It makes economic sense to give the HPV vaccine to boys, say advocates who are stepping up pressure on the Ontario government to fully fund school immunization programs against the common sexually transmitted virus.
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Despite the most recent public campaign to include boys as well as girls, the province's Ministry of Health is deferring the issue. The ministry says it's "reviewing" the current program to determine whether changes are required.
In Canada, girls between ages nine and 13 can receive a free HPV immunization no matter where they live. Four provinces — Alberta, Nova Scotia, British Columbia and P.E.I. — currently or will soon also offer the vaccine to boys.
In a growing push to make the vaccine free for boys, several young gay men made themselves available to media cameras as they were vaccinated against the human papillomavirus last week at the Hassle Free Clinic in Toronto.
A ministry statement released last Wednesday referred to "economic and societal factors" as reasons the province is still considering whether 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 the vaccine free to boys, based on cost, are unfounded.
"The economics right now make a lot of sense for funding boys," said Dr. Vinita Dubey, 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 to shape public 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 the year, it updated its recommendation and said that for young people, ages 9 to 14, only two doses are needed over a six-month period, instead of three.
"So if we go down to two doses for girls, to add boys on is only one additional dose, and we know that from when the vaccine program was launched in Ontario in 2007, the price of the vaccine has come down," Dubey said.
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 provinces already have a really well developed logistical program for vaccinating in schools, so it would be really simple to add vaccinations for boys. We could use the same system used in 2007."
Some would argue Ontario would be subsidizing school programs in other provinces by expanding its own, but only temporarily, until its purchasing power acts to put downward pressure on prices.
Boys versus girls
David Brennan, associate professor at the Faculty of Social Work at the University of Toronto, said studies show that about half the people who get HPV-related cancers are 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 offers boys protection, with so-called herd immunity.
Franco points out that Quebec policy makers decided four years ago that it would not be cost-effective to extend the free HPV programs to boys because so many girls take part.
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 — the vaccine currently offered in Canadian schools and one that protects against four types of HPV shown to cause cervical cancer and anogenital warts.
Franco said Merck and GlaxoSmithKline are selling their HPV vaccines for less than $5 a dose to developing countries and there's room to lower the price in Canada.
"We accept, socially, the responsibility that Canada plays in the role as a rich country, so we understand that we should pay a higher price to help subsidize vaccinations 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 predecessor should 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.
"Their immune systems respond very strongly and they respond for life," he said. The immune response remains 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 human papillomavirus vaccination program, to include Grade 6 boys.
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Alberta announced in September 2014 that parents can have 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 to NACI.
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.
Human papillomavirus (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.
- Read NACI's in-depth list of recommendations and who should not receive the vaccine.