We appreciate the letter from Kacew et al regarding the updated American Cancer Society (ACS) human papillomavirus (HPV) vaccination recommendations,¹ which represent an adaption of the recommendations from the Advisory Committee on Immunization Practices (ACIP).² In particular, Kacew et al take issue with the ACS Guideline Development Group's not endorsing the ACIP's recommendation that adults aged 27 to 45 years who have not been vaccinated should have an opportunity to undergo shared decision making related to catch‐up vaccination. The authors argue that: 1) rural and other at‐risk populations will interpret the ACS nonendorsement to mean that the vaccine is not safe for adults aged 27 to 45 years, and this could lead to doubts regarding its safety in children; 2) although there is lower protection against HPV infection when vaccination occurs at older ages, nonendorsement will detract from emerging data that suggest a potential role for vaccination in the prevention of recurrent cervical dysplasia among high‐risk populations; and 3) the updated guideline removes the opportunity for these groups to benefit from vaccination, if even only by a small amount. We will address each of these issues.

The importance of vaccinating girls and boys between the ages of 9 and 12 years, and especially ages 9 to 10 years, is based on the effectiveness of the vaccine during this age range and the decreased effectiveness of the vaccine when it is administered at older ages, especially after the age of 18 years.^{3, 4} We are sensitive to the challenges of achieving high vaccination rates in rural areas and among survivors of pediatric cancers, but the proper target groups for vaccination are average‐risk boys and girls aged 9 to 12 years, and then, after the age of 12 years, there still are 14 years in which to “catch up” before age 26 years, a period during which young adults have an opportunity to obtain some, albeit less, protection against developing HPV‐related cancers. As we pointed out in the new guideline,¹ shared decision making for vaccination after age 26 years, let alone being vaccinated, would have miniscule benefit, consume untold hours of clinical time, and perhaps instill false confidence, which is likely the reason that the ACIP only endorsed shared decision making, and did not make a direct recommendation, for catch‐up vaccination from ages 27 to 45 years.² The authors mention the potential benefit of secondary prevention for cervical dysplasia and other neoplastic conditions, but this purpose is therapeutic, off‐label, and not relevant to the recommendation from the ACIP. Similarly, cancer survivors should be under special care and are beyond recommendations for the general population. Kacew et al speculate that rural residents will interpret a lack of endorsement of catch‐up vaccination after age 27 years as suggesting that the vaccination is not safe. In fact, we stated, “Although HPV vaccination is safe for adults aged 27 to 45 years, there would be limited public health benefits from vaccinating people in this age range.”¹ What is more likely to occur is that the catch‐up population aged 27 to 45 years would have a shared decision‐making conversation that includes a discussion of the patient's history of sexual activity, which will have the unintended consequence of refocusing discussions concerning childhood vaccination back on sexual activity, a well‐known barrier to childhood HPV vaccinations. Finally, with regard to the new guideline removing the opportunity for rural populations to undergo vaccination from ages 27 to 45 years, it does not. Adults are free to make their own decisions, the ACIP still endorses shared decision making, and health plans will cover it.

We are in complete agreement with the goal of achieving higher rates of HPV vaccination in rural populations, but believe emphasis primarily should be on those aged 9 to 12 years, and, if not accomplished then, on those aged 13 to 26 years, and at the earliest opportunity.

我们感谢Kacew等人关于美国癌症协会（ACS）人乳头瘤病毒（HPV）疫苗更新建议的来信，¹该信是对免疫实践咨询委员会（ACIP）的建议的改编。²特别是，Kacew等人对ACS指南开发小组不支持ACIP的建议表示质疑，即未接种疫苗的27至45岁的成年人应有机会进行与追赶疫苗接种相关的共同决策。作者认为：1）农村和其他高危人群将ACS的不认可解释为该疫苗对27至45岁的成年人不安全，这可能导致对其在儿童中的安全性产生怀疑；2）尽管在较高年龄进行疫苗接种时对HPV感染的保护作用较弱，但无认可将削弱新出现的数据，这些数据表明疫苗接种在预防高危人群中复发性宫颈异型增生中具有潜在作用；3）更新后的指南消除了这些人群即使仅少量接种疫苗的机会。我们将解决所有这些问题。

为9至12岁（尤其是9至10岁）的女孩和男孩接种疫苗的重要性，是基于该年龄段疫苗的有效性以及年龄较大时疫苗有效性下降的原因，尤其是18岁之后。^3，4我们对在农村地区和小儿癌症幸存者中实现高疫苗接种率的挑战很敏感，但是合适的疫苗接种目标人群是年龄在9至12岁之间的中等风险男孩和女孩，然后是在12年中，有26年才有14年的“追赶”时间，在此期间，年轻人有机会获得一些（尽管较少）针对发展与HPV相关的癌症的保护。正如我们在新指南中指出的那样，^1个26岁以后的疫苗接种共享决策，更不用说接种疫苗了，其收益微乎其微，消耗了数小时的临床时间，也许还会灌输虚假的信心，这很可能是ACIP仅认可共享决策的原因，不建议直接接种27至45岁的补种疫苗。²作者提到二级预防对子宫颈发育不良和其他赘生性疾病的潜在益处，但此目的是治疗性的，不合标签的，与ACIP的建议无关。同样，癌症幸存者应受到特别照顾，超出了普通人群的建议。Kacew等人推测，农村居民会在27岁以后将其缺乏对追赶疫苗的认可，这表明疫苗接种是不安全的。实际上，我们说过：“尽管HPV疫苗接种对27至45岁的成年人是安全的，但在这个年龄段的人群接种疫苗对公共健康的益处将有限。” ^1个更可能发生的是，年龄在27至45岁之间的追赶人群将进行共同的决策对话，其中包括对患者性行为史的讨论，这将带来意想不到的结果，即重新关注有关儿童接种疫苗的讨论回到性活动，这是儿童HPV疫苗接种的众所周知的障碍。最后，关于消除农村人口从27岁到45岁进行疫苗接种的机会的新准则，事实并非如此。成人可以自由地做出自己的决定，ACIP仍然赞同共同的决定，而健康计划将对此予以覆盖。

我们完全同意在农村人口中实现更高的HPV疫苗接种率这一目标，但是我们认为重点应该主要放在9至12岁的人群，如果不能做到的话，重点应该放在13至26岁的人群以及最早的机会。