Including males in Canadian human papillomavirus vaccination programs: a policy analysis

Gilla K. Shapiro; Samara Perez; Zeev Rosberger

doi:10.1503/cmaj.150451

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Re:In support of the call for a gender-neutral HPV vaccination in Canada
Gilla K. Shapiro

Published on: 16 December 2016
In support of the call for a gender-neutral HPV vaccination in Canada
Cyra Patel

Published on: 21 October 2016

Published on: (16 December 2016)

Re:In support of the call for a gender-neutral HPV vaccination in Canada
Gilla K. Shapiro
Other Contributors:
We thank Patel and Macartney for their recent letter and for providing evidence of Australia's experience (1). It is particularly interesting that since males were incorporated into Australia's funded human papillomavirus (HPV) vaccination program, not only have male vaccination rates in Australia increased, but that female vaccination rates have also been positively influenced and increased as well (2). This is quite...
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We thank Patel and Macartney for their recent letter and for providing evidence of Australia's experience (1). It is particularly interesting that since males were incorporated into Australia's funded human papillomavirus (HPV) vaccination program, not only have male vaccination rates in Australia increased, but that female vaccination rates have also been positively influenced and increased as well (2). This is quite unexpected and it would be helpful to isolate the mechanisms that may have influenced this increase in female vaccination rates. Could a gender-neutral communication strategy about HPV and the HPV vaccine be more convincing and acceptable to parents of girls and their daughters? Are parents less skeptical of a vaccine that is provided to males and females?
We are optimistic that the recent change of policy to provide free male access in some Canadian provinces will also increase HPV uptake rates in both Canadian males and females. Notably, since September 2016 three additional Canadian provinces (Manitoba, Ontario, and Quebec) have joined three provinces (Alberta, Nova Scotia, and Prince Edward Island) in providing HPV vaccination for both males and females (3). While we are very encouraged by the descriptive findings showing that since Australia funded males, vaccination rates in both males and females have improved. We nevertheless wonder whether these results can be extrapolated to other countries like Canada. With additional data in the future, this trend can be statistically investigated and verified. To do so, it will be extremely important for HPV vaccination rates in Canadian provinces to be closely monitored and evaluated over time.
We also agree with Patel and Macartney that vaccinating children regardless of gender is the most equitable policy approach (1). Indeed, since publishing our article in April, British Columbia (B.C.)--a province that vaccinates females and only a subset of boys (including men who have sex with men and street youth) (4)-has faced a human rights complaint from Grade 6 twin brothers who argue that B.C.'s policy is discriminatory (5). This complaint is under review and a decision is expected in the near future.
As findings recently published in a special report on HPV-associated cancers from the Canadian Cancer Statistics 2016 have shown, HPV- associated cancers in males are increasingly becoming a serious health concern (6). The proportion of HPV-associated oropharyngeal cancers in males (i.e. 28%) greatly surpasses oropharyngeal cancers in females (i.e. 7%) and is approaching the proportion of cervical cancers (i.e. 35%; 2012 statistics) (6). The Canadian Cancer Society predicts that if the incidence trends continue, oropharyngeal cancer rates in males will soon exceed the incidence of cervical cancers in females (6, 7). An increasing need for HPV vaccination for males will further exacerbate the inequity of programs that only provide the HPV vaccine to females (7).
A gender-neutral HPV vaccination program across Canada may increase HPV vaccination rates in females, as was found in Australia, but this will only be confirmed in time. Nevertheless, we now know that vaccinating boys will help prevent a growing number of HPV-associated oropharyngeal and anal cancers in males, and it is certainly a more equitable and consistent policy approach.
References
1. Cyra Patel, Kristine Macartney. In support of the call for a gender-neutral HPV vaccination in Canada 2016. Available from: http://www.cmaj.ca/content/188/12/881.full/reply - cmaj_el_732446.
2. National HPV Vaccination Program Register. Coverage Data 2016. Available from: http://www.hpvregister.org.au/research/coverage-data. 2016.
3. Gilla K. Shapiro, Samara Perez, Zeev Rosberger. Including males in Canadian human papillomavirus vaccination programs: a policy analysis. Canadian Medical Association Journal. 2016;188 (12):881-6.
4. British Columbia. Diseases and vaccinations: HPV (Human Papillomavirus). 2016.
5. Yuliya Talmazan. WATCH: 13-year-old boy pushes B.C. government to expand HPV vaccine program. Available from: http://globalnews.ca/news/2935057/watch-13-year-old-boy-pushes-bc- government-to-expand-hpv-vaccine-program/ Global News. 2016.
6. Canadian Cancer Society. Canadian Cancer Statistics. 2016.
7. Juliet Guichon, Gilla K. Shapiro. Opinion: Give HPV vaccine to prevent mouth and throat cancers. Available from: http://vancouversun.com/opinion/opinion-give-hpv-vaccine-to-prevent-mouth- and-throat-cancers. 2016.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (21 October 2016)

