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NEW THIS SUNDAY: MALE VACCINATION AGAINST HUMAN PAPILLOMAVIRUS

Friday, 19th of July 2013

MALE VACCINATION AGAINST HUMAN PAPILLOMAVIRUS

The Lancet Infectious Diseases, Volume 12, Issue 8, Pages 582 - 583, August 2012

Editorial below; see also article from Australia at on the same subject at

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70031-2/fulltext

Original Text

David M Salisbury a

If high enough coverage for vaccination against human papillomavirus (HPV) can be achieved in girls and women, boys and men should be protected from infection. Hence, routine vaccination of male adolescents might not be cost effective. At present, only Austria and the USA have recommended routine vaccination against HPV in boys and men as well as in girls and women. No reports of the coverage among male recipients seem to be available for Austria, and the US recommendation is only newly made. The consequences of such programmes, therefore, cannot be assessed.

In The Lancet Infectious Diseases, Georgousakis and colleagues1 provide an excellent summary of currently available information on many aspects of HPV vaccination, set against the present circumstances in Australia. Some features that define the Australian programme might or might not be transferable to other countries. Vaccination of girls aged 12—13 years with a quadrivalent vaccine is provided in schools, which achieves coverage of 73%. At that level of coverage, a 59% reduction in the prevalence of genital warts was seen in girls and women aged 12—26 years and of 39% in that among heterosexual boys and men in the same age group, although prevalence did not decline in non-vaccinated women or in men who have sex with men.2 These outcomes are very encouraging, as they suggest that a degree of population protection has been achieved, and they are hopefully early indicators of prevention of cervical infection and subsequent cancer.

The UK currently uses a bivalent vaccine for girls aged 12—13 years, with which no effect on the prevalence of genital warts could have been expected. From September, 2012, a three-dose course of the quadrivalent vaccine Gardasil (Merck, Whitehouse Station, NJ, USA) will be used. At present, the coverage with all three doses is 84%, which is higher than 73% reported in Australia and, therefore, the same or better population protection against cervical and other cancers can be anticipated. Mathematical models suggest that a UK programme with this coverage will be highly cost effective.3 In the USA, where coverage seems to be static at around 35% for teenage girls,4 little population benefit is expected. Studies suggest that in this situation the addition of vaccination in boys and young men would be cost effective5 and helps to explain the different approaches in the UK and the USA.6

Despite the summary of Georgousakis and colleagues,1 many issues around HPV vaccination remain unresolved. For instance, some oropharyngeal cancers are associated with infection, especially with HPV 16, and prevalence seems to be increasing.7 Better data on the absolute numbers of oropharyngeal cancers and estimates of the proportion that might be prevented by HPV vaccination are needed. Whether HPV vaccination prevents oropharyngeal infection also needs to be established. If so, it would be reasonable to expect reductions in oropharyngeal cancers associated with HPV vaccine strains over time. Vaccination of boys and men contributes little to the cost-effectiveness of prevention of cervical cancer when there is high coverage among girls and women. Vaccination for the prevention of oropharyngeal cancer might also not be cost effective, except for in men who have sex with men.

Georgousakis and colleagues1 note the unknown outcome of offering vaccination to boys aged 12—13 years. While those who are vaccinated will benefit at an individual level, the degree of cost-effectiveness if they later choose vaccinated women as sexual partners is unclear; high vaccine coverage among men who have sex with unvaccinated women, or vice versa, would be most cost-effective. In both Australia and the UK, the promotion of HPV vaccination has been built on messages about the prevention of cervical cancer. Such messages are unlikely to persuade boys to be vaccinated, but changes to the messages could lower acceptance amongst girls and women.

The Australian Pharmaceutical Benefits Advisory Committee has received a an economic analysis from a vaccine manufacturer for the vaccination of boys aged 12—13 years, with a 2-year catch-up programme for boys aged 14—15 years. A positive recommendation for male vaccination has been issued on the basis of acceptable cost-effectiveness compared with female-only vaccination. In view of the notable uncertainties about so many of the possible outcomes, this change seems a conundrum, especially after female-only vaccination has shown a positive effect through herd immunity, and male vaccination was previously not cost effective. This situation might be difficult for policy makers in other developed countries to understand. Better value for money seems likely to come from efforts to raise the coverage among girls and younger women and, therefore, this approach should be tried before introduction of a male vaccination programme is attempted.

I declare that I have no conflicts of interest. The views are those of the author and do not necessarily represent those of the Department of Health.

References

1 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. Lancet Infect Dis 2012; 12: 627-634. Summary | Full Text | PDF(97KB) | CrossRef | PubMed

2 Donovan B, Franklin N, Guy R, et al. Quadrivalent human papillomavirus vaccination and trends in genital warts in Australia: analysis of national sentinel surveillance data. Lancet Infect Dis 2010; 11: 39-44. Summary | Full Text | PDF(196KB) | CrossRef | PubMed

3 Jit M, Choi YH, Edmonds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ 2008; 337: a769. CrossRef | PubMed

4 Centers for Disease Control and Prevention. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR Morb Mortal Wkly Rep 2011; 60: 1117-1123. PubMed

5 Chesson H. HPV vaccine cost-effectiveness: updates and review. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-jun11/07-5-hpv-cost-effect.pdf. (accessed April 5, 2012).

6 Centers for Disease Control. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011; 60: 1705-1708. PubMed

7 Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the United States: 1999 through 2008. CA Cancer J Clin 201210.3322/caac.20141. published online Jan 4. PubMed

a Department of Health, London, UK