HPV vaccination saga shows Canada’s bizarre approach to public policy

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Prince Edward Island has announced that it will extend publicly funded vaccinations for human papilloma virus to Grade 6 boys beginning in the fall. Grade 6 girls have been getting the HPV vaccine in PEI schools since 2007.

The decision is probably the right one. (We'll come back to the pros and cons of HPV vaccination in a moment.)

But the HPV saga is, more than anything else, a reminder just how bizarre the process of making public policy is in Canada, and nowhere more so than in health care.

HPV is a family of sexually transmitted viruses that are responsible for a number of types of cancers: principally cervical, but also oral, penile, anal, vaginal. HPV is also the cause of genital warts.

In 2006, a vaccine was introduced that could block transmission of four common strains of HPV – 6, 11, 16, 18. There was genuine excitement at the prospect of a vaccine that could prevent cancer.

Health Canada approved the vaccine, Gardasil, on July 18, 2006. On Feb. 15, 2007, the National Advisory Committee on Immunization, an independent group, recommended that girls and women age 9 to 26 be vaccinated. Practically, however, the plan was to immunize school-age girls before they became sexually active. Figuring out how to do so in an equitable, cost-effective fashion was the job of the Canadian Immunization Committee, a federal-provincial-territorial group. But before it could come up with a plan, the federal government made a surprise announcement in the budget, providing $300-million for provinces and territories to purchase the HPV vaccine.

There was much criticism of this move. There were suggestions that improper lobbying, not public health concerns, prompted the move and an impression that the decision was made hastily to win the votes of the so-called "socccer mom" demographic.

While the provinces were angry that this important public policy decision was made unilaterally, they muted their criticism because they welcomed the influx of money.

Still, it took until late 2010 before every province had a HPV vaccination program for girls. The shots (there are three) are done anywhere between Grade 4 and Grade 9, depending on the province. In some provinces, notably Alberta, Catholic school boards fought school-based vaccination, arguing that immunizing teen girls against the sexually transmitted HPV would somehow entice them to become sexually active.

All in all, public policy on the vaccine is all over the map. It is a reminder that while Canada has had the vague outline of a National Immunization Strategy since 2003, it still does not actually have a coherent plan. It is actually quite preposterous that all Canadian children don't get the same vaccines on the same schedule and that it depends on what province or territory they live in.

As Ottawa backs away from a role in healthcare – aside from the funding or health research that, to its credit, it has embraced – the differences in availability and funding of treatments are growing, and so too are inequalities.

Vaccination is just the most glaring example.

But back to HPV.

New research out of Australia, a country with a coast-to-coast HPV vaccination program since 2007 and uptake in excess of 80 per cent, shows impressive results. The rate of genital warts fell 93 per cent between 2007 and 2011. There was also a striking decline in high-grade cervical abnormalities in teen girls. (It can take decades for cervical cancer to develop but these abnormalities can be a precursor. This suggests cancer rates will fall, which has been the hope for the vaccine all along.)

Earlier this year, Australia extended its vaccination program to boys. While rates of penile and anal cancer are much lower than cervical cancer, the belief is that there will be similar benefits.

In Canada, as programs to vaccinate girls stumbled along – the percentage getting immunized varies a lot by province and is far from optimal overall – the debate about the wisdom of vaccinating boys grew louder. Almost all sexually active individuals will, at some point, be infected with HPV; most people clear the virus so risks are small overall, but women are at relatively higher risk of harm.

Last year, the National Advisory Committee on Immunization recommended boys be vaccinated too. The first jurisdiction to implement is PEI – as is the case with every new vaccine. The province has a no-nonsense, driven deputy chief public health officer, Lamont Sweet. It also has a small population, fewer than 150,000.

With just over 725 boys in Grade 6 (and an equal number of girls), PEI is able to move quickly on HPV vaccination.

But pharmaceutical companies are also smart enough to woo PEI. They know it is a wedge. Once one province embraces a new vaccination program, it is hard for the others to not follow suit.

The end result may be the right one. But it's a strange way to formulate public policy.

Wouldn't it make a lot more sense for the provinces to sit down together – and they already have a forum to do so, the Canadian Immunization Committee – and come up with a common plan?

Wouldn't it make sense to actually have a national (not federal) strategy, instead of a limp-along version of follow the leader?

André Picard is The Globe and Mail's health columnist.