Should HPV vaccines be mandatory for all adolescents?

Catching up with the rest of the world, the European Commission last week licensed the first human papillomavirus (HPV) vaccine, Gardasil, for use in children aged 9–15 years and women aged 16–26 years. The vaccine offers protection against HPV types 16 and 18, which are responsible for 70% of all cervical cancers, and types 6 and 11, which cause about 90% of cases of genital warts.

Following earlier approval by the US Food and Drug Administration of the vaccine in girls and women, the Michigan Senate passed a bill on Sept 21, ruling that all girls entering the sixth grade of school (11–12 years old) should be immunised. This is the first legislation of its kind in the USA, and a decision from which the EU member states should take heed.

However, despite these welcome developments, key questions remain. Who will fund these routine immunisations? Reassuringly, Gardasil has been added to the US Vaccines for Children Program that provides free immunisations to those that most need them, and the UK Department of Health is also considering government funding. But, even with these resources, the debate remains over who should be immunised. Contrary to the FDA's recommendations, there is growing support for the vaccination of both boys and girls. Modelling studies have shown that a female-specific approach would be only 60–75% as effective at reducing HPV prevalence in women as strategies that target both sexes. And other benefits of the vaccine should not be overlooked; it also offers protection against genital warts and malignancies such as anal cancer, which affect both sexes. Furthermore, previous gender-specific initiatives have not always succeeded—in 1995, the UK's rubella immunisation programme was modified after 25 years to include boys as well as girls, after a rise in the number of pregnant women contracting rubella.

For effective and long-term eradication of HPV, all adolescents must be immunised. Data from the vaccine trials in boys are urgently needed; in the mean time, EU member states should lead by making the vaccinations mandatory for all girls aged 11–12 years.

The Lancet 2006; 368:1212