If I Started Gardicel Shots and Did Not Finish Do I Need to Start Again

Human Papillomavirus (HPV)

Disease Issues 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 Usa, an estimated 79 meg persons are infected, and an estimated fourteen million new HPV infections occur every twelvemonth among persons age xv through 59 years. Approximately one-half of new infections occur among persons historic period 15 through 24 years. First HPV infection occurs inside a few months to years of becoming sexually active.

How serious is disease acquired past HPV?

Most HPV infections are asymptomatic and become away completely on their own inside 2 years after infection without causing clinical disease. Some infections are persistent and tin can pb to precancerous lesions or cancer. HPV infection caused by 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 year in the United States (25,719 amongst women and 20,424 among men). Cervical cancer, the well-nigh widely known HPV-associated cancer, caused an average of 12,200 cases in the U.South. each year 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 normally occurring HPV-associated cancers, with an boilerplate of 20,236 reported cases each year (xvi,680 amid men and 3,556 amidst women). See www.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 jail cell types in which HPV Deoxyribonucleic acid is ofttimes found. These parts of the body include the cervix, vagina, vulva, penis, anus, and oropharynx.

Which types of HPV are most likely to cause disease?

In the United States, approximately eighty% of HPV-related cancers are attributable to HPV 16 or 18 which are included in all 3 HPV vaccines that have been bachelor in the U.S. Approximately 12% are owing 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, 18, 31, 33, 45, 52, or 58 business relationship for virtually 81% of cervical cancers in the Usa. HPV types 6 or 11 cause 90% of anogenital warts (condylomata) and most cases of recurrent respiratory papillomatosis.

Is in that location a treatment for HPV infection?

There is no handling for HPV infection. Simply 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 take chances of occupational infection with HPV?

Occupational infection with HPV is possible. Some HPV-associated weather condition (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 appropriately ventilated room using standard precautions and local frazzle ventilation. Workers in HPV research laboratories who handle wild-type viruses or "quasi virions" might exist at chance 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 because no data exist on transmission take chances 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 manual is theoretically possible but has not been definitely demonstrated. This is mainly because HPV tin't be cultured and DNA detection from the environment is difficult and probable prone to false negative results.

If a person has been infected with a wild-blazon strain of HPV can they exist 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 volition have a lower chance of reinfection with the same strain. Information suggest that females are more probable than males to develop immunity afterward clearance of natural infection. Prior infection with an HPV strain does not lessen the adventure of infection with a different HPV strain.

Vaccine Recommendations Back to top

Please describe the HPV vaccines bachelor in the United States.

Gardasil nine (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 Us.

9vHPV is an inactivated 9-valent vaccine licensed by the Food and Drug Administration (FDA) in 2014. Information technology contains vii oncogenic (cancer-causing) HPV types (xvi, eighteen, 31, 33, 45, 52, and 58) and two HPV types that cause most genital warts (vi 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 age 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 equally age 9 years. Vaccination is also recommended for all people historic period 13 through 26 years who have not been vaccinated previously or who have non completed the vaccination series.

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

No. In June 2019, the Informational Committee on Immunization Practices (ACIP) voted to recommend routine catch-upward 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 past historic period group. There is one recommendation for people 9 through 26 years of historic period 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 use of HPV vaccine in people age 27 through 45 years?

Grab-up HPV vaccination is non recommended for all adults older than 26 years of age. 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 before potential exposure to HPV through sexual contact.

Why is shared clinical decision-making (a give-and-take 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 boyhood and young adulthood, at whatsoever age, having a new sex activity 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 accept sex with men, transgender persons, and persons with immunocompromising conditions. HPV vaccine works to forestall infection among persons who have not been exposed to vaccine-type HPV before vaccination. A word with your patient is the best way to make up one's mind together how much the patient may benefit from HPV vaccination to prevent new HPV infections.

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

Because HPV acquisition by and large occurs soon subsequently first sexual practice, vaccine effectiveness volition be lower in older age groups as the result of prior infections. In full general, exposure to HPV also decreases among individuals in older historic period groups. Show 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 age range.

Should I screen my patients historic period 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 immune or even so susceptible to any given HPV blazon. Most sexually agile adults have been exposed to ane 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 have a few patients who received their first or second dose of HPV vaccine at historic period 26 years or younger, only did not complete the serial. Should I routinely complete their series later historic period 26 years, or practise I demand to use the shared clinical decision-making approach?

Complete the series based on shared clinical decision-making involving the patient�s chance and want for protection.

What is the routine schedule for HPV vaccine?

ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who kickoff the vaccination series before the 15th birthday. The two doses should be 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 start the series on or after the 15th altogether and for people with certain immunocompromising weather condition (such as cancer, HIV infection, or taking immunosuppressive drugs). The second dose should be given one to 2 months after the start dose and the third dose 6 months subsequently the beginning dose. The minimum interval betwixt the kickoff and second doses of vaccine is 4 weeks. The minimum interval between the second and 3rd doses of vaccine is 12 weeks. The minimum interval betwixt the beginning and third dose is 5 calendar months. If the vaccination series is interrupted, the serial does not need to be restarted.

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

Coverage levels for HPV vaccine are improving but are still inadequate. Results from the Centers for Disease Control and Prevention's 2020 National Immunization Survey-Teen (NIS-Teen) betoken that 77.1% of girls historic period 13 through 17 years had started the series that they should have 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 one dose but just 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 can ameliorate uptake of this life-saving vaccine in two principal ways. First, studies take shown that missed opportunities are occurring. Upward to ninety% (depending on year of nascency) of girls unvaccinated for HPV had a healthcare visit where they received some other vaccine such every bit Tdap, but not HPV. If HPV vaccine had been administered at the aforementioned visit, vaccination coverage for one or more doses could be ninety% instead of lxx%. 2d, research has shown that not receiving a healthcare provider's recommendation for HPV vaccine was one of the chief 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'southward "Talking to Parents about HPV Vaccine," available at www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf can help providers with these conversations. For more than detailed data about HPV vaccination strategies for providers, visit www.cdc.gov/hpv/hcp/index.html.

Some parents resist HPV vaccination of their xi- and 12-yr-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 commencement of any kind of sexual practice. It is standard practise to vaccinate people before they are exposed to an infection, every bit is the example with measles and the other recommended babyhood vaccines. Similarly, we desire to vaccinate children earlier they get exposed to HPV. Studies of HPV vaccine indicate that younger adolescents reply better to the vaccine than older adolescents and young adults. Good for you children vaccinated at this age will need only ii doses of vaccine rather than three doses if vaccinated at an older historic period. Finally, numerous inquiry studies have shown that getting the HPV vaccine does not brand kids more likely to be sexually active or outset having sex at a younger age.

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

No. Cervarix was non approved or recommended for use in males. Doses of Cervarix administered to males should not be counted and need to exist 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 boosted doses of 9vHPV for persons who started the three-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 bespeak revaccination with 9vHPV after a three-dose series of 4vHPV is safe. Clinicians should decide if the benefit of amnesty 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) program?

Yep.

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

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

Exercise women and men whose sexual orientation is aforementioned-sexual practice demand HPV vaccine?

Aye. 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 as for all adolescents and young adults through age 26 years. Clinicians should talk over 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 three doses of HPV vaccine for females and males age ix through 26 years with principal or secondary immunocompromising conditions that might reduce jail cell-mediated or humoral amnesty. Examples include B lymphocyte antibody deficiency, T lymphocyte complete or partial defects, HIV infection, malignant neoplasm, transplantation, autoimmune illness, 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 likewise does non use to children 9 through 14 years with asthma, chronic granulomatous disease, chronic liver disease, chronic renal disease, central nervous system anatomic barrier defects (such equally a cochlear implant), complement deficiency, diabetes, centre 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 it nonetheless recommended to give HPV vaccine or to complete the HPV vaccine serial?

Yeah. HPV vaccine should be administered to people who are already sexually active. Ideally, patients should exist vaccinated earlier onset of sexual activity; however, people who have already been infected with ane or more HPV types will still exist protected from other HPV types in the vaccine that have non been acquired.

I have a patient who was diagnosed with HPV types 16 and 18. The patient received a properly spaced Gardasil serial 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 affliction amid persons without prior infection with the HPV types included in the vaccine. The near likely explanation for this situation is that the patient was exposed to at to the lowest degree HPV types 16 and xviii prior to vaccination. The HPV vaccine is not constructive 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 nine 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, virtually often type 6 or 11 which cause ninety% of genital warts. Nevertheless, 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 volition provide protection against infection with HPV serotypes the patient has not already acquired. Providers should suggest their patients/clients that the vaccine volition not take a therapeutic event on existing HPV infection or genital warts. Information technology is of import, nonetheless, 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 Dorsum to summit

What is the recommended schedule for administering HPV vaccine?

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

A 3-dose schedule is recommended for people who start the series on or later the 15th altogether 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 later the get-go dose and the third dose 6 months afterward the first dose. The minimum interval between the first and second doses of vaccine is iv weeks. The minimum interval betwixt the 2d and third doses of vaccine is 12 weeks. The minimum interval betwixt the first and third doses is 5 calendar months. If the vaccination series is interrupted, the series does not need to be restarted.

