Potential health impact and cost-effectiveness of bivalent human papillomavirus (HPV) vaccination in Afghanistan

IntroductionHuman papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making.MethodAn Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10–14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives.ResultsVaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country′s total immunization budget for 2018 or 0.13% of total health expenditures.ConclusionIn Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government′s willingness to pay for the projected health outcomes.     

The clinical benefit and cost-effectiveness of human papillomavirus vaccination for adult women in the Netherlands

Background

The use of human papillomavirus (HPV) vaccines has been universally approved for women from age 12 to 25 years, but those older than 16 years receive no reimbursement for the cost of the vaccine in the Netherlands. Reductions in the vaccine price as well as new insights in the efficacy of HPV vaccines offer renewed arguments to consider HPV vaccination in adult women. We calculated the clinical benefit and cost-effectiveness of vaccinating women aged 17-25 years in 2010.

Methods

The calculations were based on an individual-based simulation model for cervical carcinogenesis, with HPV infection risks obtained from a type-specific HPV transmission model. The indirect protective effect from vaccinating 12 to 16 year-old girls was adjusted for. Cervical screening in the model was incorporated according Dutch screening guidelines, i.e. 7 cytology-based rounds at 5-year intervals from the age of 30. As base-case, we assumed the vaccine to offer full protection against HPV16/18 only if no prior exposure to that type had occurred before vaccination. In sensitivity analyses, we considered partial cross-protection against types 31/33/45/58 and efficacy against all future infections, irrespective of previous or current infection status.

Results

In base-case analyses, vaccinating 17 year-olds reduced their lifetime risk of treatment for precancerous lesions from 7.77% to 3.48% and their lifetime cervical cancer risk from 0.52% to 0.24%. These risks were 6.12% and 0.45%, respectively, for a 25 year-old vaccinee. The incremental cost-effectiveness ratio (ICER) for vaccinating 17-25 year-olds was €22,526 per quality-adjusted life-year (QALY) at a vaccine price of €65 per dose, a 50% reduction of the 2010 pharmacy price in the Netherlands. If cross-protection against types 31/33/45/58 was included, the ICER decreased to €14,734 per QALY. Results were robust to efficacy assumptions with respect to previous or current infection status.

Conclusion

The clinical benefit of HPV vaccination of women up to 25 years moderately depends on cross-protection to non-vaccine types. Refunding the cost of the vaccine to 17-25 year-old women in the Netherlands can be considered cost-effective at anticipated price reductions.     

Comparing the cost-effectiveness of two- and three-dose schedules of human papillomavirus vaccination: A transmission-dynamic modelling study

Background

Recent evidence suggests that two doses of HPV vaccines may be as protective as three doses in the short-term. We estimated the incremental cost-effectiveness of two- and three-dose schedules of girls-only and girls & boys HPV vaccination programmes in Canada.

Methods

We used HPV-ADVISE, an individual-based transmission-dynamic model of multi-type HPV infection and diseases (anogenital warts, and cancers of the cervix, vulva, vagina, anus, penis and oropharynx). We conducted the analysis from the health payer perspective, with a 70-year time horizon and 3% discount rate, and performed extensive sensitivity analyses, including duration of vaccine protection and vaccine cost.

Findings

Assuming 80% coverage and a vaccine cost per dose of $85, two-dose girls-only vaccination (vs. no vaccination) produced cost/quality-adjusted life-year (QALY)-gained varying between $7900–24,300. The incremental cost-effectiveness ratio of giving the third dose to girls (vs. two doses) was below $40,000/QALY-gained when: (i) three doses provide longer protection than two doses and (ii) two-dose protection was shorter than 30 years. Vaccinating boys (with two or three doses) was not cost-effective (vs. girls-only vaccination) under most scenarios investigated.

Interpretation

Two-dose HPV vaccination is likely to be cost-effective if its duration of protection is at least 10 years. A third dose of HPV vaccine is unlikely to be cost-effective if two-dose duration of protection is longer than 30 years. Finally, two-dose girls & boys HPV vaccination is unlikely to be cost-effective unless the cost per dose for boys is substantially lower than the cost for girls.     

