Human papilloma virus (HPV) is a nasty sexually transmitted virus that causes around five per cent of all cancers as well as genital warts. In the UK, since 2008, women have been protected by a vaccination programme for 12/13 year old girls delivered mostly through schools. At a national level, this has been very successful with over 80 per cent of girls receiving all the doses they need. But in the past few years, it has become clear that vaccinating just girls is not enough.
A large number of organisations are now advocating the vaccination of boys as well as girls. This campaign is led by HPV Action, a collaborative partnership of patient and professional organisations whose membership has grown from two to 36 in little over a year. Its members include several organisations with a specific interest in oral health, including the British Dental Association, the British Dental Health Foundation, the British Society of Dental Hygiene and Therapy and the Mouth Cancer Foundation. The debate about vaccinating males has prompted the government’s
vaccination advisory committee (JCVI) to look at the evidence and it is expected to make its final report in late 2015.
HPV Action believes that the current HPV vaccination programme is unfair and inadequate it leaves males at risk. HPV does not just cause cervical – and vaginal and vulval – cancers in women; it can also cause several head and neck cancers as well as anal cancer in both sexes and penile cancer in men. HPV Action estimates that some 2,000 male cancers, including about 1,400 head and neck cancers, are caused by HPV each year in the UK as are approximately 48,000 male cases of genital warts. Moreover, around 600 men live with recurrent respiratory papillomatosis, an HPV-related condition that causes disabling breathing problems.
Some of these male cases will in time be prevented by a female only vaccination programme but many will not, for the simple reason that men will continue to have sexual contact with unvaccinated individuals. Some unvaccinated women will be those who have fallen through the net of the UK’s current immunisation programme (there are areas where vaccination rates for girls are well below the critical threshold of 80 per cent) and many men have sexual partners from outside the UK who are unvaccinated.
Vaccinating boys would also protect men who have sex with men (MSM), a group completely outside of any so-called ‘herd protection’ created by the vaccination of girls. MSM, especially HIV-positive MSM, are at increased risk (compared to heterosexual men and women) of anal cancer caused by HPV.
The JCVI recently suggested that MSM should be offered HPV vaccinations via sexual health clinics. HPV Action sees this as a small step in the right direction but not nearly sufficient. Such an approach is unlikely to reach a sufficient number of the at-risk population because most MSM have had multiple sexual partners, with increased risk of acquiring HPV, before they attend any clinic. In fact, optimal protection against HPV infection occurs only when vaccination is administered before sexual ‘debut’ — the median age of attendance by MSM at one major UK sexual health services is 32 years. There are also MSM who do not identify themselves as gay or homosexual and will not disclose their sexual activity to a healthcare professional and they will therefore not be offered the vaccine.
HPV Action estimates that the additional cost of extending the HPV vaccination programme to boys in the UK would be in the region of £20m-22m a year, a relatively small sum when set against the total costs of treating HPV-related diseases. One study of the cost of treating nine major HPV-related diseases in Italy produced an estimate of about £430m a year. The Australian government has calculated that it is cost-effective to vaccinate boys as well as girls and has now begun to do so. The vaccination of boys is also recommended by the Austrian, Canadian and United States governments.
It is time the UK government followed suit. Sir Paul Beresford MP, who continues to work as a part-time dentist, made the case of vaccinating boys in a parliamentary debate in July 2014. “It is not fair, ethical or socially responsible,” he said, “to have a public health policy that leaves 50 per cent of the population vulnerable to infection. … Vaccination, combined with early detection and action on smoking and heavy drinking of alcohol, could save a huge number of lives just as we are facing a dramatic increase in head and neck cancer.”
A recent BMJ editorial on the issue made a similar point: “The only sensible answer ... is a gender neutral vaccination strategy in schools that gives two doses of the vaccine to all 12 to 13-year-old boys and girls. Anything else is discriminatory, inequitable, less effective, and difficult to explain.”