The human papillomavirus (HPV) is responsible for 5% of cancers worldwide. Treatment for these cancers, which include anogenital and oropharyngeal malignancies, is often painful and toxic, with life-changing side effects. What is more, the incidence of many of these cancers is on the rise. Despite receiving strong recommendations from global government bodies, inclusive of the Center for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the National Health Service (NHS), among many others, coverage rates of the HPV vaccine are still not high enough to end the cancers caused by HPV.
In the UK, this gender-equal virus is still only being protected against in a gender-discriminatory way, as the national vaccination programme continues to cover only girls. This ignores the fact that boys and men are affected too. In fact, it is predicted that the incidence of HPV-associated oropharyngeal cancer in males will overtake the incidence of HPV-associated cervical cancer in females in developed countries such as the UK in just five years.
In the US, both boys and girls have equal access to the protection afforded by the vaccine. However, the vaccination recommendations are not being implemented at high enough rates to make a true impact on HPV infection.
The HPV and Anal Cancer Foundation has been vocal on both sides of the pond about the need for improved vaccination access for all genders, but we need your help to really make our voices heard. Below we lay out the case for vaccination so that you too can help fight for equitable and adequate policy surrounding this life-saving vaccine.
Current UK Vaccination Policy
In the UK, since 2008 women have been protected against HPV by a vaccination programme for 12 and 13-year-old girls delivered mostly through schools. At a national level, this has been very successful with over 80% of girls receiving all the doses they need. HPV causes at least six cancers in men and women. The next step is to provide boys with equal access to the vaccine so they can be protected against HPV-related precancer and cancer, too.
Why Vaccinate Boys?
The case for vaccinating all boys is as follows:
- HPV is an incredibly common virus transmitted through skin-to-skin contact that causes diseases in both men and women, including cancer. HPV-related diseases affect a significant number of men: over 50,000 per annum in the UK (see figures below). It is inequitable not to offer men and women the same level of protection against these diseases. In the UK, per year, over 360,000 12 and 13-year-old boys are left unprotected and at risk of cancer and other HPV-related diseases by the current girl only HPV vaccination programme.
- Men will not be protected by a female only vaccination programme. Men who have sex with men (MSM) are not protected at all in female only programs. In addition, men will continue to have sexual contact with unvaccinated women. Some unvaccinated women will be those who have fallen through the net of the UK’s current immunisation programme (some areas including Manchester, Cornwall, East Sussex and about half of all London boroughs – have vaccination rates for girls well below 80%) and many men have sexual partners from outside the UK who are unvaccinated.
- Genuine ‘herd immunity’ cannot be achieved unless all people are vaccinated because the virus will continue to be transmitted between MSM as well as between unvaccinated women and men. If vaccination rates in women should fall significantly, men will be even less protected and boys who are not vaccinated will continue to infect unprotected women, as they do today.
- Vaccinating boys will help protect women in the UK who have not been vaccinated through the national programme, as well as unvaccinated women from other countries.
- Even though all people get HPV, women alone currently shoulder the responsibility for protecting all people against HPV infection in the UK. By including males in the program, the entire population will participate in eradicating HPV-related malignancies.
- HPV Action estimates that the additional cost of extending the HPV vaccination programme to boys in the UK would be about £20–22 million a year, a relatively small sum when set against the total costs of treating HPV-related diseases. The cost of treating genital warts alone in England is estimated to be £52 million a year. One study of the cost of treating nine major HPV-related diseases in Italy produced an estimate of about £430 million a year.
WHat countries SUPPORT GENDER EQUAL VACCINATION?
The vaccination of all children is now government policy in Australia, USA, Austria and several Canadian provinces. Israel is set to include boys in its vaccination programme in the coming school year, while the Federal Office of Public Health in Switzerland has also recommended that the inclusion of boys be considered.
Who supports gender-equal immunization in the UK?
A large and growing number of organisations are advocating the vaccination of adolescent boys as well as girls. This campaign is led by HPV Action (HPVA), a collaborative partnership of 36 patient and professional organisations that are working to reduce the health burden of HPV in the UK. The coalition includes a wide range of leading public health, cancer, oral health, sexual health and men’s health organisations.
Cancer Research UK, the BMA and Jo’s Cervical Cancer Trust also support the vaccination of all boys. In Parliament, it is supported by the All Party Parliamentary Group on Cancer and a number of MPs.
Current JCVI Recommendation
The Joint Committee on Vaccination and Immunisation (JCVI) recommended in November 2014 that MSM, who are at higher risk of HPV-related cancers than men who have sex with women, should be offered HPV vaccinations when they attend sexual health clinics. A consultation on this recommendation closed in early January.