Factors associated with human papillomavirus vaccination among young adult women in the United States

Background

Human papillomavirus (HPV) vaccination is recommended to protect against HPV-related diseases.

Objective

To estimate HPV vaccine coverage and assess factors associated with vaccine awareness, initiation and receipt of 3 doses among women age 18–30 years.

Methods

Data from the 2010 National Health Interview Survey were analyzed to assess associations of HPV vaccination among women age 18–26 (n = 1866) and 27–30 years (n = 1028) with previous HPV exposure, cervical cancer screening and selected demographic, health care and behavioral characteristics using bivariate analysis and multivariable logistic regression.

Results

Overall, 23.2% of women age 18–26 and 6.7% of women age 27–30 years reported receiving at least 1 dose of HPV vaccine. In multivariable analyses among women age 18–26 years, not being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with HPV vaccination. One-third of unvaccinated women age 18–26 years (n = 490) were interested in receiving HPV vaccine. Among women who were not interested in receiving HPV vaccine (n = 920), the main reasons reported included: not needing the vaccine (41.3%); concerns about safety of the vaccine (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); a doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Among women with health insurance, 10 or more physician contacts within the past year and no contraindications, 74.5% reported not receiving HPV vaccine.

Conclusions

HPV vaccination coverage among women age 18–26 years remains low. Opportunities to vaccinate are missed. Healthcare providers can play an important role in educating young women about HPV and encouraging vaccination. Successful public health and educational interventions will need to address physician attitudes and practice patterns and other factors that influence vaccination behaviors.     

Comparative cost-effectiveness of the quadrivalent and bivalent human papillomavirus vaccines: A transmission-dynamic modeling study

Background

The quadrivalent and bivalent human papillomavirus (HPV) vaccines are now licensed in several countries. We compared the cost-effectiveness of the HPV vaccines to provide evidence for policy decisions.

Methods

We developed HPV-ADVISE, a multi-type individual-based transmission-dynamic model of HPV infection and disease (anogenital warts, and cervical, anogenital and oropharyngeal cancers). We calibrated the model to sexual behavior and epidemiologic data from Canada, and estimated quality-adjusted life-years (QALYs) lost and costs ($CAN 2010) from the literature. Vaccine-type efficacy was based on a systematic literature review. The analysis was performed from the healthcare provider perspective, and costs and benefits were discounted at 3%. Predictions are presented using the median [10th;90th percentiles] of simulations.

Results

Under base-case assumptions (vaccinating 10-year-old girls, 80% coverage, $95/dose), using the quadrivalent and bivalent vaccines is estimated to cost $15,528 [12,056;19,140] and $20,182 [15,531;25,240] per QALY-gained, respectively. At equal price, the quadrivalent vaccine is more cost-effective than bivalent under all scenarios investigated, except when assuming longer duration of protection for the bivalent and minimal anogenital warts burden. Under base-case assumptions, the maximum additional cost per dose for the quadrivalent vaccine to remain more cost-effective than the bivalent is $32 [17;46] (using a $40,000/QALY-gained threshold). Results were most sensitive to discounting, time-horizon, differences in durations of protection and anogenital warts burden.

Conclusions

Vaccinating pre-adolescent girls against HPV is predicted to be highly cost-effective. If equally priced, the quadrivalent is the most economically desirable vaccine. However, ultimately, the most cost-effective HPV vaccine will be determined by their relative price.     

Singaporean men's knowledge of cervical cancer and human papillomavirus (HPV) and their attitudes towards HPV vaccination

Little is known of men's knowledge of cervical cancer and its links with human papillomavirus (HPV), or of their attitudes and beliefs about HPV vaccination. This is despite men's sexual behaviour contributing to HPV transmission and their potential role in deciding whether their children are vaccinated against HPV. To address this, a comprehensive survey was conducted in Singapore where plans are underway for an HPV vaccination program. A representative sample of 930 Singaporean men was found to have moderate knowledge of cervical cancer but poor knowledge and awareness of HPV. Although these men showed strong support for HPV vaccination, overall findings highlight the importance of including men in education campaigns that aim to decrease the incidence of cervical and other HPV-related cancers and to increase the uptake of HPV vaccination.     

