Do I Need to Start the Hep B Series Over Again

Man Papillomavirus (HPV)

Disease Problems Contraindications and Precautions Vaccine Recommendations Vaccine Prophylactic Scheduling and Administering Vaccines Storage and Handling

Disease Issues

How mutual is homo papillomavirus (HPV) infection?

HPV is the most common sexually transmitted infection in the U.s.. In the United States, an estimated 79 meg persons are infected, and an estimated fourteen million new HPV infections occur every year amidst persons historic period 15 through 59 years. Approximately half of new infections occur amidst 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?

About HPV infections are asymptomatic and get away completely on their own within 2 years after infection without causing clinical affliction. Some infections are persistent and can pb to precancerous lesions or cancer. HPV infection caused past certain HPV types cause almost 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 yr in the United States (25,719 amid women and 20,424 among men). Cervical cancer, the most widely known HPV-associated cancer, caused an average of 12,200 cases in the U.Due south. each yr 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 about usually occurring HPV-associated cancers, with an average of 20,236 reported cases each twelvemonth (16,680 amongst men and iii,556 among women). See www.cdc.gov/cancer/hpv/statistics/cases.htm for more than information on trends in HPV-associated cancer.

*Note: CDC defines HPV-associated cancer equally cancers at specific anatomic sites with specific cell types in which HPV Dna is frequently institute. These parts of the body include the cervix, vagina, vulva, penis, anus, and oropharynx.

Which types of HPV are about likely to cause disease?

In the U.s.a., approximately 80% of HPV-related cancers are attributable to HPV 16 or 18 which are included in all three HPV vaccines that accept been available 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; 6% for males; approximately 3,800 cases annually), which are included in the ix-valent HPV vaccine. HPV types 16, 18, 31, 33, 45, 52, or 58 account for about 81% of cervical cancers in the United States. HPV types 6 or 11 cause ninety% of anogenital warts (condylomata) and most cases of recurrent respiratory papillomatosis.

Is there a handling 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 hazard 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 be performed in an appropriately ventilated room using standard precautions and local frazzle ventilation. Workers in HPV enquiry laboratories who handle wild-blazon viruses or "quasi virions" might be at risk of acquiring HPV from occupational exposures. In the laboratory setting, proper infection command should exist instituted including, at minimum, biosafety level 2. Whether HPV vaccination would be of benefit in these settings is unclear because no information exist on transmission risk or vaccine efficacy in this situation.

Can human papillomavirus (HPV) be transmitted by non-sexual manual routes, such as clothing, undergarments, sex toys, or surfaces?

Nonsexual HPV transmission is theoretically possible simply has non been definitely demonstrated. This is mainly because HPV can't exist cultured and DNA detection from the environs is difficult and likely prone to false negative results.

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

If a person is infected with an HPV strain that does not articulate (that is, the person becomes persistently infected) the person cannot exist reinfected considering they are continuously infected. If a person is infected with an HPV strain that clears, some only not all persons will accept a lower chance of reinfection with the aforementioned strain. Data propose that females are more probable than males to develop immunity afterwards clearance of natural infection. Prior infection with an HPV strain does not lessen the chance of infection with a dissimilar HPV strain.

Vaccine Recommendations Dorsum to top

Delight draw the HPV vaccines available in the Usa.

Gardasil ix (9vHPV, Merck) is the only HPV vaccine being distributed in the Usa. 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 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 cause most genital warts (half dozen and 11). The 9vHPV vaccine is licensed for females and males age 9 through 45 years.

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

The ACIP recommends that routine HPV vaccination be initiated for all children at historic period 11 or 12 years. Vaccination tin be started as early equally age 9 years. Vaccination is also recommended for all people age 13 through 26 years who have non been vaccinated previously or who have not completed the vaccination series.

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

No. In June 2019, the Advisory Commission on Immunization Practices (ACIP) voted to recommend routine take hold of-upwards HPV vaccination of all previously unvaccinated or incompletely vaccinated males age 22 through 26, the same as the recommendation for females. HPV vaccination recommendations differ by age group. At that place is 1 recommendation for people nine through 26 years of age and some other recommendation for people 27 through 45 years of age.

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 employ of HPV vaccine in people age 27 through 45 years?

