By Isabel Teotonio/Torstar News Service
When Becky Maddigan took her 14-year-old son Jack to a public health clinic for a free HPV immunization he never did get around to rolling up his sleeve and being pricked in the arm.
She, however, got “all up in arms” when health officials raised a subject she found prickly: The vaccine is only publicly funded for girls.
“I was just livid,” says the Brampton mom about that trip last spring to the Peel clinic, which prompted her to write letters to politicians, urging them to extend coverage to boys.
“Why should (Jack) not be vaccinated just because he’s a male when the HPV (vaccine) would still protect him?” asks Maddigan about her only child. “I don’t think it’s fair.”
She’s not alone. A growing chorus of parents, doctors and health officials are calling on the province to offer a gender-neutral vaccination program for HPV or Human Papillomavirus, the most common sexually transmitted infection. After all, it affects both males and females, infecting three out of four Canadians in their lifetime. Most people show no symptoms and their own body fights infection, but in some cases it can lead to genital warts and cancers of the cervix, genitals and throat and mouth.
In the coming weeks, Grade 8 girls across Ontario will line up to receive a free HPV shot in school-based clinics organized by their local health units. But if boys want the shot, they must get it from a doctor at a cost of about $500, which covers three treatments of Merck’s Gardasil. (Some private insurers may pay to vaccinate boys.)
Ontario, however, is considering following in the footsteps of PEI, which announced this year it would also pay for boys to get the shots. Alberta is also committed to providing the vaccine to boys. And this year, Australia became the first country to immunize boys as part of its school-based vaccination program.
“There is a process underway and the government is actively looking at this issue of whether or not we should expand our program, beyond the delivery to young women,” says Dr. Arlene King, the province’s chief medical officer of health.
Among the considerations, she says, are issues such as value for money, fairness and equity and whether inoculating males would encourage more girls to get the shot.
“Value for money, I think, includes things like cost-effectiveness, but also considerations like: Would there be improved acceptability of the vaccine? Would there be improved coverage of the vaccine? Would there be reduced stigmatization related to this being a vaccine that potentially prevents disease in women only?”
From an ethical and equity perspective, a gender-neutral program makes sense, says Dr. Shelley Deeks, medical director of Immunization and Vaccine-Preventable Diseases at Public Health Ontario. It’s the accompanying price-tag that makes it a tricky decision. (It costs the province $16.5 million to deliver the vaccine to about 75,000 Grade 8 girls.)
“A more difficult question is whether the vaccine should be publicly funded for boys — and why that’s a difficult question is because the vaccine is really expensive,” says Deeks. “If the cost were to come down it would make the decision much easier.”
She certainly supports the HPV vaccine for boys and has even purchased it for her two sons — she’s just not certain if it should be publicly funded.
The question gets more difficult when looking at studies that show vaccinating females can also benefit males, says Deeks, also an associate professor at the Dalla Lana School of Public Health at the University of Toronto. She refers to one study from Australia, an early adopter of the vaccine, which shows the incidence of genital warts decreased among young women who received the vaccine, and men of the same age who had not.
“A number of the cost-effectiveness studies have shown it is not cost-effective from a health-care system approach to vaccinate boys,” says Deeks. “But, that’s not the only consideration.”
So far, the impact of the vaccination program, which began in Ontario in 2007, is unknown because scientists are waiting for the first cohort of girls to become sexually active — they’re about 19 years old now.
Next year, Public Health Ontario will begin studying data to see if there’s been a decrease in the incidence of genital warts. However, a study by the Centers for Disease Control and Prevention, published in the June issue The Journal of Infectious Diseases, showed the vaccine had cut HPV infections by 56 per cent among teenage girls, since its introduction in 2006. (The reduction was among infections from the four strains of HPV the vaccine targets.)
In part, the thinking behind the female-only vaccination program has been that it’s important to prevent cervical cancer, which has a higher incidence than other HPV-related cancers. And, inoculating females provides herd immunity, benefiting males who will become their sexual partners.
