A Fair Shot
Should we vaccinate boys against Canada’s most common STD?
Here is something you won’t want to think about: if your children are sexually active, chances are they have the human papilloma virus. The Society of Obstetricians and Gynaecologists of Canada estimates that 10 to 30 percent of them (and of you, too, actually) are infected at this very moment. The odds that an HPV strain will pass through your body in your lifetime are so high that no rational person would bet against them. Yet tens of thousands of parents each year don’t sign the vaccine consent form their daughters bring home from school.
The unlucky girls will develop cervical cancer, or the more common and unpleasant genital warts. Even those who show no symptoms can still pass on Canada’s most common sexually transmitted disease. Gardasil, the pre-eminent HPV vaccine, protects against high-risk strains 16 and 18, which means it could—in theory—reduce cervical cancer by 75 percent; but so far it hasn’t, despite free vaccination for girls in select grades being offered by all provinces and territories. Even after six years of free coverage in Ontario, opposition from reluctant parents and faith-based schools has kept the compliance rate at an abysmal 55 percent. In Alberta, where girls are immunized in grade five, three years earlier than their Ontario peers, it’s 61 percent—an improvement, but far from the level required for “herd immunity.”
To improve these numbers, James Talbot, Alberta’s new chief medical officer, is investigating an initiative that would cover the other half of the student population: boys. He is closely watching PEI, which implemented Canada’s first program to vaccinate all sixth graders at the beginning of the 2013 school year. Meanwhile, public health officials across Canada are closely watching Talbot.
With a current vaccination rate of 85 percent, the island already boasts one of the highest uptakes in Canada, and has technically immunized the herd, thanks to a sweeping campaign across its tiny population; just seven of Canada’s 2,100 cervical cancer diagnoses each year occur in the province. Deputy chief public health officer Lamont Sweet thinks he can bring those statistics down even further, now that the province’s twenty-four elementary schools offer the vaccination program to both genders. The PEI government is the only one in North America to do this, and the experiment is affordable: 731 grade six boys are eligible for the pinch this year, at $230 a pop, which makes the small cohort a perfect test case for the rest of the country.
In 2012, the National Advisory Committee on Immunization recommended Gardasil for males nine to twenty-six, to guard them against warts and primarily male cancers, such as anal. However, it stopped short of recommending that provinces include the vaccine in their universal programs, because the warts can be treated and the more serious diseases rarely afflict males.
Talbot acknowledges that spending $30 million over a decade to stop a typically asymptomatic infection is hard to justify when Alberta doesn’t even cover rotavirus, a more easily contracted intestinal infection. However, when you add cervical cancer prevention to the equation, vaccinating boys starts making economic sense, given how unlikely the province is to achieve herd immunity exclusively through females. It also raises an uncomfortable question: should men be implicated in women’s reproductive health?
Sweet thinks so. His message to boys and their families is suasive: the vaccine helps guard their future families from tragedy. “We may not be able to say that it saves health care dollars in the long run,” he says, “but we do know that it will prevent considerable illness and death, and therefore we don’t have to justify it on the basis of saving money.”
Talbot’s stance is comparatively circumspect: “It’s a shared responsibility. Almost every STI campaign is built on this idea,” he says in his measured, cautious manner. In all of Edmonton, population 817,000, about fifteen men are diagnosed with HPV-related anal cancer each year and ten with penile cancer. Oral cancers caused by the infection may be more common (the evidence remains inconclusive), but they are still minuscule compared with occurrences of cervical cancer, virtually all of which can be linked to high-risk strains of the virus.
The question, then, is whether a sweeping vaccination campaign for males can save enough lives to justify the annual $3-million price tag in Alberta. “From our perspective, it’s all about the numbers,” says Talbot, referring to the cost analysis, the opportunity cost, “quality-adjusted life years,” and other economic jargon you would never want to come out of your GP’s mouth.
Talbot’s staff at Alberta Health crunched the data using two equations, one of them from Merck, the global pharmaceutical company and manufacturer of Gardasil. In the coming months, he will make his final recommendation to the Alberta government about whether or not to expand the program. Should he decide affirmatively, the next step is marketing it to parents and their sons, which won’t be easy, because HPV is widely considered a women’s disease. A sudden rebranding would be like trying to sell training bras to boys.
But males in any HPV-immunized community already benefit from shots administered to females. Two years after Australia introduced a national vaccination program for girls in 2007, cases of genital warts in young women and men dropped 59 and 39 percent, respectively. There, in the only country to federally fund coverage of both genders since February 2013, the conversation no longer focuses solely on cervical cancer. It’s about all of the symptoms, including warts, regardless of who is more likely to be affected.
New evidence suggests that a universal program could save more lives than anticipated. Oral HPV infections are now almost three-to-one male. Some researchers believe this is because men on average have more sexual partners, but Nigel Brockton, a Calgary oncologist who studies the relationship between HPV type 16 and oral pharyngeal cancers, links this ratio to the desquamation (shedding) of infectious cells, which occurs more readily on female genitalia. With fewer Canadians smoking than a generation ago, tonsil tumours should technically be declining, but they aren’t, perhaps because cunnilingus has become standard sexual practice. Since the lag time between infection and symptoms can be decades, HPV could become as much a men’s health issue as a women’s concern before all of the evidence is in.
“Let me put it this way,” says Brockton. “I have a seven-year-old son, and if he doesn’t get the vaccine through some sort of program I will take him and get it done. I can’t see a downside to it—but I don’t have a provincial budget to balance.”
This appeared in the January/February 2014 issue.