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

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

Why is shared clinical determination-making (a discussion betwixt 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 commonly acquired in adolescence and young adulthood, at any age, having a new sex activity partner is a adventure gene for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical gamble factors for HPV infection or disease, including men who have sex with men, transgender persons, and persons with immunocompromising conditions. HPV vaccine works to prevent infection among persons who have not been exposed to vaccine-blazon HPV before vaccination. A discussion with your patient is the all-time way to make up one's mind 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 subsequently first sexual practice, vaccine effectiveness will be lower in older age groups as the result of prior infections. In general, exposure to HPV besides decreases among individuals in older historic period groups. Testify suggests that although HPV vaccination is safe for adults 27 through 45 years, population benefit would be minimal; all the same, some adults who are unvaccinated or incompletely vaccinated might exist at risk for new HPV infection and might benefit from vaccination in this age range.

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

No. No screening laboratory test can decide whether a person is already allowed or yet susceptible to any given HPV blazon. Most sexually agile adults have been exposed to ane or more than 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 have a few patients who received their first or second dose of HPV vaccine at historic period 26 years or younger, just did non complete the serial. Should I routinely consummate their series after historic period 26 years, or do I need to use the shared clinical controlling arroyo?

Consummate the series based on shared clinical decision-making involving the patient�s adventure and desire 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 series before the 15th birthday. The 2 doses should exist separated past 6 to 12 months. The minimum interval betwixt doses is 5 calendar months.

A 3-dose schedule is recommended for all people who offset the series on or after the 15th birthday and for people with sure immunocompromising conditions (such as cancer, HIV infection, or taking immunosuppressive drugs). The second dose should be given 1 to 2 months later the starting time dose and the 3rd dose half dozen months after the outset dose. The minimum interval betwixt the first and second doses of vaccine is 4 weeks. The minimum interval betwixt the 2nd and tertiary doses of vaccine is 12 weeks. The minimum interval between the first and tertiary dose is five calendar months. If the vaccination series is interrupted, the series does non need to be restarted.

I read that HPV vaccination rates are nonetheless low. What can we do as providers to better these rates?

Coverage levels for HPV vaccine are improving just are yet inadequate. Results from the Centers for Illness Command and Prevention'south 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 xiii years and 61.iv% had completed the series. In 2020, 73.1% of boys age 13 through 17 years had received one dose merely only 56% had received all recommended doses. A summary of the 2020 NIS-Teen survey is available at www.cdc.gov/mmwr/volumes/seventy/wr/mm7035a1.htm.

Providers tin improve uptake of this life-saving vaccine in two chief ways. Kickoff, studies have shown that missed opportunities are occurring. Upward to 90% (depending on twelvemonth of birth) of girls unvaccinated for HPV had a healthcare visit where they received some other vaccine such as Tdap, but non HPV. If HPV vaccine had been administered at the aforementioned visit, vaccination coverage for 1 or more than doses could exist 90% instead of seventy%. Second, research has shown that not receiving a healthcare provider'due south recommendation for HPV vaccine was i 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 11 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 about HPV vaccination strategies for providers, visit www.cdc.gov/hpv/hcp/index.html.

Some parents resist HPV vaccination of their 11- and 12-year-olds because 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 whatever kind of sexual action. It is standard do to vaccinate people earlier they are exposed to an infection, equally is the instance with measles and the other recommended childhood vaccines. Similarly, we want to vaccinate children before they become exposed to HPV. Studies of HPV vaccine indicate that younger adolescents respond meliorate to the vaccine than older adolescents and young adults. Healthy children vaccinated at this age volition need only two doses of vaccine rather than 3 doses if vaccinated at an older age. Finally, numerous enquiry studies take shown that getting the HPV vaccine does not make kids more likely to be sexually agile or start having sex at a younger age.

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

No. Cervarix was non canonical or recommended for use in males. Doses of Cervarix administered to males should non exist counted and need to be repeated using 9vHPV.

Are additional 9vHPV doses recommended for a person who started a three-dose series with 2vHPV or 4vHPV and completed the serial with one or two doses of 9vHPV?

At that place is no ACIP recommendation for additional doses of 9vHPV for persons who started the three-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 serial of 2vHPV or 4vHPV?

ACIP has not recommended routine revaccination with 9vHPV for persons who accept completed a 3-dose series of another HPV vaccine. There are data that betoken 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 cause 12% of HPV-attributable cancers) is justified for their patients.

