PRO:

JEAN SOMESHWAR, MD
Currently, only about 35% of 13- to 17-year-old girls receive the human papillomavirus (HPV) vaccine.¹ If obtaining vaccine acceptance for girls is difficult, obtaining vaccine acceptance for boys presents an even greater challenge.

The lay public is being increasingly educated about the significant impact of HPV infection and the potential benefits of vaccination in reducing female cervical cancer. More medical providers need to recognize the substantial disease that could be prevented in men. Genital warts, caused predominantly by HPV types 6 and 11, as well as anogenital tract and oropharyngeal cancers are associated with a significant burden of disease in the male population; the incidence of all these diseases can be effectively decreased with vaccination.

Both bivalent and quadrivalent vaccines have been tested in boys. Both have been found to have efficacy against HPV and decrease the incidence of genital warts and anal cancers.² A strategy that includes routine vaccination of 12-year-old boys and girls is projected to reduce HPV-16 infection by 88% to 94% in women and by 68% to 82% in men by 2050.³

In addition, because men have a role in sexual transmission of HPV to women, vaccinating boys significantly benefits girls by reducing HPV-related disease. Australian data, derived from a population in which girls are vaccinated at age 12 or 13 years through a government-funded school-based program, show a decrease in genital warts in men. As Dr Humphreys notes, this finding suggests that herd immunity occurs with HPV vaccination.^4,5

In short, vaccination of boys helps alleviate the burden of HPV disease in women and men. As such, vaccination should be recommended regardless of sex-purely from a public health standpoint alone.

REFERENCES:

1. Zimet GD. Rosenthal SL. HPV vaccine and males: issues and challenges. Gynecol Oncol. 2010;117(2 suppl 1):S26–S31.
2. Giuliano AR, Anic G, Nyitray AG. Epidemiology and pathology of HPV disease in males. Gynecol Oncol. 2010;117(2 suppl 1):S15–S19.
3. Garland SM. Prevention strategies against human papillomavirus in males. Gynecol Oncol. 2010;117(2 suppl 1):S20–S25.
4. Canfeil K, Brotherton SM, Lew JB, et al. Impact of female vaccination on males in Australia. Presented at: International Papillomavirus Conference; 2009; Malmo, Sweden. P11.16
5. Fairley CK, Hocking JS, Gurrin LC, et al. Rapid decline in presentations of genital warts after the implementation of a national quadrivalent human papillomavirus vaccination programme for young women. Sex Transm Infect. 2009;85:499–502.

CON:

STACEY M. HUMPHREYS, MD
At this time, pediatricians should not recommend HPV vaccination of boys. Research on the effectiveness of the HPV vaccine in boys and men has shown variable results.¹ Although HPV vaccination of boys has been shown to reduce the incidence of genital warts and anogenital cancers, its cost–effectiveness has not been established.² The efficacy of the HPV vaccine in preventing head and neck cancers has not been sufficiently studied; it is thought to help reduce the incidence, but no conclusive evidence is available.²

The claim that the HPV vaccine given to boys will help prevent cervical cancer in girls is speculative, and no conclusive supportive data are available.3 In Australia in 2007, vaccination of adolescent girls became mandatory; preliminary evidence shows a decrease in the incidence of genital warts in both men and women, which suggests herd immunity from the vaccine, eliminating the need to vaccinate boys.4

In assessing the cost–effectiveness of HPV vaccination of boys, researchers consider the costs associated with genital warts, anogenital cancers, and cervical cancer. ² Currently in the United States, fewer than 50% of girls have been vaccinated against HPV, which makes vaccination of boys cost–effective. However, as the number of girls receiving the HPV vaccine increases, the costs associated with cervical cancer decrease and the vaccination of boys becomes less cost–effective.⁵

In light of current health care reform and limitations on individual health care spending, one must ask why we should consider initiating interventions that are not cost–effective and have not been shown to benefit the community? Pediatricians struggle with parental acceptance of the number of already proven, highly effective vaccines. To add controversial vaccination of boys to the mix with limited data available may only further taint vaccine acceptance.

REFERENCES:

1. Zimet GD, Rosenthal SL. HPV vaccine and males: issues and challenges. Gynecol Oncol. 2010;117(2 suppl 1):S26–S31.
2. Alexander KA. HPV immunization in males. In: Clinical Controversies and Challenges in HPV Vaccination. http://www.pediatricsupersite.com/ view.aspx?rid=63293. Accessed August 10, 2010.
3. Garland SM. Prevention strategies against human papillomavirus in males. Gynecol Oncol. 2010;117(2 suppl 1):S20–S25.
4. Giuliano AR, Anic G, Nyitray AG. Epidemiology and pathology of HPV disease in males. Gynecol Oncol. 2010;117(2 suppl 1):S15–S19.
5. Feemster K, Kahn JA. HPV vaccine: meeting the challenge. Contemp Pediatr. 2010;6:34–41.