Introduction of human papillomavirus vaccination in Nordic countries

Introduction

Cervical screening has helped decrease the incidence of cervical cancer, but the disease remains a burden for women. Human Papillomavirus (HPV) vaccination is now a promising tool for control of cervical cancer. Nordic countries (Denmark, Finland, Greenland, Iceland, Norway and Sweden) are relatively wealthy with predominantly publicly paid health care systems. The aim of this paper was to provide an update of the current status of introduction of HPV vaccine into the childhood vaccination programs in this region.

Methods

Data on cervical cancer, cervical screening programs, childhood immunization and HPV vaccination programs for Nordic countries were searched via PubMed and various organizations. We furthermore contacted selected experts for information.

Results

The incidence of cervical cancer is highest in Greenland (25 per 100,000, age standardized, World Standard Population, ASW) and lowest in Finland (4 per 100,000 ASW) and rates in the other Nordic countries vary between 7 and 11 per 100,000 ASW. Greenland and Denmark were first to introduce HPV vaccination, followed by Norway. Vaccination programs are underway in Sweden and Iceland, while Finland has just recently recommended introduction of vaccination. HPV vaccination has been intensively debated, in particular in Denmark and Norway.

Discussion

In Nordic countries with a moderate risk of cervical cancer and a publicly paid health care system, the introduction of HPV vaccination was a priority issue. Many players became active, from the general public to health professionals, special interest groups, and the vaccine manufacturers. These seemed to prioritize different health care needs and weighed differently the uncertainty about the long-term effects of the vaccine.

Conclusion

HPV vaccination posed a pressure on public health authorities to consider the evidence for and against it, and on politicians to weigh the wish for cervical cancer protection against other pertinent health issues.     

Cost-effectiveness analysis of a gender-neutral human papillomavirus vaccination program in the Netherlands

BackgroundVaccinating girls against human papillomavirus (HPV) infection is a highly effective and cost-effective intervention to provide protection against HPV-induced cancers. Since vaccination coverage rates among girls is modest in the Netherlands, additional strategies should be implemented to improve the protection against HPV-related cancer. Here we assessed the benefits and cost-effectiveness of gender-neutral vaccination.MethodsWe designed a static Markov model with a lifelong time horizon to simulate a cohort of 100,000 12-year-old Dutch boys. The model compares health and economic effects of HPV vaccination taking the current female vaccination coverage into consideration. HPV prevalence in boys was corrected for the predicted herd effects of the female programme in 2017. We extracted transition probabilities from peer-reviewed literature and previously constructed models. The robustness of the model was tested with multiple sensitivity analyses.ResultsVaccinating 30% of 100,000 12-year-old boys prevents 18, 13 and 25 cases of anal, penile, and oropharyngeal cancers in men, respectively. A total of 205 quality-adjusted life-years (QALYs) are saved by preventing cancer-related morbidity and mortality. Assuming a vaccine price of €50 per dose, the incremental cost-effectiveness ratio (ICER) is €17,907 per QALY. In addition, due to vaccine-induced herd effects, we estimated that 110 cases of cancer in females would be additionally prevented and 246 QALYs would be gained in the female cohort, bringing the total to 166 cancers prevented and 451 QALYs gained. Taking these additional benefits of boys’ vaccination into account, the overall ICER was estimated at €7310 per QALY gained. The model outcomes are most sensitive to variation in vaccine price, herd immunity from females and vaccine efficacy.ConclusionsVaccination of boys, additional to girls, will prevent a relevant number of cancers in both boys and girls. Based on the current Dutch situation vaccination of HPV in boys is likely cost-effective.GSK Study identifier: HO-18-19169. A graphical abstract and supplementary data to this article can be found online at https://doi.org/10.1016/j.vaccine.2020.05.031.     

