Primary Care Matters
Why I Offer HPV (Gardasil) Immunization at Age 9
by William W. Long, MD, FAAP
I often get asked why I recommend starting the HPV vaccine series at age 9, rather than waiting until patients are 11 or older. For me, the answer is both practical and rooted in the evidence. I’d like to share why this has become standard in my practice.
The goal for preventing HPV-related disease is immunization. We have a safe and highly effective vaccine that can dramatically reduce the burden of cervical cancer, oropharyngeal cancer and other HPV-associated conditions. Offering it early gives us the best chance of protecting patients before they are ever exposed.
Better immune response at younger ages
Children mount a stronger immune response to the HPV vaccine at 9 to 11 years compared with later adolescence. Antibody titers are higher, and this enhanced immunogenicity translates to durable protection. By starting earlier, we take advantage of this biologic window to optimize vaccine effectiveness. Studies are in progress to see if just one dose of vaccine given in this age range produces durable immunity.
Higher series completion rates
In my own practice, I’ve seen how difficult it can be to complete a multi-dose vaccine series once kids are older and busier. Adolescents at 13 or 14 are juggling sports, school, activities and (often) reduced well-child visits. When I start the HPV vaccine at 9, parents are generally more receptive, and follow-up doses align with existing visits. Also, if they don’t start at age 9, we bring it up every year as a reminder. Completion rates are significantly higher, something the literature confirms as well.
Separating HPV from conversations about sexual activity
By framing HPV immunization as “just another routine vaccine” at age 9, I can avoid some of the stigma and discomfort families may feel when the vaccine is first presented in the context of adolescence and sexual debut. That’s why I mention the vaccine at the 8-year-old visit to prepare the patient and family. Parents are more likely to accept it when it’s part of the routine 9- and 10-year-old immunization schedule, alongside Tdap and meningococcal discussions that will come later.
Equity and prevention
Finally, offering the vaccine at age 9 helps ensure we reach children who might otherwise fall through the cracks. Missed opportunities accumulate quickly, and delaying vaccination increases the chance that a child may never receive it. Or worse, if they’re exposed to HPV before they’re protected. From a public health perspective, earlier initiation is a matter of equity and cancer prevention.
For all these reasons, I’ve shifted to offering HPV starting at age 9. It’s a small change in timing, but it has made a big difference in uptake, in parent acceptance and ultimately in my confidence that I’m giving my patients the best protection possible against HPV-related disease.
Some learnings to share
- Forewarn your patients at the 8-year-old checkup
- Be flexible in shared decision-making with parents, but be consistent about offering it to every 9-year-old and every year thereafter
- Families will generally fall into three groups: those who accept the vaccine and start it at age 9, those who want to wait and those who will never consent to the vaccine. It’s helpful to know all those groups and listen to their concerns.