In support of the call for a gender-neutral HPV vaccination in Canada
Cyra Patel, Research Officer
Other Contributors:
We commend Shapiro and colleagues on their recent policy analysis of HPV vaccination for males in Canada and their call for gender-neutral programs in all provinces and territories. As Australia has the highest uptake of HPV vaccine in males at a country-level worldwide, we write to add evidence that may inform Canada's approach. Quadrivalent HPV vaccine was included for males under the Australian National Immunisation Program (NI...
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We commend Shapiro and colleagues on their recent policy analysis of HPV vaccination for males in Canada and their call for gender-neutral programs in all provinces and territories. As Australia has the highest uptake of HPV vaccine in males at a country-level worldwide, we write to add evidence that may inform Canada's approach. Quadrivalent HPV vaccine was included for males under the Australian National Immunisation Program (NIP) from February 2013, following introduction for females in 2007. Australia's nationally centralised systems for economic assessment and vaccine procurement facilitate program decisions: inclusion was deemed cost-effective, albeit at an undisclosed price.(1-3)
The gender-neutral HPV vaccination program has been extremely well-received, with support for vaccination in both genders reported even before the female vaccination program commenced.(4) Uptake in males was high in the first year of the program and has increased: 77.0%, 74.0% and 66.4% of boys turning 15 years of age had received one, two and three doses, respectively, by 2015.(5, 6) Female HPV vaccination coverage has also increased by approximately 6% since male immunisation was funded (from 71.0% to 77.4% for 3-dose coverage between 2013 and 2015).(5) Targeting all young people allows more consistent framing of HPV vaccination as a cancer prevention strategy and has likely negated the vaccine resistance observed to some extent in Australia and in other countries. A strong communications strategy, together with strengthening vaccine safety surveillance,(7) have also facilitated vaccine uptake.
The increasing recognition and incidence of HPV-related diseases like anal and oropharyngeal cancers(8, 9) and growing evidence of vaccine immunogenicity, safety and efficacy in males from clinical trials(10-12) underpins establishment of equitable HPV vaccination programs. Reliance on herd immunity from a female HPV vaccination program to protect males against HPV-associated disease is arguably unethical,(13) particularly in the context of demonstrated cost-effectiveness in high income countries. We fully support our colleagues in their efforts to advocate for equitable HPV vaccination throughout Canada.
Ms Cyra Patel
Research Officer, MSPH, MBA; National Centre for Immunisation Research and Surveillance, Westmead NSW, Australia
Kristine Macartney
Deputy Director, MBBS, BMedSci, MD, FRACP; National Centre for Immunisation Research and Surveillance, Westmead NSW, Australia
Associate Professor, University of Sydney, School of Child and Adolescent Health, Sydney NSW, Australia
References
1. Pharmaceutical Benefits Advisory Committee. Quadrivalent human papillomavirus (Types 6, 11, 16, 18) recombinant vaccine, solution for injection, 0.5 mL, solution for injection pre-filled syringe single dose, Gardasil? - November 2011. In: Pharmaceutical Benefits Scheme, editor. 2011.
2. Nolan TM. The Australian model of immunization advice and vaccine funding. Vaccine. 2010;28:A76-A83.
3. Georgousakis M, Jayasinghe S, Brotherton J, Gilroy N, Chiu C, Macartney K. Population-wide vaccination against human papillomavirus in adolescent boys: Australia as a case study. The Lancet Infectious Diseases. 2012;12(8):627 - 34.
4. Marshall H, Ryan P, Roberton D, Baghurst P. A cross-sectional survey to assess community attitudes to introduction of human papillomavirus vaccine. Australian and New Zealand Journal of Public Health. 2007;31(3):235-42.
5. National HPV Vaccination Program Register. Coverage Data 2016 [cited 2016 27 June]. Available from: http://www.hpvregister.org.au/research/coverage-data.
6. Brotherton JM, Batchelor MR, Bradley MO, Brown SA, Duncombe SM, Meijer D, et al. Interim estimates of male human papillomavirus vaccination coverage in the school-based program in Australia. Communicable diseases intelligence quarterly report. 2015;39(2):E197-200.
7. Therapeutic Goods Administration. Enhanced school-based surveillance of acute adverse events following immunisation with human papillomavirus vaccine in males and females, 2013. Therapeutic Goods Administration, Department of Health, 2015 May 2015. Report No.
8. Stanley MA, Winder DA, Sterling JC, Goon PKC. HPV infection, anal intra-epithelial neoplasia (AIN) and anal cancer: current issues. BMC cancer. 2012;12(398).
9. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, Curado MP, Ferlay J, Ferlay J, et al. Worldwide trends in incidence rates for oral cavity and oropharyngeal cancers. Journal of Clinical Oncology. 2013;31(36):4550-9.
10. Giuliano AR, Palefsky JM, Goldstone S, Moreira Jr ED, Penny ME, Aranda C, et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males. New England Journal of Medicine. 2011;364(5):401-11.
11. Palefsky JM, Giuliano AR, Goldstone S, Moreira ED, Jr., Aranda C, Jessen H, et al. HPV vaccine against anal HPV infection and anal intraepithelial neoplasia. New England Journal of Medicine. 2011;365(17):1576-85.
12. Goldstone SE, Jessen H, Palefsky JM, Giuliano AR, Moreira ED, Jr., Vardas E, et al. Quadrivalent HPV vaccine efficacy against disease related to vaccine and non-vaccine HPV types in males. Vaccine. 2013;31(37):3849-55.
13. Stanley M. Perspective: Vaccinate boys too. Nature. 2012;488(7413):S10.
Conflict of Interest:
None declared
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Competing Interests: None declared.