Knowledge differences between male and female university students about human papillomavirus (HPV) and cervical cancer: Implications for health strategies and vaccination

Knowledge about HPV and cervical cancer (CC) depends on several factors such as gender and education, which brings implications for health strategies and vaccination. A survey was conducted in Portugal with a representative sample of 1706 university students. Only 55.4% (n = 945) had already heard of HPV, although 88.3% (n = 834) from that know that is a risk factor for CC. 89% students (n = 841) wants to be vaccinated against it, but only 13.8% stated as main reason to be vaccinated “prevention of the disease”. Mean scores of knowledge were calculated. Statistical differences were found, regarding “CC knowledge”, in gender (p < 0.001) and between health sciences schools and non-health sciences schools (p < 0.001). Differences regarding the study area in “knowledge and beliefs of HPV” (p < 0.001) and in “relation between HPV and CC” (p < 0.001) were found. Therefore, these differences may help to develop effective strategies that lead to decline CC incidence and mortality.     

Ecological validity of cost-effectiveness models of universal HPV vaccination: A systematic literature review

BackgroundThe protective (herd) effect of the selective vaccination of pubertal girls against human papillomavirus (HPV) implies a high probability that one of the two partners involved in intercourse is immunised, hence preventing the other from this sexually transmitted infection. The dynamic transmission models used to inform immunisation policy should include consideration of sexual behaviours and population mixing in order to demonstrate an ecological validity, whereby the scenarios modelled remain faithful to the real-life social and cultural context.The primary aim of this review is to test the ecological validity of the universal HPV vaccination cost-effectiveness modelling available in the published literature.MethodsThe research protocol related to this systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016034145). Eight published economic evaluations were reviewed.ResultsNone of the studies showed due consideration of the complexities of human sexual behaviour and the impact this may have on the transmission of HPV.DiscussionOur findings indicate that all the included models might be affected by a different degree of ecological bias, which implies an inability to reflect the natural demographic and behavioural trends in their outcomes and, consequently, to accurately inform public healthcare policy. In particular, ecological bias have the effect to over-estimate the preference-based outcomes of selective immunisation. A relatively small (15–20%) over-estimation of quality-adjusted life years (QALYs) gained with selective immunisation programmes could induce a significant error in the estimate of cost-effectiveness of universal immunisation, by inflating its incremental cost effectiveness ratio (ICER) beyond the acceptability threshold. The results modelled here demonstrate the limitations of the cost-effectiveness studies for HPV vaccination, and highlight the concern that public healthcare policy might have been built upon incomplete studies.     

Decline in prevalence of human papillomavirus infection following vaccination among Australian Indigenous women,a population at higher risk of cervical cancer: The VIP-I study

BackgroundCervical cancer occurrence and mortality are strongly correlated with socioeconomic disadvantage, largely due to unequal access to screening and treatment. Universal human papillomavirus (HPV) vaccination provides the opportunity to greatly reduce this global health disparity. Australian Indigenous women have substantially higher rates of cervical cancer than non-Indigenous women, primarily due to under-screening. We investigated HPV infection rates in Indigenous women 7 years after implementation of the national HPV vaccination program.MethodsWe used a repeat cross-sectional design, with the baseline being provided by an HPV prevalence survey among Indigenous women attending clinics for cervical cytology screening, prior to the start of the vaccination program in 2007. We returned to clinics in four locations during 2014–15, and invited women aged 18–26 years attending for screening to provide a cervical specimen for HPV testing, as well as to complete a short questionnaire and consent to allow access of their records in the National HPV Vaccination Program Register. We used well-established laboratory methods to test specimens for specific HPV genotypes.ResultsA total of 142 women were recruited at participating sites and compared to 155 who had been recruited at the same locations in the 2007 pre-vaccine survey. The two groups were identical in regard to age, with the more recent group having a higher proportion of hormonal contraception users, and a lower proportion of smokers. The proportion found to have any HPV type fell from 58 to 36% with the decline being entirely due to reductions in vaccine types, which fell by 94% from 24 to 1.4%.ConclusionAustralia’s national HPV vaccination program appears to be successfully protecting a very high proportion of Indigenous women against vaccine targeted HPV types, who have in the past been at elevated risk of cervical cancer.     