Is utilize of HPV vaccine covered under the Vaccines For Children (VFC) programme?

Aye.

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

Yes. Vaccinated women even so demand to encounter their healthcare provider for periodic cervical cancer screening. The vaccine does non provide protection confronting all types of HPV that cause cervical cancer, so even vaccinated women will nonetheless be at risk for some cancers from HPV.

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

Yes. 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 every bit for all adolescents and young adults through age 26 years. Clinicians should discuss the risks of HPV affliction 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 3 doses of HPV vaccine for females and males age 9 through 26 years with primary or secondary immunocompromising weather condition that might reduce cell-mediated or humoral immunity. Examples include B lymphocyte antibiotic deficiency, T lymphocyte complete or partial defects, HIV infection, malignant 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 employ to children 9 through 14 years with asthma, chronic granulomatous disease, chronic liver affliction, chronic renal disease, central nervous arrangement anatomic barrier defects (such as a cochlear implant), complement deficiency, diabetes, center disease or sickle cell disease unless the person is receiving immunosuppressive therapy for the condition.

If a patient has been sexually active for a number of years, is information technology still recommended to requite 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 earlier onset of sexual activity; however, people who accept already been infected with ane or more than HPV types will still exist protected from other HPV types in the vaccine that have non been acquired.

I take a patient who was diagnosed with HPV types xvi and xviii. 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 exist highly effective (more than 95%) for prevention of HPV vaccine-blazon infection and disease amongst persons without prior infection with the HPV types included in the vaccine. The most likely explanation for this state of affairs is that the patient was exposed to at least HPV types 16 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 besides cannot prevent progression of HPV infection or HPV-related disease. The 9vHPV vaccine protects against ix dissimilar types of HPV.

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

A history of genital warts or clinically axiomatic genital warts indicates previous infection with HPV, most oft type 6 or 11 which cause ninety% of genital warts. Even so, people with this history might not accept been infected with both HPV half-dozen and eleven 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 advise their patients/clients that the vaccine will not take a therapeutic result on existing HPV infection or genital warts. It is important, however, that patients receive a full age-appropriate series of HPV vaccine to go full protection from genital warts, in add-on 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 starting time the vaccination series before the 15th birthday. The two doses should exist separated by 6 to 12 months. The minimum interval betwixt doses is v calendar months.

A three-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 one to 2 months after the get-go dose and the tertiary dose 6 months after the kickoff dose. The minimum interval between the start and second doses of vaccine is 4 weeks. The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the offset and third doses is 5 calendar months. If the vaccination serial is interrupted, the serial does not demand to be restarted.

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

Aye. ACIP recommends the 2-dose schedule for people starting the HPV vaccination series before the 15th birthday, every bit long every bit they are immunocompetent.

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

No, do non restart the series. Y'all should continue where the patient left off and complete the serial.

Can the iv-day "grace catamenia" be applied to the minimum intervals for HPV vaccine?

Yes.

A 16 yr old received the third dose of HPV vaccine 12 weeks afterwards the second dose but only four months later on the first dose. Should the third dose be repeated?

Yes. If an HPV vaccine dose is administered at less than the recommended minimum interval so the dose should be repeated. The repeat tertiary dose should be repeated 5 months afterwards the offset dose or 12 weeks later on the invalid third dose, whichever is after.

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

The 2-dose schedule can be completed with any combination of HPV vaccine brands as long as dose #1 was given before historic period 15 years. Dose #2 should be administered half-dozen–12 months later dose #ane.

If dose #1 of HPV vaccine was given earlier the 15th birthday and it has been more than a year since that dose was given, would the series be complete with merely one additional dose?

Aye. Adolescents and adults who started the HPV vaccine series prior to the 15th altogether and who are not immunocompromised are considered to exist fairly vaccinated with just one additional dose of HPV vaccine.

We have adolescents in our practice who accept received the offset two doses of the HPV serial 1 or 2 months apart according to the 3-dose schedule. Can we consider their HPV vaccine serial to be complete or do we need to give these patients a 3rd dose?

People who have received 2 doses of HPV vaccine separated by less than 5 months should receive a third dose 6�12 months later on dose #1 and at to the lowest degree 12 weeks after dose #2.

