The recommendation by the panel, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, is likely to transform the use of the HPV vaccine, since most private insurers pay for vaccines once the committee recommends them for routine use. The HPV vaccine is unusually expensive. Its three doses cost pediatricians more than $300, and pediatricians often charge patients hundreds more.
The committee recommended that boys ages 11 and 12 should be vaccinated. It also recommended vaccination of ages males 13 through 21 who had not already had all three shots. Vaccinations may be given to boys as young as 9 and to men between the ages of 22 and 26.
The committee recommended in 2006 that girls and young women between the ages of 11 and 26 should be vaccinated, but vaccination rates in the United States have so far been disappointing.
The vaccine has been controversial because the disease it prevents results from sexual activity, and that controversy is likely to intensify with the committee’s latest recommendation since many of the cancers in men result from homosexual sex. The HPV vaccine became a source of contention among Republican presidential candidates after some candidates criticized Gov. Rick Perry of Texas for trying to require that girls in his state be vaccinated. Representative Michele Bachmann falsely suggested that the vaccine causes mental retardation.
But for the public health experts gathered in Atlanta, the vaccine’s remarkable effects were irresistible.
“This is cancer, for Pete’s sake,” said Dr. William Schaffner, chairman of the department ofpreventive medicine at Vanderbilt University School of Medicine and a nonvoting member of the committee. “A vaccine against cancer was the dream of our youth.”
HPV infection is the most common sexually transmitted disease — between 75 percent and 80 percent of females and males in the United States will be infected at some point in their lives. Most will overcome the infection with no ill effects. But in some people, infections lead to cellular changes that cause warts or cancer, including cervical, vaginal and vulvar cancers in women and anal cancer in men. A growing body of evidence suggests that HPV also causes throat cancers in men and women as a result of oral sex.
HPV infections cause annually about 15,000 cancers in women and 7,000 cancers in men. And while cervical cancer rates have plunged over the past four decades because of widespread screening, anal cancer rates in men and women have been increasing. Head and neck cancers have also been increasing, with the share associated with HPV infection increasing rapidly — perhaps because oral sex has increased in popularity.
Parents of boys face some uncomfortable realities when choosing whether to have their child vaccinated. The burden of disease in males results mostly from oral or anal sex, but vaccinating boys will also benefit female partners since cervical cancer in women results mostly from vaginal sex with infected males.
Vaccinating the nation’s 11- and 12-year-old boys will cost almost $140 million annually, but the one-time catch-up among males 13 to 21 will cost hundreds of millions more. The government generally pays for about half of all vaccinations.
The committee has become increasingly concerned about the cost effectiveness of vaccines, since the newest vaccines tend to be very expensive while protecting against diseases that affect fewer people. Vaccinating boys is cost effective when vaccination rates in girls are relatively low, which they are now. Fewer than half of girls between the ages of 13 and 17 have received at least one dose of the HPV vaccine, and fewer than a third have received all three doses.
Presently, only about 1 percent of boys have received the HPV vaccine, even though the vaccine advisory committee has previously said that boys could be vaccinated against the disease if they or their parents wished.
Vaccinating homosexual boys would be far more cost effective than vaccinating all boys, since the burden of disease is far higher in homosexuals. “But it’s not necessarily effective or perhaps even appropriate to be making those determinations at the 11 to 12 year old age,” said Kristen R. Ehresmann of the Minnesota Department of Health and a committee member.
Dr. S. Michael Marcy, a clinical professor of pediatrics at the University of Southern California and a committee member, said that the money needed to vaccinate 11- and 12-year-old boys would pay for only a few hours of the war in Afghanistan while potentially saving thousands of lives in the United States.
“I’m constantly being told we don’t have the money. Well, we do have the money,” Dr. Marcy said. “We need a new set of priorities, and we if we don’t set those priorities, who will?”
The vaccine loses effectiveness as teenagers and young adults become sexually active. More than one in five boys and girls have had vaginal sex by the age of 15, surveys show. But there are many strains of HPV, and Gardasil — the HPV vaccine manufactured by Merck — protects against four of those strains. Older boys and young men may receive the vaccine even after becoming sexually active in hopes that it might protect them against an HPV strain they have yet to encounter.
The committee voted 8 to 5, with one abstention, to approve a recommendation that males 13 to 21 be vaccinated, with those voting against the recommendation hoping to make the upper age limit 26. Vaccinating men between the ages of 22 and 26 is not only expensive but likely to provide relatively few health benefits.
“The bottom line is that not all kids start having sex when they’re 13. Mine didn’t, I promise you,” Dr. Sandra Adamson Fryhofer, a clinical associate professor of medicine at Emory University School of Medicine and a committee member, said to laughter from the audience.
Not only are the committee’s recommendations routinely used by private insurers to determine which vaccines to pay for, but the health reform legislation of 2010 requires insurers that participate in health exchanges to offer vaccines that are routinely recommended by the committee.
“This is the first time we have a vaccine that is primarily designed to prevent cancer,” said Dr. Joseph Bocchini, chairman of the department of pediatrics at Louisiana State University Health Sciences in Shreveport, and a member of the committee. “It’s an important opportunity for the improvement of women’s health by reducing cervical cancer, and now we have the opportunity to prevent cancer in men.”