I Received My First Guardasil 9 Shot but I Have Not Done My 2nd Dose Do I Have to Start Again?

Human Papillomavirus (HPV)

Affliction Issues Contraindications and Precautions Vaccine Recommendations Vaccine Safe Scheduling and Administering Vaccines Storage and Treatment

Disease Issues

How common is human papillomavirus (HPV) infection?

HPV is the most mutual sexually transmitted infection in the United States. In the Usa, an estimated 79 million persons are infected, and an estimated 14 meg new HPV infections occur every year amongst 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 becoming sexually active.

How serious is disease caused by HPV?

Almost HPV infections are asymptomatic and get away completely on their own inside two years subsequently infection without causing clinical illness. Some infections are persistent and tin lead to precancerous lesions or cancer. HPV infection caused by sure HPV types cause nearly 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 of america (25,719 among women and xx,424 among men). Cervical cancer, the most widely known HPV-associated cancer, caused an boilerplate of 12,200 cases in the U.Southward. each year during that fourth dimension. HPV is besides 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 virtually commonly occurring HPV-associated cancers, with an boilerplate of twenty,236 reported cases each twelvemonth (16,680 amongst men and 3,556 among women). Run across www.cdc.gov/cancer/hpv/statistics/cases.htm for more than information on trends in HPV-associated cancer.

*Annotation: CDC defines HPV-associated cancer every bit cancers at specific anatomic sites with specific cell types in which HPV Deoxyribonucleic acid is frequently institute. These parts of the trunk include the cervix, vagina, vulva, penis, anus, and oropharynx.

Which types of HPV are most likely to crusade disease?

In the United States, approximately 80% of HPV-related cancers are attributable to HPV sixteen or 18 which are included in all three HPV vaccines that have been bachelor in the U.S. Approximately 12% are attributable to HPV types 31, 33, 45, 52, and 58 (16% of all HPV-attributable cancers for females; half dozen% for males; approximately 3,800 cases annually), which are included in the 9-valent HPV vaccine. HPV types 16, eighteen, 31, 33, 45, 52, or 58 business relationship for well-nigh 81% of cervical cancers in the U.s.. HPV types half-dozen or 11 cause 90% of anogenital warts (condylomata) and well-nigh cases of recurrent respiratory papillomatosis.

Is in that location a treatment for HPV infection?

In that location 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 bachelor therapies for HPV-associated lesions reduce infectiousness is unclear.

Are healthcare personnel at risk 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 light amplification by stimulated emission of radiation or electrosurgical procedures that could produce airborne particles. These procedures should exist performed in an accordingly ventilated room using standard precautions and local frazzle ventilation. Workers in HPV research laboratories who handle wild-type viruses or "quasi virions" might be at risk of acquiring HPV from occupational exposures. In the laboratory setting, proper infection control should exist instituted including, at minimum, biosafety level 2. Whether HPV vaccination would be of do good in these settings is unclear because no data be on transmission run a risk or vaccine efficacy in this situation.

Tin can homo papillomavirus (HPV) be transmitted by non-sexual transmission routes, such as clothing, undergarments, sex toys, or surfaces?

Nonsexual HPV transmission is theoretically possible but has not been definitely demonstrated. This is mainly because HPV tin't exist cultured and Deoxyribonucleic acid detection from the surround is difficult and likely prone to false negative results.

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

If a person is infected with an HPV strain that does non 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 merely non all persons will take a lower chance of reinfection with the same strain. Information suggest that females are more likely than males to develop immunity after clearance of natural infection. Prior infection with an HPV strain does not lessen the risk of infection with a different HPV strain.

Vaccine Recommendations Back to acme

Delight draw the HPV vaccines available in the United States.

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

9vHPV is an inactivated nine-valent vaccine licensed by 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 crusade near genital warts (6 and 11). The 9vHPV vaccine is licensed for females and males age 9 through 45 years.

What are the recommendations for use of HPV vaccine in people historic period 9 through 26 years?

The ACIP recommends that routine HPV vaccination be initiated for all children at historic period xi or 12 years. Vaccination can be started as early on as age 9 years. Vaccination is also recommended for all people age xiii through 26 years who have not been vaccinated previously or who accept non completed the vaccination series.

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

No. In June 2019, the Advisory Committee on Immunization Practices (ACIP) voted to recommend routine take hold of-up HPV vaccination of all previously unvaccinated or incompletely vaccinated males historic period 22 through 26, the same as the recommendation for females. HPV vaccination recommendations differ by age grouping. In that location is one recommendation for people 9 through 26 years of age and another recommendation for people 27 through 45 years of age.