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

Yeah. Whatsoever person who always received 2 doses of any combination of HPV vaccines can be considered fully vaccinated if dose #1 was given before the 15th birthday and the 2 doses were separated past at least 5 months.

I piece of work with university students and many of them miss coming in on time for their next dose of HPV vaccine. What's the longest interval allowed before we demand to start the series over?

No vaccine series needs to be restarted because of an interval that is longer than recommended (with the exception of oral typhoid vaccine in certain circumstances). Yous should keep the serial where information technology was interrupted.

I accept 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 employ during pregnancy. HPV vaccines have non been associated causally with adverse outcomes of pregnancy or adverse events in the developing fetus. Notwithstanding, if a person is found to exist pregnant after initiating the vaccination series, the remainder of the serial should be delayed until completion of pregnancy. Pregnancy testing is not needed earlier vaccination.

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

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

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

Can HPV vaccine exist administered at the aforementioned time every bit other vaccines?

Yeah, administration of a different inactivated or live vaccine, either at the same visit or at any 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 demand to be repeated?

Yes. No data exist 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 road. In the absenteeism of information on subcutaneous administration, CDC and the manufacturer recommend that a dose of HPV vaccine given by any route other than intramuscular should exist 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 whatsoever 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 found to be pregnant afterward starting the vaccination series, the remainder of the ii or 3-dose series (depending on the age of showtime 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. You tin can find more than information about HPV vaccine and pregnancy in the ACIP recommendations at: world wide web.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm.

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

Yes. A woman with evidence of nowadays or past HPV infection identified through cervical screening may exist vaccinated. Recipients of HPV vaccinations should exist counseled that the vaccine volition not have a therapeutic consequence on whatsoever existing HPV infections or cervical lesions.

Can a woman who is breastfeeding receive HPV vaccine?

Yes.

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

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

Vaccine Condom Back to top

What adverse events can exist expected following HPV vaccine?

In clinical trials of 9vHPV involving more than 15,000 subjects, the most common adverse event was injection site pain, which was reported in about 90% of recipients. Other local reactions, such as redness and/or swelling, were reported in about 40% of recipients. Fever was less common, reported past virtually 6% of recipients. The rates and severity of agin reactions post-obit each dose of 9vHPV were similar between boys and girls.

We've heard stories in the media virtually severe reactions to the HPV vaccine. Is there any substance to these stories?

No. Since 2006, more than 120 meg doses of HPV vaccine take been distributed in the United states. Among all reports to the Vaccine Adverse Upshot Reporting System (VAERS) following HPV vaccines, the nigh ofttimes reported symptoms overall were dizziness; fainting; headache; nausea; fever; and hurting, redness, and swelling in the arm where the shot was given. Of the reports to VAERS, 6% were classified every bit "serious." About 22% of the VAERS reports were non related to wellness bug, but were reported for reasons such as improper vaccine storage or the vaccine being given to someone for whom it was not recommended. Although deaths accept been reported amongst vaccine recipients none has been conclusively shown to have been acquired by the vaccine. Occurrences of rare weather, such every bit Guillain-Barré Syndrome (GBS) have besides been reported among vaccine recipients but there is no show that HPV vaccine increased the rate of GBS in a higher place what is expected in the population.

CDC, working with the FDA and other immunization partners, volition go along to monitor the safety of HPV vaccines. Yous can find complete information on this and other vaccine safety problems at www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safe-faqs.html.

Do HPV vaccines crusade fainting?

Nearly all vaccines have been reported to be associated with fainting (syncope). Mail-vaccination syncope has been most frequently reported after iii vaccines commonly given to adolescents (HPV, MenACWY, and Tdap). However, it is not known whether the vaccines are responsible for post-vaccination syncope or if the association with these vaccines just reflects the fact that adolescents are generally more likely to feel syncope.

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

How should HPV vaccine be stored?

HPV vaccine should exist stored at refrigerator temperature betwixt ii°C and eight°C (36°F and 46°F). The vaccine must not exist frozen and must not be used if it has been frozen. Protect the vaccine from calorie-free. Administer every bit presently as possible after being removed from refrigeration. The manufacturer package insert contains additional information and can be found at world wide web.immunize.org/packageinserts. For complete data on vaccine storage and handling all-time practices and recommendations please refer to CDC's Vaccine Storage and Handling 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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