The human papilloma virus (HPV) vaccination has been offered across the UK to girls aged 12 and 13 since 2008, in an attempt to prevent the virus causing cervical cancer. HPV is also linked to sexually transmitted infections (STIs), and when it comes being at risk of these, boys and girls are pretty much equal.
When the vaccination programme was introduced for girls, it was thought that high coverage among them would provide enough ‘herd protection’ for boys, so it wasn’t extended to both sexes. This idea is now considered out of date and Public Health England (PHE) is currently considering plans to extend the vaccination programme to boys, after international studies showed that by 2020 the number of men contracting cancer from the HPV infection will outstrip the number of women.
Human papilloma virus (HPV) is the name given to a group of viruses that affect the skin and the moist membranes that line the body, such as the cervix, anus, mouth and throat. There are more than 100 types of HPV and around 30 of them can affect the genital area. Spread during sexual intercourse and genital area skin-to-skin contact, these infections are common and highly contagious.
Infection with some types of genital HPV can cause:
Other types of HPV infection can cause minor problems, such as common skin warts and verrucas.
Girls in the UK aged 12 and 13 are offered a vaccination against HPV to help protect them against four types of the virus: types 6, 11, 16 and 18.
Type 16 causes oral cancer and, together with type 18, is responsible for 70 per cent of all cases of cervical cancer in Europe. Types 6 and 11 are responsible for around 90 per cent of cases of genital warts.
The first dose of the vaccine is offered during school year eight, with the second dose either six or 12 months later. According to the World Health Organization, girls aged 15 or older who have not previously been vaccinated should have three doses of the vaccine to ensure good protection. If a girl is not in school or misses one or both doses of the vaccine, catch-up vaccination can be provided by her GP surgery.
In clinical trials, the vaccine was found to be more than 99 per cent effective at preventing cancer caused by HPV types 16 and 18 in young women, and it is expected that vaccination will reduce the number of cases of the most common kind of cervical cancer by at least 70 per cent.
The only way that boys in the UK can receive the HPV vaccine currently is to pay for it. Boots UK, for example, has recently extended its private HPV vaccination service to men and teenage boys as well as girls.
The service is available in 68 stores across the UK to 12- to 14-year-olds for £300 for a course of two vaccinations. For those aged 15 and over, a series of three vaccinations is available for £450. The service protects against nine types of HPV, including those that are responsible for 90 per cent of cervical cancers, 90 per cent of HPV-related anal cancers, and 90 per cent of genital warts.
However, there are drawbacks to having the vaccine only available on a paid-for basis. For instance, Peter Baker, campaign director at HPV Action, believes it is unfair to deny boys access to free vaccinations in school, particularly as HPV is “easily prevented by a safe vaccination given in adolescence”.
He also worries that the cost of going private is too high for many families. “This option is obviously not open to everyone,” he says, “so most boys will not end up being protected.”
After many years of debate, progress has been made towards offering boys the HPV vaccine, and it is now available to boys on a private basis (see box below). In addition, PHE is currently considering plans to extend the NHS HPV vaccination programme to include boys. So why now?
The main argument against vaccinating boys has previously been that the girls’ programme indirectly protects boys. However, this belief has been widely dismissed because it fails to take into account men who have sex with unvaccinated women (from the UK and other countries) and men who have sex with men.
The charity HPV Action says it is estimated that vaccinating boys would cost between £20 and £22 million a year at most – a figure that is dwarfed by the cost of treating HPV-related cancers and warts.
Every year in England, an estimated £57.1 million is spent treating head and neck cancer, while almost £7 million is spent on treating men with anal cancer and an estimated £58.44 million a year goes on treatment for anogenital warts.
According to Peter Baker, campaign director at HPV Action, without vaccination “almost 400,000 more boys each year are being left at risk from HPV-related cancers”.
Dr Andrew Green, a member of the British Medical Association (BMA) General Practitioners Committee, also backs the move to vaccinate boys, saying: “If we want to see an end to some of the most aggressive and hard-to-treat cancers, such as throat, head, neck and anal cancer, boys as well as girls must be given the HPV vaccination. It is ridiculous that people are still dying from these cancers when their life could have easily been saved by a simple injection.”
In March this year, the HPV sub-committee of the Joint Committee on Vaccination and Immunisation (JCVI) stated that the reduction in HPV prevalence in the population occurs faster if boys are vaccinated as well as girls. “At high coverage – 80 per cent – in both genders and with high efficacy and duration of protection, most of the models predict elimination of HPV,” it said.
For Leyla Hannbeck, National Pharmacy Association (NPA) chief pharmacist, the concern is that vaccinating boys as well as girls must not replace the need to educate adolescents on the wider dangers of unprotected sex. “Vaccinating both genders could create a false sense of security and increase the risks and likelihood of unprotected sex or sexual promiscuity,” she says. “Males could also be potentially less likely to use condoms due to the fact they have been vaccinated, increasing the chances of STI transmission and teenage pregnancy.”
Men who have sex with men are at high risk of HPV infection and associated diseases but receive very little indirect health benefit from the current HPV vaccination programme.
In November 2014, the Joint Committee on Vaccination and Immunisation (JCVI) recommended that the HPV vaccine should be offered to all 16- to 40-year-olds in this group, as long as the vaccination programme is able to operate at a cost-effective price.
Studies have found a high level of willingness to be vaccinated, and in 2016, Public Health England introduced a pilot programme in selected genitourinary medicine (GUM) and HIV clinics in North London, where 80 per cent of those offered the vaccine took it up.
As a result, the JCVI has recommended a targeted programme of HPV vaccination for 16- to 40-year-old men who have sex with men, offered through GUM and HIV clinics in the UK, using the same vaccine that is used for teenage girls.
If an HPV vaccination scheme goes ahead for this population group, it will be closely monitored to see how successful it is.
Leyla says that posters and leaflets on HPV should be clearly displayed in pharmacies to highlight the importance of completing the schedule of two vaccinations given six to 24 months apart, and to provide information for those who have missed their second vaccination.
If parents are concerned about the safety of the vaccine – particularly for boys – Dr Anatole Menon-Johansson, medical director at sexual health and wellbeing charity Brook, says that pharmacy teams can reassure them that it has been available to boys for a couple of years already in Australia.
“The vaccine has been tested on tens of thousands of young Australians, and British girls, and is very safe,” he says. “We would be delighted if there was a national vaccination programme in the UK to reduce the anxiety and stress of anogenital warts or life-threatening anal or cervical cancer. The vaccine can prevent these, so we think it’s a no brainer.”
This vaccination programme could be yet another example of how community pharmacy staff can use their skills to support their customers’ health, both now and long term, at times and locations that suit them.
Accessible information resources for parents and young people include:
It was thought that high coverage among girls would provide enough ‘herd protection’ for boys
Originally Published by Training Matters