1.0 IssueThe purpose of this briefing note is to presentrecommendations regarding the provincial school-based human papillomavirus(HPV) vaccination program, which was expanded to include males last fall. Thisprogram will decrease long-term healthcare costs and reduce rates of HPVinfection and cervical, anogenital and oropharyngeal cancers.
2.0 BackgroundHPV is the most common sexually transmitted infection,affecting 75% of non-immunized sexually active Canadians within their lifetime.1 Most HPV infections arenaturally resolved, however some cause anogenital warts and precancerouslesions that can progress to cancer. Almost all (99%) cases of cervical cancer,as well as some cases of oropharyngeal and anogenital cancers (anal, penile,vulvar and vaginal), are caused by HPV infection.2–4 There are three HPV vaccines available in Canada: Cervarix,Gardasil and Gardasil 9. All vaccines protect against the high-risk strains ofHPV, type 16 and 18, which are responsible for 70% of cervical cancer cases.Type 16 also causes oropharyngeal and anogenital cancers.2,5 Gardasil and Gardasil 9 alsoprotect against types 6 and 11, which are responsible for 90% of anogenitalwart cases.
1 Gardasil 9 includesvaccination for five additional strains which are less common, but alsocontribute to cancer.Health Canada recommends vaccination for individuals aged 9-27to prevent cervical cancer (if applicable), anogenital cancers and genitalwarts.1 Males must receive Gardasilor Gardasil 9. It is recommended that 2 or 3 doses of the vaccine are provided,with the number and schedule dependent on the vaccine and age, gender andimmune status of the patient.
13.0 CurrentSituationNewfoundland andLabrador was one of the first provinces to establish a school-based HPV vaccinationprogram for females in 2007.5 The program has had consistentvaccination rates of approximately 90% of eligible students.5 It wasexpanded in September 2017 to include males.5Currently, allCanadian provinces and territories have school-based HPV vaccination programsfor all genders (primarily in Grade 6 or 7). Additionally, Alberta, Manitobaand Ontario have catch-up programs for males in Grade 8 or 9 who were too oldto receive the vaccination in the scheduled grade when it was introduced formales.6 4.0 KeyConsiderations4.
1 HealthBenefitsCervical cancer is the 13th most common cancer inCanadian women.6 Newfoundland and Labrador hasthe highest rate in the country, with 10.7 cases per 100,000 people annually.Given that the HPV vaccine prevents 66-69% of cervical cancers,1 it is likely that rates willdecrease as gender-neutral vaccination is implemented and immunization rates increase.Oropharyngeal cancer rates are rising in Canada, now representingone-third of HPV-related cancers.
4 Males experience a 4.5 higherincidence rate compared to females.4 Initial studies have shownthat HPV vaccination may decrease oral HPV infections that lead tooropharyngeal cancer, but more research is required to be conclusive.7,8Rates of anal and penile cancer are low (approximately 200annual cases each).9,10 However, 80-90% of analcancer cases and 40-64% of penile cancer cases are linked to HPV.
The vaccine preventsapproximately 70% of anogenital cancers.1HPV vaccines are most effective when administered prior toHPV exposure.2 Vaccination at a young ageresults in a stronger immune response, offering better protection.11 The current provincialprogram falls into the age range recommended by the Canadian National AdvisoryCommittee on Immunization.1Vaccinating all genders would contribute to herd immunityfor high-risk HPV infections, decreasing risks for individuals who are unableto receive the vaccine.
4.2 EquityFemale-only vaccination programs favour cisgender females, discriminatingagainst transgender individuals, non-binary individuals, and males,particularly men who have sex with men (MSM). MSM have a higher risk of HPVinfection compared to heterosexual men.12 To accommodate for this, somejurisdictions provide coverage for MSM.12 However, this forcesindividuals to openly identify as MSM to receive the vaccination, creating abarrier to access. The provincial gender-neutral program eliminates thisbarrier, ensuring that all students, regardless of sexual orientation orgender, receive the benefits of vaccination.Although females are disproportionately affected by HPVinfections due to high rates of cervical cancer, anyone can be a carrier of thedisease and transmit it onto other individuals.
Thus, responsibility for health(i.e. vaccination) should lie with all individuals. 4.
3 Economic ConsiderationsThe cost to execute the provincial school-based vaccination programfor all genders has been estimated to be $360,000 annually.13 Comparatively, cancer careplaces a significant economic burden on the Canadian healthcare system.14 For example, one year of cervicalcancer care costs an average of $40,000 per patient in Ontario.15 Additionally, there are costsassociated with social assistance or loss of productivity for patients who areunable to work. Vaccinating all genders would save approximately $35,000 perquality-adjusted life year gained.165.
0Recommendations5.1 Continue funding thegender-neutral HPV vaccination program in Newfoundland and Labrador schools. Gender-neutral vaccination has significanthealth and economic benefits, and is more equitable than the previousfemale-only policy. 5.2 Establish a short-term catch-up program for youth who were previouslyunvaccinated. A catch-up program would furtherincrease health and economic benefits, while providing an opportunity fornon-cisgender females who were not previously included to receive the vaccine.6.
0 ConclusionNewfoundland and Labrador is currently a leader inschool-based vaccination, with extremely high vaccination rates. Continuedfunding of the gender-neutral school-based HPV vaccination program will reducerates of HPV infection, consequently reducing rates of cervical, anogenital andpotentially oropharyngeal cancers. The program will also reduce costsassociated with treatment of these cancers, outweighing the costs of programimplementation.