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

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

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

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

Why is shared clinical determination-making (a give-and-take betwixt the provider and the patient) recommended to determine whether to provide HPV vaccine to an adult historic period 27 through 45 years?

Although new HPV infections are about commonly acquired in boyhood and young adulthood, at any age, having a new sex partner is a risk gene for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical adventure factors for HPV infection or illness, including men who have sex with men, transgender persons, and persons with immunocompromising conditions. HPV vaccine works to foreclose infection amid persons who take not been exposed to vaccine-type HPV before vaccination. A word with your patient is the best manner to decide together how much the patient may benefit from HPV vaccination to preclude new HPV infections.

Why is HPV vaccination not routinely recommended for all adults age 27 through 45 years?

Because HPV acquisition more often than not occurs soon after outset sexual activity, vaccine effectiveness will be lower in older age groups as the result of prior infections. In full general, exposure to HPV likewise decreases among individuals in older age groups. Prove 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 determine whether a person is already allowed or however susceptible to any given HPV blazon. About sexually active 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 preclude infection with vaccine types to which a person is all the same susceptible.

I have a few patients who received their commencement or second dose of HPV vaccine at age 26 years or younger, only did non complete the series. Should I routinely complete their series after historic period 26 years, or exercise I need to use the shared clinical controlling approach?

Consummate the series based on shared clinical decision-making involving the patient�s hazard and desire for protection.

What is the routine schedule for HPV vaccine?

ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who beginning the vaccination series before the 15th birthday. The two doses should exist separated by six to 12 months. The minimum interval between doses is 5 calendar months.

A 3-dose schedule is recommended for all people who outset the series on or after the 15th birthday and for people with certain immunocompromising conditions (such as cancer, HIV infection, or taking immunosuppressive drugs). The 2nd dose should exist given ane to ii months after the showtime dose and the third dose 6 months after the outset dose. The minimum interval betwixt the starting time and second doses of vaccine is 4 weeks. The minimum interval between the 2d and third doses of vaccine is 12 weeks. The minimum interval between the first and third dose is 5 agenda months. If the vaccination series is interrupted, the series does not need to exist restarted.

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

Coverage levels for HPV vaccine are improving only are all the same inadequate. Results from the Centers for Illness Command and Prevention's 2020 National Immunization Survey-Teen (NIS-Teen) indicate that 77.1% of girls age 13 through 17 years had started the series that they should accept completed by age 13 years and 61.4% had completed the series. In 2020, 73.1% of boys age thirteen through 17 years had received ane dose only only 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 improve uptake of this life-saving vaccine in two main ways. Outset, studies have shown that missed opportunities are occurring. Upward to 90% (depending on year of birth) of girls unvaccinated for HPV had a healthcare visit where they received another vaccine such as Tdap, just non HPV. If HPV vaccine had been administered at the same visit, vaccination coverage for ane or more doses could be 90% instead of 70%. 2nd, enquiry has shown that non receiving a healthcare provider's recommendation for HPV vaccine was one of the main 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, especially 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 help providers with these conversations. For more detailed information most 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 considering they are not sexually active. How should I counter this position?

Explain to the parent that vaccination starting at 11 or 12 years volition provide the best protection possible long before the start of any kind of sexual activity. It is standard practice to vaccinate people before they are exposed to an infection, as is the instance with measles and the other recommended childhood vaccines. Similarly, nosotros want to vaccinate children earlier they become exposed to HPV. Studies of HPV vaccine indicate that younger adolescents respond better to the vaccine than older adolescents and immature adults. Healthy children vaccinated at this age volition need only ii doses of vaccine rather than 3 doses if vaccinated at an older age. Finally, numerous enquiry studies have shown that getting the HPV vaccine does not brand kids more likely to be sexually active or starting time having sex at a younger historic period.

We take several males in our higher health service whose records indicate that they received doses of Cervarix. Can we count these doses as valid?

No. Cervarix was not approved or recommended for use in males. Doses of Cervarix administered to males should not be counted and demand 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 one or 2 doses of 9vHPV?

At that place is no ACIP recommendation for boosted doses of 9vHPV for persons who started the 3-dose series with 2vHPV or 4vHPV and completed the serial with 9vHPV.

Does ACIP recommend revaccination with 9vHPV for patients who previously received a 3-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 bespeak revaccination with 9vHPV after a 3-dose series of 4vHPV is safe. Clinicians should decide if the benefit of immunity against 5 additional oncogenic strains of HPV (which crusade 12% of HPV-attributable cancers) is justified for their patients.