Offering vaccination to MSM at sexual health clinics is a step forward but is not nearly enough to protect MSM. This is because:
- Most MSM are likely to remain unvaccinated. The Stonewall health survey found that 44% of gay and bisexual men had never discussed sexually transmitted infections with a healthcare professional; this suggests that they may have never attended a sexual health service. There are also MSM who do not identify as gay or bisexual and who will not disclose their sexual activity to a healthcare professional, making it highly unlikely that they will be offered the vaccination.
- It will not prevent HPV infection in the significant proportion of men who acquire HPV soon after becoming sexually active. A study of teenage MSM in Australia found that 39% had at least one HPV DNA type detected and 23% had a HPV type preventable by the vaccine currently used in the UK. Vaccination after sexual debut provides minimal protection and will do little to break the chain of infection.
- MSM who attend sexual health clinics generally do not do so until they are in their late 20s. A review of all MSM attending an NHS sexual health service in Southampton found that the median age at attendance was 32 and the median age at first attendance at the clinic was 28. This additionally sends the wrong message to practitioners, MSM, and the general public about when the vaccine should be implemented and its ability to confer protection at later ages.
- Immunity against HPV is greater if the vaccine is administered before the age of 16. Older people have a less significant immune response. The data to support this statement came from a study that found post-vaccination antibody titers in males aged 9-15 were significantly higher than those in males aged 16-26.
- It is not practical or ethical to separate 12 and 13 year old boys for vaccination who might go on to have sex with men.
The only effective way to protect all men is to vaccinate all adolescent boys before they become sexually active.
what can be done?
HPVAction has put together a useful page about the steps you can take to make sure your voice is heard in the fight to eradicate HPV in the UK. Check it out here and take action today!
Current US Vaccination Policy
In the US, HPV vaccination is recommended by the CDC for all 11 and 12 year-old girls and boys. Girls and boys between the ages of 9 and 26 who did not receive the vaccine or complete the series are also approved to get the vaccine by the FDA. Both boys and girls are vaccinated with Gardasil or Gardasil 9. Girls can be additionally vaccinated with Cervarix.
The vaccine is most effective when administered at younger ages when immune response is higher, and prior to sexual debut.
Despite these wide and gender-equal approvals, and recommendations by the leading medical associations, including the American Medical Association and American Academy of Pediatrics, HPV vaccination uptake in the US has been slow, but rates are improving. According to the CDC, in 2017, about 50% of adolescents were up to date on the HPV vaccine, and 66 percent had received the first dose of the series. On average, tthe percentage of adolescents who started the HPV vaccine series improved 5% each year from 2013-2017.
Fig 1: HPV vaccination coverage in the US.
The CDC notes that increasing vaccination coverage to 80% in girls alone will prevent an estimated 53,000 future cervical cancer cases over the course of a lifetime for today’s 12 year olds. This statement addresses one of the six cancers caused by HPV. Tens of thousands of cases of other cancers, inclusive of penile, anal, vaginal, vulvar and oropharyngeal would likely be prevented within the same timeframe . The need to improve vaccine uptake, especially in boys is especially pertinent in light of the alarming rise of HPV-associated oropharyngel and anal cancers in men in recent years. The American Cancer Society estimates that by 2020, at current rates of incidence of these cancers, HPV-positive oropharyngeal squamous cell carcinomas will likely surpass cervical cancer as the most common HPV-associated cancer in the US.
What can be done?
The underuse of the HPV vaccine is a serious but correctable threat to the fight against cancer. President Obama's Cancer Panel outlined several strategies for improving vaccine uptake in the US:
- Educational efforts must be bolstered to improve public awareness of this highly effective, and safe, tool.
- Physicians must work to decrease missed opportunities to vaccinate children and strive to include the HPV vaccine among the standard childhood vaccinations, which are already widely accepted.
- Targeted efforts should be made to improve vaccine acceptability amongst parents, caregivers, and adolescents alike, inclusive of working to eliminate stigma and misconceptions surrounding the vaccine.
- Finally, access to the vaccine must be maximised though increasing the range of venues and providers offering to administer it. Ensuring that it is available in all locations where teens receive healthcare will vastly improve the likelihood that adolescents receive all three doses.
Concerted action surrounding the HPV vaccine would cause hundreds of thousands of people annually to avoid a diagnosis of an HPV-related cancer. The HPV and Anal Cancer is doing everything we can to raise awareness of this important and crucial tool, and you can join us. Your voice is the key to increasing uptake of this lifesaving vaccine and advancing the fight to end 5% of cancer.