Knowledge and attitude of students studying at health department towards HPV and HPV vaccination

The human papillomavirus (HPV) is the most common diagnosed sexually transmitted infection in the world. The most frequent disease linked to HPV is cervical cancer as well as other cancers including those of the vulva, vagina, penis, anus, and oropharynx.Our research sought to evaluate the knowledge and attitudes concerning human papillomaviruses and their vaccine among students enrolled in Alt?nba? University's faculties of health sciences.MethodA cross-sectional study was carried out using a survey containing 41 questions about demographic variables, knowledge, and attitudes toward HPV and HPV vaccines. The questions were distributed to students via Google form using social media applications such as WhatsApp.ResultsThe study involved 144 students, 71.5 % of whom were female. 37.5 % of the participants learned about HPV from social media. Knowledge of HPV is present in 82 % of females and 25 % of males. Most of the questions had more accurate replies from female than from male students p < 0.05. As a result, 88 %, 46 % of female respondents and 27 %, 14 % of male respondents, respectively, correctly answered the questions about who should receive HPV vaccinations p < 0.001 and how many doses are necessary.ConclusionParticipants' awareness of HPV, HPV vaccination, and cervical cancer was rather high when compared to other research. However, there are knowledge gaps that need to be corrected and provided through educational programs.     

Reduced dose human papillomavirus vaccination: An update of the current state-of-the-art

Human papillomavirus (HPV) infection is the primary cause of genital warts, some oropharyngeal cancers and anogenital cancers, including cervical, vagina, vulvar, anal and penile cancers. Primary prevention of cervical cancer requires the prevention of high-risk HPV infections, particularly HPV genotypes 16 and 18. Both Gardasil^® and Cervarix^® vaccines when administered by a three-dose schedule have been demonstrated to be effective against cervical, vulva, and vaginal cancer precursors from vaccine genotypes in phase III clinical trials, and post-marketing studies; Gardasil^® vaccine also offers additional protection against anal cancer precursors. However, high costs of HPV vaccines and the logistics of delivering a three-dose schedule over 6 months are challenging in countries with limited resources. Several studies have demonstrated non-inferiority in antibody response between adolescents (9–15 years old) who received two doses (6 months apart) and women (>15 years old) who received the standard three-dose schedule. These studies provided evidence for the World Health Organization and European Medical Association to revise its recommendation to give two instead of three doses of HPV vaccine to adolescents below 15 years of age, provided the 2nd dose is given 6 months apart. Although reduced dose schedules can alleviate costs and logistics associated with HPV vaccination, especially in resource-poor countries, there are still gaps in this area of research, particularly regarding long-term protection. This review discusses the findings on antibody response and clinical outcomes in studies evaluating reduced dose HPV schedules, and highlights the important considerations of its implementation. In addition, other important immunological biomarkers that may be associated with long-term protection are highlighted and discussed.     

青春前期女性接种人乳头瘤病毒疫苗专家共识

人乳头瘤病毒（HPV）疫苗接种是子宫颈癌防控的重要措施之一。通过综合考虑HPV疫苗接种的有效性、安全性、成本效益等多方面因素,专家强烈推荐青春前期（9~14岁）女性作为重点目标人群应优先接种HPV疫苗,提高重点目标人群HPV疫苗免疫覆盖率,以达到子宫颈癌一级预防策略的最佳效果。     

