IN 20 years’ time will our sons ask why we forgot about them? Why did we think of the girls but not the boys?
First-year girls in secondary schools all over Ireland have had the HPV vaccine available free to them since 2010. Gardasil protects against four HPV types – strains 6 and 11, responsible for 90% of genital warts, and strains 16 and 18 responsible for 70% of cervical cancers.
“When people talk about HPV, all they think about is cervical cancer,” says Professor James Paul O’Neill, professor of otolaryngology, head and neck surgery at Royal College of Surgeons in Ireland and Beaumont Hospital. He says there’s poor public awareness that one in 40 of all cancers today are HPV-derived.
“The high-risk types, 16 and 18 are the real players. They’re causing a lot of the cancers in the urogenital and head and neck area – they cause 95% of anal cancers, 75% of oropharyngeal cancers, 75% of vaginal cancers, 70% of vulval cancers and 60% of penile cancers. It’s a real problem.”
By 2020, the annual incidence of HPV-related oropharyngeal disease is expected to outnumber cases of HPV-mediated cervical cancer.
“In the old days, oropharyngeal cancer was chemically-driven. It was the smokers, the drinkers. Now it’s viral driven,” says O’Neill.
And it’s four times more common in men, with patients tending to present about 10 years younger compared to HPV-negative patients.
On the rise worldwide, sexually-transmitted HPV viruses spread through contact with infected genital skin, mucous membranes or bodily fluids.
They’re not gender-specific – 85% of women and 91% of men with at least one heterosexual partner will contract a HPV infection during their lifetime.
“Most healthy people with a normal, healthy sex life will be exposed to HPV at some stage,” says O’Neill, confirming most common transmission is through vaginal and anal sex, but oral sex is “also a way in”.
Professor Mark Lawler, Dean of Education in the Faculty of Medicine, Health and Life Sciences at Queen’s University Belfast (QUB), points to worldwide data showing patients with head and neck cancer are more likely to have had a higher number of sexual partners including oral sexual partners.
Initial HPV exposure is usually between ages 15-24 — reason why national vaccine programmes target adolescents ahead of sexual activity. While most people spontaneously clear HPV infections, there’s no way to know who won’t.
“Development of oncological problems can come decades after infection,” says O’Neill, adding that persistent high-risk infection is usually related to types 16 and 18.
O’Neill points to “superb” Australian vaccination results. In 2013, Australia became the first country to implement a HPV vaccine programme for all boys aged 12/13.
"They’d had it in place for girls since 2007 and research studies show 77% reduction in HPV types responsible for almost 75% of cervical cancer – and almost 50% reduction in incidence of high-grade cervical abnormalities in under 18-year-old girls from Victoria.
Globally, 70 governments have national HPV immunisation programmes – 56 are female-only, 14 are gender-neutral (include boys). Alongside Australia, countries such as Austria, Canada, Israel, Switzerland, the US, the German region of Saxony and the Italian regions of Emilia-Romagna and Sicily now recommend HPV vaccination for both sexes.
“In all parts of the world, initial programmes were for girls – they knew earlier about the link between HPV and cervical cancer. When Australia realised the link between HPV and oropharyngeal cancer, they saw it made sense to also vaccinate boys,” explains Lawler.
Knowing HPV types 16 and 18 are involved in a range of cancers, it’s quite reasonable to ask ‘shouldn’t we be giving it to boys as well?’, says Professor Karina Butler, chair of Ireland’s National Immunisation Advisory Committee.
“In principle, it’s a very good idea. It’s recommended by the Advisory Committee on Immunization Practices in the US.
"But while it might be recommended, it doesn’t mean a country will elect to fund it as a national programme. If there were no cost restraints, it would be available for everybody.”
In 2014, consultant in infectious diseases Dr Corinna Sadlier was lead author in a TCD and St James’s Hospital study that found 69% of men who have sex with men were infected with HPV. At least one in four had HPV type 16, linked to over 80% of anal cancers.
Aside from the big drop in pre-cancerous cervical abnormalities arising out of the Australian vaccination programme, Sadlier cites the “almost eradication” of genital warts there in heterosexual men and women aged under 21 – incidence reduced by over 90%.
“Genital warts aren’t a dreadful diagnosis but it can be very psychologically upsetting for those who have to seek treatment and follow-up. The condition will go within a year but it can be problematic for a certain cohort,” she says, adding that benefits of gender-neutral vaccination would be significant at both individual and population level.
Here, since January 2017, men aged up to 26 who have sex with men and people living with HIV can access the HPV vaccine free through sexual health clinics and through hospital genitourinary clinics.
Meanwhile, HIQA is completing a health technology assessment (HTA), looking at feasibility of introducing a gender-neutral HPV vaccination programme.