Is use of HPV vaccine covered nether the Vaccines For Children (VFC) program?

Yes.

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

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

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

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

Should transgender persons receive HPV vaccine?

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

What immunocompromising weather are an indication for a 3-dose HPV schedule?

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

Is asplenia considered to exist an indication for a iii-dose HPV schedule?

No. The recommendation for a three-dose HPV schedule likewise does not apply to children 9 through 14 years with asthma, chronic granulomatous disease, chronic liver disease, chronic renal affliction, central nervous organisation anatomic barrier defects (such equally a cochlear implant), complement deficiency, diabetes, middle disease or sickle cell illness unless the person is receiving immunosuppressive therapy for the status.

If a patient has been sexually active for a number of years, is it yet recommended to give HPV vaccine or to complete 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 sexual activity; nonetheless, people who have already been infected with ane or more than HPV types will still exist protected from other HPV types in the vaccine that have not been acquired.

I accept a patient who was diagnosed with HPV types 16 and 18. The patient received a properly spaced Gardasil series in 2006 when she was 25 years old. 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 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 most likely caption for this situation is that the patient was exposed to at to the lowest degree HPV types 16 and 18 prior to vaccination. The HPV vaccine is not effective in preventing infection from HPV types a person has been exposed to prior to vaccination. The vaccine likewise cannot prevent progression of HPV infection or HPV-related disease. The 9vHPV vaccine protects confronting 9 different types of HPV.

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

A history of genital warts or clinically evident genital warts indicates previous infection with HPV, near often type 6 or eleven which cause 90% of genital warts. Notwithstanding, people with this history might non have been infected with both HPV vi and xi or with the other HPV types included in HPV vaccine. Vaccination will provide protection against infection with HPV serotypes the patient has not already acquired. Providers should propose their patients/clients that the vaccine will not have a therapeutic result on existing HPV infection or genital warts. Information technology is important, however, that patients receive a full age-appropriate series of HPV vaccine to get full protection from genital warts, in addition to the cancer-causing HPV types in the vaccine.

Scheduling and Administering Vaccines Back to height

What is the recommended schedule for administering HPV vaccine?

ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who start the vaccination series before the 15th birthday. The ii doses should be separated by six 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 birthday and for people with certain immunocompromising conditions (such as cancer, HIV infection, or taking immunosuppressive drugs). The 2nd dose should be given 1 to two months after the first dose and the third dose six months later on the showtime dose. The minimum interval between the first and 2d doses of vaccine is 4 weeks. The minimum interval between the 2nd and third doses of vaccine is 12 weeks. The minimum interval between the first and third doses is v agenda months. If the vaccination serial is interrupted, the serial does not need to exist restarted.

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

Aye. ACIP recommends the ii-dose schedule for people starting the HPV vaccination series before the 15th birthday, as long equally they are immunocompetent.

If a dose of HPV vaccine is significantly delayed, practice I demand to get-go the series over?

No, do not restart the serial. Y'all should continue where the patient left off and complete the serial.

Tin the iv-day "grace period" exist applied to the minimum intervals for HPV vaccine?

Yes.

A 16 year old received the tertiary dose of HPV vaccine 12 weeks after the 2d dose but but iv months after the commencement dose. Should the third dose exist repeated?

Yeah. If an HPV vaccine dose is administered at less than the recommended minimum interval so the dose should exist repeated. The repeat 3rd dose should be repeated 5 months after the starting time dose or 12 weeks after the invalid third dose, whichever is later.

Does the two-dose HPV vaccine schedule demand to be completed with the same vaccine, or can it include dissimilar vaccines (such equally bivalent or quadrivalent vaccine)?

The two-dose schedule can be completed with whatever combination of HPV vaccine brands every bit long every bit dose #ane was given before age 15 years. Dose #2 should exist administered 6–12 months after dose #1.

If dose #1 of HPV vaccine was given before the 15th altogether and it has been more than than a year since that dose was given, would the series exist consummate with only one additional dose?

Yes. 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 only one boosted dose of HPV vaccine.

We have adolescents in our exercise who have received the commencement ii doses of the HPV series 1 or 2 months autonomously according to the 3-dose schedule. Can we consider their HPV vaccine series to exist consummate or practice nosotros need to give these patients a 3rd dose?