But last year, the National Advisory Committee on Immunization (NACI) recommended also inoculating boys aged 9 to 26, to prevent anal and genital cancers and genital warts, and men who have sex with men, deemed to be at high risk, especially if HIV-positive.
NACI, however, only recommends who should get a vaccine, it doesn’t advise whether it should be publicly funded — that’s a provincial and territorial decision. The Canadian Immunization Committee will release a report later this year on the cost-effectiveness of a gender-neutral program. Other groups, such as The Society of Obstetricians and Gynaecologists of Canada and Toronto Public Health, have already called on government to publicly fund the vaccine for males.
“A gender-neutral program removes the sexual stigma, which has impeded successful uptake of HPV vaccination,” wrote the Society’s CEO Dr. Jennifer Blake to provincial and territorial health ministers in the spring. “To achieve the goal of eradicating HPV-related infection and disease will require the vaccination of both males and females.”
There are “multiple benefits” in extending the program to boys, says Dr. Monica Hau, associate medical officer of health at Toronto Public Health.
It would prevent HPV-related cancers and genital warts that affect males, and also reduce oropharyngeal cancers in the throat and mouth, which scientists warn are increasing and expected to surpass HPV-related cervical cancers by 2020. (The subject recently garnered attention when actor Michael Douglas told The Guardian that HPV, transmitted through oral sex, caused his throat cancer.)
Inoculating only females doesn’t protect those males who have sex with other men, Hau says. Even girls would benefit because immunizing boys would protect females who have not been vaccinated, she says.
And when determining the cost-effectiveness of a vaccine, it’s important to remember how costly HPV is, she says, adding diagnosing and treating related infections costs the Canadian health care system more than $300 million each year.
Ultimately, boys should have the same publicly-funded access to this disease-preventing vaccine — a position that’s received “a lot of public support” from parents and physicians, says Hau.
One of those parents is Sandi Kleinman, who this year paid $540 for her son to get the HPV vaccine — an amount too steep for some.
“Preventative medicine is for everybody — it should be equitable and it should be fair and accessible,” says Kleinman. “If it’s offered to some it should be offered to everybody.”
In June, she addressed the Toronto Board of Health, urging it to support funding the vaccine for all teens. She also shared her frustration with a program that only pays for girls: “It not only appears inequitable from a gender perspective, but also homophobic and classist.”
“The long-term monetary costs of treating HPV-related cancers and illnesses in the males would likely outweigh the cost of giving our young men the vaccine,” she told the board. “It would appear penny-wise and pound-foolish to only vaccinate girls.”
Brampton mom Becky Maddigan is going to wait a year or two before paying to have Jack vaccinated, hoping that in the interim the province decides to fund it. But if not, she says, “I’ll do it anyways.”
“I’ve always heard that prevention is the best medicine.”
The HPV vaccine in Ontario
In Ontario, female-only HPV vaccination programs began in September 2007, largely as a way to prevent cervical cancer, which according to the World Health Organization is the second most common type of cancer in women worldwide. (The Canadian Cancer Society estimates that this year 1,450 Canadian women will be diagnosed with cervical cancer and 380 women will die of it.) Since then, Grade 8 girls have been eligible for the vaccine, which should be given before sexual activity begins. In September 2012, a catch-up program was introduced to high school girls who had not gotten the shots earlier.
When it comes to HPV vaccination coverage rates, Ontario is on par with the rest of the country at 70 per cent, according to the most recent data from 2011-2012. That’s below the 90 per cent target the federal government hoped the program would reach within five years of implementation, but figures have been gradually rising. By comparison, the rate was 59 per cent in 2009.
It’s not known how many boys have received the vaccine from a doctor because there’s no immunization registry in Ontario. Officials keep track of how many girls have gotten the shots through the school-based system.