vaccine component, including yeast. The precaution to HPV vaccine is a moderate or severe astute illness with or without fever. Vaccination should be deferred until the condition improves. HPV vaccines are not recommended for employ during pregnancy. If a person is found to be meaning afterward starting the vaccination series, the remainder of the 2 or 3-dose series (depending on the age of first HPV vaccination) should be delayed until completion of pregnancy. Pregnancy testing is not needed before vaccination. If a vaccine dose has been administered during pregnancy, no intervention is needed. Y'all tin find more information about HPV vaccine and pregnancy in the ACIP recommendations at: www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm.

If a woman has had HPV infection detected in cervical cancer screening, can she still be vaccinated?

Yes. A adult female with evidence of present or past HPV infection identified through cervical screening may exist vaccinated. Recipients of HPV vaccinations should exist counseled that the vaccine will not accept a therapeutic upshot on any existing HPV infections or cervical lesions.

Can a woman who is breastfeeding receive HPV vaccine?

Yes.

Is the history of an aberrant Pap test a contraindication to the HPV vaccine series?

No. Even a woman institute to be infected with a strain of HPV that is present in the vaccine could receive protection from the other strains in the vaccine.

Vaccine Prophylactic Back to top

What adverse events tin can exist expected following HPV vaccine?

In clinical trials of 9vHPV involving more than 15,000 subjects, the virtually common adverse event was injection site hurting, which was reported in well-nigh 90% of recipients. Other local reactions, such as redness and/or swelling, were reported in about forty% of recipients. Fever was less common, reported by about 6% of recipients. The rates and severity of adverse reactions post-obit each dose of 9vHPV were similar betwixt boys and girls.

We've heard stories in the media about severe reactions to the HPV vaccine. Is at that place whatever substance to these stories?

No. Since 2006, more than than 120 meg doses of HPV vaccine have been distributed in the United States. Among all reports to the Vaccine Adverse Issue Reporting System (VAERS) following HPV vaccines, the nigh ofttimes reported symptoms overall were dizziness; fainting; headache; nausea; fever; and pain, redness, and swelling in the arm where the shot was given. Of the reports to VAERS, 6% were classified as "serious." Almost 22% of the VAERS reports were not related to wellness problems, only were reported for reasons such as improper vaccine storage or the vaccine beingness given to someone for whom information technology was not recommended. Although deaths have been reported among vaccine recipients none has been conclusively shown to have been caused by the vaccine. Occurrences of rare weather condition, such as Guillain-Barré Syndrome (GBS) accept also been reported among vaccine recipients but in that location is no prove that HPV vaccine increased the charge per unit of GBS to a higher place what is expected in the population.

CDC, working with the FDA and other immunization partners, will go along to monitor the rubber of HPV vaccines. You lot can find complete information on this and other vaccine prophylactic issues at www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safe-faqs.html.

Practice HPV vaccines cause fainting?

Nearly all vaccines have been reported to be associated with fainting (syncope). Post-vaccination syncope has been most oftentimes reported later on three vaccines commonly given to adolescents (HPV, MenACWY, and Tdap). However, it is non known whether the vaccines are responsible for mail-vaccination syncope or if the association with these vaccines but reflects the fact that adolescents are generally more probable to experience syncope.

Syncope can cause serious injury. Falls that occur due to syncope later vaccination can be prevented by having the vaccinated person seated or lying down. The person should be observed for fifteen minutes following vaccination.

How should HPV vaccine be stored?

HPV vaccine should be stored at refrigerator temperature between 2°C and viii°C (36°F and 46°F). The vaccine must not exist frozen and must not exist used if it has been frozen. Protect the vaccine from calorie-free. Administer as shortly as possible afterwards being removed from refrigeration. The manufacturer package insert contains additional information and can exist found at www.immunize.org/packageinserts. For complete information on vaccine storage and handling all-time practices and recommendations please refer to CDC's Vaccine Storage and Treatment Toolkit at world wide web.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-treatment-toolkit.pdf.

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Source: https://www.immunize.org/askexperts/experts_hpv.asp

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