“They’re looking at the clinical and economic benefits of providing the vaccine on a gender-neutral basis,” says Donal Buggy, head of services and advocacy at the Irish Cancer Society.
He believes a recommendation will come within 12 months and that the HTA will show a vaccine programme to be beneficial for boys.
“If there’s a vaccine at our disposal to prevent cancer, we [Irish Cancer Society] would want this.”
HPV Action – a collaborative British partnership of patient and professional organisations working to reduce the HPV health burden – estimates additional cost of providing a vaccine programme to boys in Britain as well as girls would be £20-22m a year.
Lawler says cost of treating anogenital warts alone in Britain is estimated at £58.44 million annually – and secondary care costs of treating HPV-related oropharyngeal cancer are likely to exceed £21m a year. Similar HPV health economics would apply in Ireland, he says.
“Cost of treating the various HPV-related diseases would far outweigh cost of providing the vaccine for every boy in Ireland.”
In Australia, just after the ‘girls-only’ vaccine programme began in 2007, the percentage of genital warts cases dropped by almost 92% — and in the same cohort of unvaccinated boys there was an 81% drop in genital warts.
An example of herd immunity, which some cite as a reason not to vaccinate boys — the idea is vaccinated females won’t be able to pass the virus to males, so males will benefit from ‘herd protection’.
But Lawler points to a European study that showed vaccinating 12-year-old boys, as well as girls, will bring substantial additional benefits around reducing HPV-related disease.
“It will protect men who have sex with men, as well as men who have sex with unvaccinated women.”
In Ireland, though, we’re on the “dangerous threshold” of losing herd immunity, says one expert. This is due to fear sparked by claims that girls became very ill after getting the vaccine.
Anxieties of parents’ group Regret (Reactions and Effects of Gardasil Resulting in Extreme Trauma) centre on ailments such as chronic fatigue and complex regional pain syndrome.
Butler says she doesn’t dismiss the conditions these girls are enduring but points to detailed investigations that consistently find no evidence of a causal link between HPV vaccination and these symptoms. Yet, the fears have had an impact.
In the school year 2014-’15, HPV vaccine uptake among girls was 87%. The following year, it dropped to 70% and this year dipped below 50%. Herd immunity needs vaccine uptake rate of at least 50%.
“It’s really concerning,” says Butler.
“The downside is the benefit to girls will be lost — cervical cancer is a terrible disease, affecting people in their prime with young families. And so will the benefit to the wider community.”
Lawler says procrastinating about a boys’ HPV vaccine programme will cost lives.
“The longer we wait the more boys we’re unfairly putting at risk of developing cancer or genital warts.”
And oropharyngeal cancers, for example, are difficult cancers, often presenting at an advanced stage (apart from cervical cancer, screening isn’t “available or feasible for almost all HPV-associated cancers,” says O’Neill) and requiring multi-modality treatment.
“Treatment can involve a lot of impact on the face area so there’s a visual impact on the patient, as well as difficulty swallowing, eating, tolerating food, quite apart from the question around ongoing patient survival,” says Buggy.
At their 2015 AGM, the Irish Medical Organisation passed a motion, calling on the Health Minister and HSE to ‘provide resources for a vaccination programme for teenage boys in respect of Gardasil so as to prevent infection and its consequences’.
Now retired, Dr Patrick O’Sullivan, a former director of public health for the North-East, seconded that motion. He sees ethical reasons for providing a vaccine programme for boys.
“We have a vaccine that works, that prevents disease. But just immunising girls is only tackling half the problem — it means there’s a reservoir of disease in boys, who can infect girls who aren’t immunised.”
And having a girls-only vaccine programme might suggest females are solely responsible for transmitting and preventing HPV.
“There may be the idea that girls are to blame, whereas HPV is deeply common in both girls and boys,” says O’Sullivan.
In Northern Ireland, the Jabs for the Boys campaign says it’s unethical and discriminatory to withhold a medical intervention of proven effectiveness from a population group — in this case, males — that, if untreated, remains at risk of a range of potentially life-threatening diseases.
“Not vaccinating boys also minimises the importance of men’s health,” says Lawler, who points to further discrimination: increasing numbers of British parents, well-informed about HPV and with financial resources, are choosing to have their sons vaccinated privately.
"Yet, “males in lower-income groups will be left at greater risk of HPV-related diseases”.
O’Neill says incidence of non-cervical HPV-associated cancers is “certainly likely to continue to rise” until the present generation of vaccinated girls reach middle age, 30 years hence. The HSE, he says, is constantly “putting out fires”, going from crisis to crisis.
“It’s an opportunity to look upstream to the issues that will affect the next generation. If we put a robust vaccination programme in place, including boys, within a generation we’ll significantly reduce the benign and oncological burden of HPV-associated disease.”