HPV vaccine: The growing campaign for including boys

It makeseconomic senseto give the HPV vaccineto boys, say advocates who arestepping uppressure onthe Ontario government to fullyfund school immunizationprogramsagainst the common sexually transmitted virus.

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Despite the mostrecent publiccampaign to include boys as well as girls, the province's Ministry of Health is deferring the issue.Theministry says it's "reviewing" the current programto determine whether changes are required.

In Canada, girls between ages nine and 13 can receive a free HPV immunization no matter where they live. Fourprovinces Alberta, Nova Scotia, British Columbia and P.E.I.currentlyor will soon alsoofferthe vaccine to boys.

In a growing pushto make the vaccinefree for boys, several young gay men made themselves available to media cameras as they were vaccinated againstthe human papillomaviruslast weekat the Hassle Free Clinicin Toronto.

Aministry statement released lastWednesday referred to "economic and societal factors" as reasons the province is still consideringwhether to expand the program, without elaborating,beyond mentioning "cost effectiveness and impact on the health system."

Money argument shot down

Many doctors and researchers say arguments against providing thevaccinefree to boys,based on cost, are unfounded.

"The economics right now make a lot of sense for funding boys,"saidDr.VinitaDubey, associate medical officer of health for Toronto Public Health. She said the cost would be"actually very minimal."

The National Advisory Committee on Immunization (NACI), which helps toshapepublic policy,recommended in 2012 that the HPV vaccine should be provided to boys, just as it is to girls.

2-dose schedule trims cost

At the beginning of theyear,it updated itsrecommendation and said that for young people,ages 9 to 14,only two doses are needed overa six-month period, instead of three.

"So ifwe go down to two doses for girls, to add boys on is only one additional dose, andwe know that from when the vaccine program was launched in Ontario in 2007, the price of the vaccine has come down,"Dubeysaid.

Dr. Eduardo Franco, director of McGill University's division of cancer epidemiology, has studied HPV for three decades, He also says the cost argument doesn't fly, even though it's a key reason provinces are hesitant to expand funding.

"That's the only reason, money," he said. "[But] the provincesalready have a really well developed logisticalprogram for vaccinating in schools, so it would be really simple to add vaccinationsfor boys. We could use the same system used in 2007."

Some would argue Ontario wouldbe subsidizingschoolprograms in other provinces by expanding its own, but only temporarily,until its purchasing power acts to putdownward pressure on prices.

Boys versus girls

DavidBrennan, associate professor at the Faculty of Social Work at the University of Toronto, said studies show that abouthalf the people who get HPV-related cancersare men.

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"Many of the studies that have been done that have looked at cost-effectiveness regarding HPV vaccination coverage for boys have not taken into account cancers related to anal, penile and oral cancers. Most of those studies have been conducted around cervical cancers."

"I know our health ministry is committed to equity and I believe that we're a little bit behind the times in terms of addressing this equitable health issue for boys and men," he told reporters.

Those in the public health debate do point out that vaccinating girls also offersboys protection, with so-called herd immunity.

Franco points out that Quebec policy makers decided four years ago that it would not becost-effective to extend the freeHPVprograms to boys because so many girls takepart.

But in 2013, when Alberta became the second province to offer HPV vaccinations to boys, its health minister referred to the importance of "today's investments" to reduce the "health-care costs of tomorrow."

So how much does it cost?

That number varies. An individual can expect to pay as much as $200 for one injection of Gardasil 9.

However, there are reports that school boards have been able to negotiate a lower price of between $70 and $90 for a single dose of Gardasil 4 thevaccine currently offered in Canadianschoolsandone thatprotects against four types of HPV shown to cause cervical cancer and anogenital warts.

Franco said Merck andGlaxoSmithKlineare selling theirHPVvaccines for less than$5 a dose to developing countriesandthere's room to lower the price in Canada.

"We accept, socially, theresponsibility that Canada plays in the role as a richcountry, so we understand that we should pay a higher price tohelp subsidizevaccinations in developing countries ... but up to close to $100 a dose is a bit too much," he said.

Franco said with the nine-strain Gardasil 9 now approved for use, the cost for Merck's four-strain predecessorshould go down significantly.

Federal officials can help lower the cost, he said, by lobbying pharmaceutical companies for better deals.

Why start so young?

The physical response to a new immunity is "fantastic" in the "crucial years of 10, 11 and 12" in both girls and boys, Franco said.

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"Their immune systems respond very strongly and they respond for life," he said. The immuneresponseremains strong for a couple of more years, although it "falls a little bit."

The four- and nine-strain Gardasil vaccines are recommended for boys, while Cervarix by GlaxoSmithKline only guards against two strains with the highest risk for causing cervical cancer in women.

Availability across Canada

In April 2013, P.E.I. became the first province to announce it's expanding its humanpapillomavirusvaccination program, to include Grade 6 boys.

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Alberta announced in September 2014 that parents canhave their sons in Grade 5 vaccinated against HPV.

Last April, Nova Scotia said free HPV vaccines would be available to Grade 7 boys in the fall.

In July, British Columbia said boys and young men up to age 26 who are at a higher risk of contracting HPV will be able to receive the vaccine at no charge starting in September.

Reasons for immunization

In the absence of vaccination, it is estimated that 75 per cent of sexually active Canadians will have a sexually transmitted HPV infection in their lifetime, according toNACI.

Two types of HPV cause 70 per cent of cervical cancer in women, according to the Canadian Cancer Society. In men, the virus is responsible for a high percentage of mouth, nose and throat cancers, as well as some cancers of the penis and anus.

Humanpapillomavirus(HPV) refers to "a group of more than 100 different types of related viruses," according to the Canadian Cancer Society. It's the most commonly transmitted STI.

It says an HPV infection can cause cervical, anal, vaginal and penile cancers, among others.

• ReadNACI'sin-depth list of recommendationsand who should not receive the vaccine.