People who have received 2 doses of HPV vaccine separated by less than five months should receive a third dose 6�12 months after dose #ane and at least 12 weeks after dose #2.

Is the 2-dose recommendation retroactive for children and teens vaccinated prior to 2016?

Yes. Any person who ever received ii doses of whatsoever combination of HPV vaccines can be considered fully vaccinated if dose #1 was given before the 15th birthday and the two doses were separated by at least 5 months.

I work with university students and many of them miss coming in on fourth dimension for their next dose of HPV vaccine. What's the longest interval allowed before we need to get-go 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 go along the series where it was interrupted.

I have read that HPV vaccine should not be administered during pregnancy. Exercise we 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 accept not been associated causally with adverse outcomes of pregnancy or adverse events in the developing fetus. However, if a person is constitute to be pregnant later initiating the vaccination serial, the residual 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 meaning at the time. How should we consummate the schedule?

You should withhold farther HPV vaccine until she is no longer meaning. After the pregnancy is completed, administer the remaining doses of the series using the usual 2- or 3-dose schedule (depending on the age at initiation of the series).

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

Yes, administration of a different inactivated or alive vaccine, either at the same visit or at any fourth dimension before or subsequently 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?

Aye. No data be on the efficacy or safety of HPV vaccine given past the subcutaneous route. All data 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 any route other than intramuscular should be repeated. There is no minimum interval betwixt 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 immediate hypersensitivity to whatever vaccine component, including yeast. The precaution to HPV vaccine is a moderate or severe acute illness with or without fever. Vaccination should be deferred until the condition improves. HPV vaccines are not recommended for use during pregnancy. If a person is plant to be pregnant after starting the vaccination series, the balance of the two 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 can find more information well-nigh 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 notwithstanding be vaccinated?

Yes. A woman with evidence of present or past HPV infection identified through cervical screening may be vaccinated. Recipients of HPV vaccinations should be counseled that the vaccine will not have a therapeutic effect on whatever existing HPV infections or cervical lesions.

Tin can a woman who is breastfeeding receive HPV vaccine?

Yep.

Is the history of an abnormal Pap exam a contraindication to the HPV vaccine series?

No. Even a adult female found 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 Safety Back to acme

What adverse events can exist expected following HPV vaccine?

In clinical trials of 9vHPV involving more than fifteen,000 subjects, the well-nigh common agin event was injection site pain, which was reported in about 90% of recipients. Other local reactions, such equally redness and/or swelling, were reported in nigh xl% of recipients. Fever was less common, reported past nearly vi% of recipients. The rates and severity of agin reactions post-obit each dose of 9vHPV were similar betwixt boys and girls.

Nosotros've heard stories in the media virtually severe reactions to the HPV vaccine. Is in that location any substance to these stories?

No. Since 2006, more 120 one thousand thousand doses of HPV vaccine have been distributed in the United States. Among all reports to the Vaccine Agin Event Reporting System (VAERS) following HPV vaccines, the most frequently 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." Nearly 22% of the VAERS reports were non related to health issues, but were reported for reasons such every bit improper vaccine storage or the vaccine existence given to someone for whom it was not recommended. Although deaths have been reported amid vaccine recipients none has been conclusively shown to accept been caused by the vaccine. Occurrences of rare conditions, such equally Guillain-Barré Syndrome (GBS) have also been reported among vaccine recipients but at that place is no evidence that HPV vaccine increased the rate of GBS to a higher place what is expected in the population.

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

Do HPV vaccines crusade fainting?

Nearly all vaccines have been reported to exist associated with fainting (syncope). Mail service-vaccination syncope has been most often reported afterward iii vaccines commonly given to adolescents (HPV, MenACWY, and Tdap). However, information technology is not known whether the vaccines are responsible for postal service-vaccination syncope or if the association with these vaccines simply reflects the fact that adolescents are generally more likely to feel syncope.

Syncope tin cause serious injury. Falls that occur due to syncope after vaccination tin can be prevented past having the vaccinated person seated or lying down. The person should be observed for 15 minutes following vaccination.

How should HPV vaccine be stored?

HPV vaccine should be stored at fridge temperature betwixt 2°C and 8°C (36°F and 46°F). The vaccine must not be frozen and must not be used if it has been frozen. Protect the vaccine from light. Administer as before long equally possible afterward being removed from refrigeration. The manufacturer package insert contains additional information and can be found at www.immunize.org/packageinserts. For complete information on vaccine storage and handling all-time practices and recommendations please refer to CDC'southward Vaccine Storage and Treatment Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.

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

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