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Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States

BMJ 2009; 339 doi: (Published 08 October 2009) Cite this as: BMJ 2009;339:b3884

Rapid Response:

Quadrivalent HPV vaccination cost effectiveness: a missed opportunity in the UK?

I read with great interest, and slight disappointment, Kim and
Goldie’s cost effectiveness analysis of including boys in an HPV
vaccination programme. Interest - because it opens an exciting debate of
health inequalities, where boys could potentially be benefiting from
immune protection against genital warts, anal and oropharyngeal carcinomas
[1]. And disappointment – not because of anything Kim and Goldie had
done, but because the moral debate had not been opened, the front cover
tempted readers and promised so much more.

With quadrivalent vaccines, protection is offered against HPV types
6/11/16/18, implicated in the aetiology of genital warts, cervical, anal
and oropharyngeal carcinomas. As a sexually transmitted infection, the
benefits are rewarded to both the individual being vaccinated, and also
indirectly to their sexual partners. Societal benefits can also be
considered. Sex education programmes in schools include both boys and
girls. Adolescent girls subsequently engage more with health services.
When seeking contraceptive advice, girls are reminded of safe sex messages
and offered screening. Adolescent boys have fewer reasons to attend, and
so the opportunity to reinforce messages of safe sex that they should have
learnt in schools may be lost. If boys were offered HPV vaccination, it
could be another opportunity to talk about safe sex and the responsibility
they should be taking for protection against other STIs.

Unfortunately cost effectiveness will always be an issue, and never
more so than in the current global recession. Sadly too, this article
must surely remind its UK audience of another not so distant discussion
which followed the economic evaluation leading to the Department of Health
(DoH) decision to choose bivalent Cervarix over quadrivalent Gardasil
vaccines [2]. Cervarix offers no protection against HPV types 6 and 11,
responsible for genital warts. It would be a shame if the DoH’s
vaccination choice precludes the opportunity for this moral debate of the
health inequality currently excluding boys from vaccination.

1. Giuliano AR, Palefsky J. The efficacy of quadrivalent HPV (types
6/11/16/18) vaccine in reducing the incidence of HPV-related genital
disease in young men. EUROGIN. Nice, France, 12-15 Nov, 2008. 2009.

2. Jit M, Choi YH, Edmunds WJ. Economic evaluation of human
papillomavirus vaccination in the United Kingdom. BMJ 2008;337:a769.

Competing interests:
None declared

Competing interests: No competing interests

19 October 2009
Elizabeth C.F. Brown
GP Trainee
Enfield and Haringey VTS, EN2 8JL