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HPV vaccination during azathioprine-associated immunosuppression — DFSRH MCQ

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EasyAzathioprineHPV vaccination during azathioprine-associated immunosuppressionDFSRH

A 23-year-old woman attends for a contraceptive review. She has Crohn’s disease in sustained remission and takes azathioprine 2 mg/kg/day as maintenance monotherapy. Her UK immunisation record confirms that she missed HPV vaccination at school and has received no subsequent doses. She is afebrile, has no relevant vaccine allergy and is not pregnant. She asks whether HPV vaccination should be postponed or azathioprine interrupted because it suppresses her immune system. Which is the most appropriate HPV vaccination plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Administer Gardasil 9 at 0, 1 and 4–6 months without interrupting azathioprine

Explanation lettering: E = shown as A · A = shown as B · B = shown as C · C = shown as D · D = shown as E

She remains eligible for NHS HPV catch-up vaccination because females may receive catch-up vaccination until their 25th birthday. Although immunocompetent eligible people younger than 25 years usually require one dose, UKHSA guidance specifies three doses at 0, 1 and 4–6 months for people who are immunosuppressed at vaccination. Azathioprine is an immunosuppressive antimetabolite, so this modified schedule applies. Gardasil 9 is a non-infectious recombinant, inactivated vaccine. It can therefore be administered during azathioprine treatment; routine interruption of effective maintenance therapy is not indicated. Immunosuppression may reduce vaccine immunogenicity, but this supports use of the recommended three-dose schedule rather than withholding vaccination. B is the routine schedule for an eligible immunocompetent person under 25. C is the schedule used for eligible GBMSM aged 25 years or older, not for an immunosuppressed 23-year-old woman. D resembles an older three-dose HPV schedule but is not the current UK schedule for immunosuppressed people. E incorrectly applies precautions for live vaccines: azathioprine-associated restrictions on live vaccination do not apply to Gardasil 9.

Reference: HPV vaccination guidance for healthcare practitioners (2023; checked 19 August 2026) — https://www.gov.uk/government/publications/hpv-universal-vaccination-guidance-for-health-professionals/hpv-vaccination-guidance-for-healthcare-practitioners The UK immunisation schedule (30 March 2026) — https://assets.publishing.service.gov.uk/media/69cbb5ef8017673ffec0f313/Green-book-chapter-11-immunisation-schedules_30_03_26.pdf Gardasil 9 suspension for injection: Summary of Product Characteristics (23 September 2024) — https://www.medicines.org.uk/emc/product/7330/smpc