HPV Vaccination Program
Dear Minister Matthews,
This letter is to urge the government of Ontario to expand the current publicly funded Human Papillomavirus (HPV) Vaccination Program targeted to females to a universal model that would be gender inclusive for all, including males.
In 2007 the HPV vaccine was approved for use in females by the National Advisory Committee on Immunization (NACI) to prevent cervical cancer and genital warts, and in the same year the provincial government funded it for females. Since 2012, NACI has recommended the HPV vaccine for males given the evidence that it is also effective for males to prevent genital warts, penis, anal, mouth and throat cancers. Specifically, the Public Health Agency of Canada estimates that expanding the funding for vaccination for the male population represents protection for males for 25% of oral cancers, 35% of throat cancers 40-50% of penile cancers, and 80-90% of anal cancers.
We believe that the vaccine should be funded universally so that people who are male, female, transgender, or intersexed will have equitable access to health care. In our present program, females receive all three shots without charge whereas males are forced to pay out of pocket. It is only fair to remove the cost barrier when increased uptake of the HPV vaccine will improve both individual and community health outcomes. Another equity consideration is that implementing universal funding will help to reduce the stigma that females experience as a result of a female-only vaccine that provides protection for a sexually transmitted infection.
Universal funding is a public good that will reduce transmission. Current vaccine uptake is not high enough to produce herd immunity and control HPV transmission. Even though HPV uptake rates have been increasing among eligible females in Ontario, the coverage estimates for 2009-2010 were only 59.4% and in 2011-2012, 70.2%. This is well below the Canadian Immunization Committee recommendations of 80% within the first two years of program implementation and the 90% recommended within 5 years and these figures represent only the female portion of the population. The $400 to $500 charge for all three shots for a male seeking HPV immunization from their health care provider is prohibitive for many families. With only a very small portion of the total population being vaccinated, we can usefully learn from what has occurred before in history. When the rubella vaccination first became available, some countries offered it to females only. The vaccine uptake rates were not high enough to ensure female immunity to rubella, or herd immunity among the population. The result was that outbreaks of congenital rubella syndrome occurred, that is, infant congenital malformations from exposure to rubella during pregnancy. When the female uptake rates were not high enough and males were not vaccinated, spread occurred among the population.
In February 2013, the National HPV Vaccination Program in Australia became the first country to provide publicly funded HPV vaccine to males aged 12-13 years as part of a school-based vaccination program, which has been available to 12 to 13 years old females since 2007. As of August 2013, HPV immunization has been provided at no cost to Grade 6 girls and boys in Prince Edward Island. The government of Alberta will be starting universal HPV immunization for boys and girls in Grade 5 starting in September 2014.
The support for universal public funding of the HPV vaccine has been growing and includes: the Public Health Agency of Canada; the Association of Local Public Health Agencies; individual public health units in Ontario; AIDS Committee of Toronto; Immunize Canada; the Society of Obstetricians and Gynecologists of Canada and members of the public.
RNAO urges the province to implement the following recommendations that are built on those proposed by the Toronto Board of Health and Toronto Public Health:
- The current school-based publicly funded HPV vaccination program should be universally administered in grade 7 rather than grade 8. This would improve the logistics of delivering the vaccine to the students and improve the efficiency of the program as any catch-up doses of missed vaccines can be delivered in the school while the nurses are at the school instead of setting up additional clinics.
- Current public funding for the HPV vaccination program should be expanded to include males, starting in grade 7.
- Expand the current HPV catch-up program to age 26 years across the gender spectrum and ensure that it is publicly funded.
- Publicly fund the HPV vaccine for men who have sex with men, especially those with HIV.
- Develop a comprehensive educational campaign to ensure improved rates of HPV uptake for all eligible Ontarians.
- Continue to work with Public Health Ontario to monitor adverse events following immunization for the HPV vaccine and report the results publicly to ensure the safety of the vaccine.
Minister Matthews, RNAO urges the Ministry of Health and Long-Term Care to expand the funding of the HPV vaccine to a universal model. The public health evidence has reached a critical mass. Expanding the program now will prevent the transmission of genital warts and reduce morbidity and mortality due to cancer as well as the associated costs to the health care system. Most importantly, it is the right thing to do from an equity perspective.
Thank you for considering these recommendations on behalf of our members. We look forward to your response.
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer
Registered Nurses' Association of Ontario