Rationale

HPV is causally linked to cervical, vulval, vaginal, penile, anal and oropharyngeal cancers and to anogenital warts. Standardised incidence ratios for these cancers are 2–30-fold higher in OTRs.
Mucosal high-risk HPV genotypes (16, 18, 31, 33, 45, 52, 58) cause the majority of anogenital cancers.
Cutaneous β-HPV genotypes have been implicated in cSCC pathogenesis, particularly in immunosuppressed patients; evidence is suggestive rather than causal.
HPV-driven cutaneous warts and verrucous cSCC are very common in long-term OTRs.
Standard HPV vaccines do not cover β-HPV types but the cross-protective immunological response to high-risk α-HPV may have some bystander effect on cutaneous disease — the focus of recent prevention studies.

Evidence base

Trial Anogenital cancer prevention in immunocompetent adolescents — vaccine efficacy > 90% against high-grade cervical, vulval and anal intraepithelial neoplasia from the targeted genotypes. Well-established randomised and population evidence (FUTURE I/II, KEN HPV, Australia cohort).
Trial Immunogenicity in OTRs — seroconversion rates are lower than in immunocompetent recipients; three-dose schedules improve immunogenicity over two-dose. Adult kidney transplant cohort studies (Kumar 2013, Gomez-Lobo 2014) show seroconversion 70–90% with three doses.
Trial cSCC prevention — emerging: small studies (Nichols 2017; Bossart 2020) describe reduction in new keratinocyte cancers after 9-valent vaccination in high-burden patients. Larger trials are ongoing.
Consensus Pre-transplant vaccination is preferred — better immunogenicity than post-transplant.
Vaccine is not live; safe in immunosuppressed patients.

UK NHS HPV programme: 9-valent vaccine; adolescents aged 12–13 (school-based, gender-neutral since 2019). MSM eligible up to age 45. One- or two-dose schedule per current Green Book (in evolution).

Vaccinate before transplantation where possible.
Three-dose schedule recommended in adults at risk of immunosuppression: 0, 2 and 6 months.
Aim to complete the course at least one month before transplantation if planning permits.

Vaccinate as soon as the patient is on a stable maintenance immunosuppression regimen (typically ≥ 6 months post-transplant).
Three-dose schedule at 0, 2 and 6 months regardless of prior partial vaccination — complete the course.
Patients who received HPV vaccination as children should have catch-up doses to complete a three-dose adult OTR schedule per current local protocols.
Routine post-vaccination antibody titres are not required.

The 9-valent vaccine is used off-label in OTRs with multiple, recurrent or aggressive cSCCs at some UK transplant dermatology centres as part of a multi-modal prevention strategy.
It is not NICE-approved or NHS-funded for this indication.
Decision-making sits with the transplant dermatology MDT in collaboration with the transplant team.

Generally well tolerated. Local: injection site pain, erythema, swelling.
Systemic: low-grade fever, fatigue, headache, myalgia.
No association with autoimmune disease, multiple sclerosis or other major adverse events in post-marketing surveillance.
Anaphylaxis: rare (~1 per million doses).
Recipient and graft outcomes are unaffected in published OTR cohorts.

HPV vaccination should be considered for every patient entering the transplant pathway who is not fully vaccinated — both for anogenital cancer prevention (the primary indication) and as part of skin cancer prevention discussions.
Coordination between transplant team, dermatology, primary care and immunisation services.
Document doses given, vaccine type and intervals.
HPV vaccination is one element of a multi-modal cSCC prevention pathway in OTRs: photoprotection, regular surveillance, acitretin chemoprophylaxis, mTOR inhibitor conversion, field therapy (5-FU, imiquimod, MAL-PDT) and access to a transplant dermatology clinic.
Refer also to the transplant skin cancer monograph.