Case for HPV vaccination for boys

A debate has been tabled in Westminster Hall on 2 May 2018 on the case for HPV vaccination for boys. It will be led by Sir Roger Gale.

The debate is likely to focus on whether HPV vaccination should be offered to boys. Currently, a HPV vaccination programme is offered to girls aged 12-13.

The Government body responsible for advising Government on vaccinations (JCVI) have been consulting with stakeholders on a recommendation not to extend the vaccination programme to boys. The rationale was that the risk of infection in males had been dramatically reduced by the girl’s vaccination programme, and that the additional benefits of extending the programme to boys were relatively small.

Some stakeholders have expressed concern about this decision. The final recommendation has not yet been published.

Human papillomavirus

Human Papillomavirus (HPV) are a group of more than 100 viruses that can affect the skin and the mucous membranes of the body (such as mouth, throat, anus, vagina and cervix).

HPV is common, often infections do not cause symptoms and resolve without treatment. However, infection with HPV is associated with certain types of cancer, and genital warts. HPV that are linked to the development of cancer are classified as ‘high risk’ with other HPV classified as ‘low risk.’

As well as being associated with cervical cancer, certain strains of HPV are also associated with other less common cancers, such as cancer of the vulva, penis, anus and some head and neck cancers.

HPV is transmitted primarily through sexual contact. The use of condoms can reduce but not eliminate the transmission of HPV.

For more background on HPV, the NHS Choices website, Cancer Research UK and the Green book published by Public Health England may be useful.

The HPV vaccination programme

A school based HPV vaccination programme to help protect against cervical cancer has been offered to girls aged 12-13 since autumn 2008. There has also been a catch-up programme to immunise girls between 13 and 18 years of age.

The vaccine used in the UK, Gardasil, protects against the two types of HPV that cause 70% of cervical cancers and provides protection against HPV that can cause genital warts.[1]

The Public Health England Green Book provides further information on the HPV vaccine.[2]

HPV vaccination for men who have sex with men

The Joint Committee on Vaccination and Immunisation (JCVI) provides advice and recommendations on vaccinations to the UK Health departments.

In November 2015, following a review of the existing schedule of HPV vaccination, the JCVI recommended that HPV vaccination be offered to men who have sex with men (MSM) who attend sexual health and HIV clinics, provided that the vaccine could be procured at a cost-effective price. [1]

The UK Government announced in 2016 that it would conduct a pilot programme offering HPV vaccination to MSM in sexual health and HIV clinics. [2] Following the results of this, it announced in 2018 that a national programme would be rolled out offering vaccination to all MSM aged 45 and younger.[3]

The Scottish, Welsh and Northern Irish Governments announced in 2016 that a vaccination programme in line with the JCVI’s recommendations would be rolled out. [4], [5] [6]

HPV vaccination for boys

In July 2017, the JCVI published an interim statement for consultation on extending the HPV vaccination programme to boys. The Committee concluded that there was a benefit in vaccinating boys. However, it stated that the evidence suggested that the risk of infection in males had been dramatically reduced by the girl’s vaccination programme, and that the additional benefits of extending the programme to boys were relatively small. The Committee did not recommend the extension of the vaccination programme to boys:

Clearly there is benefit in vaccinating boys and the data considered by the Committee shows that the HPV vaccine is both safe to use in boys and generates comparable immunogenicity to that seen in girls. While it is clear that a programme to vaccinate adolescent males would provide those vaccinated with direct protection against HPV infection, and associated disease, all the evidence suggests that the risk of infection in males has already been dramatically reduced by the girls programme and that these herd effects will continue to have a substantial impact. Therefore, most of the benefit in boys can be achieved through achieving high uptake in a girl’s only vaccination programme

The additional benefits gained from extending the programme to adolescent boys therefore, would be small, relative to the impact of the girls programme. The findings of both cost-effectiveness analyses provided specifically to the committee predict that extending the HPV programme to adolescent boys would not be a cost-effective use of health service resources in the UK setting. These findings are also supported by the meta-analysis of 16 published models. Taking the evidence as a whole the Committee therefore is unable to recommend extension of the national HPV programme to adolescent boys according to the most robust cost-effectiveness analyses undertaken.

In the consultation, some medical organisations have expressed disappointment that the JCVI did not recommend extension of the programme. The Royal Society of Public Health has said that the decision now leaves “400,000 boys in the UK at risk from contracting the virus.”[1]

The group HPV Action, a partnership of patient and professional organisations, has suggested that, in its view, not vaccinating boys could constitute sexual discrimination under the Equality Act 2010.[2] The organisation reports that 15 countries worldwide either currently offer the HPV vaccination to boys or plan to do so.[3]

A final statement from the JCVI on this subject has not yet been published. An April 2018 Parliamentary Question response from the Parliamentary Under-Secretary of State for Health, Lord O'Shaughnessy, reports that the timing for the final advice from JCVI is dependent on review of Public Health England modelling work and receiving legal advice on stakeholder comment:

The Joint Committee on Vaccination and Immunisation (JCVI) is currently reviewing evidence on the impact and cost-effectiveness of extending the human papillomavirus vaccination programme to adolescent boys. This includes mathematical modelling being undertaken by Public Health England.

In February 2018 JCVI agreed that it needed to see the results of the independent peer review of the modelling work, and the additional analyses being undertaken, before concluding its advice. The JCVI further agreed that legal advice should be obtained in response to stakeholder correspondence. Once JCVI has reached a decision, the Committee’s advice will be published most likely in the form of a statement alongside the minutes of the relevant meeting. The JCVI will not be in a position to conclude its advice until the required modelling, peer review and legal advice has been considered. This work will continue through 2018 and timeframes for JCVI concluding its advice are dependent on completion of the analyses requested.[1]

[1] HL Written Question HL6740: Human Papillomavirus: Vaccination, 9 April 2018

[1] RSPH, RSPH dismayed by JCVI decision on HPV vaccinations, 19 July 2017

[2] HPV Action, HPV Vaccination for Boys – Equality Issues Submission to the Department of Health, 11 July 2017

[3] HPV Action, HPV Action response to JCVI postponed decision regarding boys receiving the Human Papillomavirus (HPV) vaccination. 21 November 2017

[1] Call for evidence to support HPV immunisation programme review, 14 August 2012, gov.uk

[2] HC Written Statement, HPV vaccination, 26 May 2016

[3] Department of Health and Social care, HPV vaccination programme for men who have sex with men, February 2018

[4] Scottish Government, HPV vaccination programme, 23 March 2016

[5] Welsh Government, New HPV vaccine programme for gay men to be introduced in Wales, 21 December 2016

[6] nidirect, HPV vaccine for men who have sex with men

[1] NHS Choices, HPV vaccine, September 2014

[2] Public Health England, Green Book: Human Papillomavirus, June 2014