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

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

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

No, do not restart the series. You should go along where the patient left off and complete the serial.

Can the 4-day "grace period" be applied to the minimum intervals for HPV vaccine?

Yes.

A xvi year onetime received the third dose of HPV vaccine 12 weeks afterwards the second dose but simply 4 months afterwards the first dose. Should the third dose be repeated?

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

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 two-dose schedule tin be completed with any combination of HPV vaccine brands every bit long as dose #1 was given before age fifteen years. Dose #two should be administered 6–12 months afterward dose #1.

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

Yeah. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be fairly vaccinated with merely one additional dose of HPV vaccine.

We take adolescents in our practise who have received the first 2 doses of the HPV series 1 or 2 months apart according to the iii-dose schedule. Tin can we consider their HPV vaccine serial to be complete or practice nosotros demand to requite these patients a third dose?

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

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

Yes. Any person who e'er received two doses of any combination of HPV vaccines tin 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 time for their next dose of HPV vaccine. What's the longest interval immune earlier we need to showtime the serial 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). Y'all should keep the serial where it was interrupted.

I take read that HPV vaccine should not be administered during pregnancy. Exercise we demand 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. Nonetheless, if a person is constitute to be pregnant after initiating the vaccination series, the residue of the serial 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 adult female who didn't know she was meaning at the time. How should nosotros complete the schedule?

You 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 two- or 3-dose schedule (depending on the age at initiation of the series).

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

Aye, administration of a different inactivated or live vaccine, either at the same visit or at any fourth dimension before or after HPV vaccine, is acceptable because HPV is non a live vaccine.

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

Aye. No information be on the efficacy or safety of HPV vaccine given by the subcutaneous route. All data on efficacy and duration of protection are based on a vaccine series administered past the intramuscular route. In the absenteeism of information on subcutaneous administration, CDC and the manufacturer recommend that a dose of HPV vaccine given past whatsoever route other than intramuscular should exist 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 acute illness with or without fever. Vaccination should be deferred until the condition improves. HPV vaccines are non recommended for use during pregnancy. If a person is institute to be pregnant subsequently starting the vaccination serial, 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 non needed before vaccination. If a vaccine dose has been administered during pregnancy, no intervention is needed. You can observe more information most 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 still be vaccinated?

Yes. A woman with evidence of nowadays or past HPV infection identified through cervical screening may be vaccinated. Recipients of HPV vaccinations should be counseled that the vaccine will non take a therapeutic consequence 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 examination a contraindication to the HPV vaccine series?

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

Vaccine Rubber Dorsum to superlative

What agin events can be expected following HPV vaccine?

In clinical trials of 9vHPV involving more 15,000 subjects, the most mutual agin result was injection site pain, which was reported in about xc% of recipients. Other local reactions, such as redness and/or swelling, were reported in most twoscore% of recipients. Fever was less common, reported past nearly half dozen% of recipients. The rates and severity of adverse reactions post-obit each dose of 9vHPV were like between boys and girls.

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

No. Since 2006, more than 120 million doses of HPV vaccine accept been distributed in the United States. Among all reports to the Vaccine Adverse Upshot Reporting System (VAERS) following HPV vaccines, the nearly 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 not related to wellness problems, 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 have been reported among vaccine recipients none has been conclusively shown to take been caused past the vaccine. Occurrences of rare weather condition, such as Guillain-Barré Syndrome (GBS) have also been reported among vaccine recipients simply in that location is no prove that HPV vaccine increased the rate of GBS above 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 can discover consummate information on this and other vaccine safety issues at www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-prophylactic-faqs.html.

Do HPV vaccines crusade fainting?

Nearly all vaccines have been reported to exist associated with fainting (syncope). Post-vaccination syncope has been most frequently reported after three vaccines usually given to adolescents (HPV, MenACWY, and Tdap). All the same, it is non known whether the vaccines are responsible for post-vaccination syncope or if the clan with these vaccines merely reflects the fact that adolescents are generally more than probable to feel syncope.

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

How should HPV vaccine exist stored?

HPV vaccine should be stored at refrigerator temperature between two°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 lite. Administer as soon as possible later existence removed from refrigeration. The manufacturer bundle insert contains additional data and can exist found at www.immunize.org/packageinserts. For complete data on vaccine storage and handling all-time practices and recommendations delight refer to CDC'southward Vaccine Storage and Handling Toolkit at world wide web.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.

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