Cost-effectiveness of a tetravalent human papillomavirus vaccine in Germany

Aim  Clinical trials have demonstrated the efficacy of the tetravalent human papillomavirus (HPV) vaccination in the prevention of cervical cancer and genital warts associated with HPV types 6, 11, 16 and 18. We used an empirically calibrated Markov cohort model of the natural history of HPV to assess the cost-effectiveness of the vaccine administered to 12-year-old girls alongside existing cervical screening programmes in Germany. Subjects and methods  The model estimated cervical cancer (CC), cervical intraepithelial neoplasia (CIN) and genital wart lifetime risks and total lifetime health care costs, life years gained and quality-adjusted life years (QALY) gained. The analysis was conducted from the perspective of the German health care payer. Results  In the base case (considering a lifetime duration of protection and 100% efficacy) it was estimated that 2,835 cervical cancer cases and 679 deaths could be prevented among a cohort of 400,000, at an incremental cost per QALY gained of 10,530 €. A total of 120 girls needed to be vaccinated to prevent 1 case of CC. Cost-effectiveness is sensitive to a duration of protection of less than 20 years and to the discount rate for costs and benefits. Conclusion  A policy of vaccinating adolescent girls has been recommended by the German Standing Committee on Vaccinations. This study has demonstrated that such a policy is cost-effective based on thresholds of cost-effectiveness that apply in Germany.     

Human papillomavirus vaccination and Pap testing profile in Manitoba,Canada

Background

Females who receive the human papillomavirus (HPV) vaccine may believe they are protected from developing cervical cancer and no longer require screening. Concern has also been expressed that vaccinated females are those that would be screened regularly. This study assesses the Pap testing behavior of vaccinated and non-vaccinated females.

Methods

For this population-based retrospective cohort study, vaccination and screening registries were linked for 3540 vaccinated females aged 15 years and over and 9592 matched non-vaccinated females. Conditional logistic regression, the Kaplan–Meier method and Cox regression were used to examine the association between vaccination and Pap testing.

Results

Vaccinated females were more likely to have had a Pap test within the year prior to the index date than non-vaccinated females (15–19 years old: OR = 1.38, 95% CI 1.20–1.59; 20+ years old: OR = 2.34, 95% CI 1.98–2.76). In the three-year period after the index date, vaccinated females had a significantly higher cumulative probability of having a Pap test (83.3%) than non-vaccinated females (66.1%). Females who had a Pap test within three years prior to the index date were more likely to have a Pap test after the index date (vaccinated: HR = 5.03, 95% CI 4.65–5.45; non-vaccinated HR = 3.97, 95% CI 3.70–4.24). Being vaccinated had a significant effect on Pap testing (15–19 years old: HR = 1.54, 95% CI 1.39–1.69; 20+ years old: HR = 1.87, 95% CI 1.52–2.31). 80.1% of vaccinated females who had a Pap test prior to the index date also had one subsequent to it, compared to 70.1% for non-vaccinated females. 41.1% of females had not been vaccinated nor had a Pap test.

Conclusion

The majority of vaccinated females continue to participate in screening, and do so at a higher rate than non-vaccinated females. Renewed efforts need to be made to include the large proportion of non–vaccinated, non–screened females in vaccination and/or screening.     

Impact of vaccine protection against multiple HPV types on the cost-effectiveness of cervical screening

Cross-protection against non-HPV16/18 types and the emergence of broad spectrum vaccines protecting against multiple HPV types will influence the cost-effectiveness of future screening. To assess this influence we used an individual-based simulation model describing the relation between 14 HPV types and cervical disease, allowing the occurrence of multiple type infections. Screening scenarios for vaccinated women were evaluated, firstly for HPV16/18 vaccination with partial cross-protection against HPV 31, 33, 45 and 58 and secondly, for broad spectrum vaccination against 5-13 HPV types. The vaccine-induced incidence reduction of type-specific infection was varied from 0 to 95% in the cross-protection setting and set at 100% in the setting of broad spectrum vaccines. Scenarios of either cytology or HPV DNA screening were considered under varying lifetime number of screening rounds. At a cost-effectiveness threshold of €20,000/QALY, four times HPV DNA screening between 30 and 60 years was the selected scenario in addition to HPV16/18 vaccination, whether or not cross-protection was conferred (€6707 and €9994/QALY, respectively). In the absence of cross-protection, a fifth screening round might be considered (ICER €22,967/QALY). In addition to broad spectrum vaccination, one screen during lifetime was cost-effective up to an 11-valent vaccine. If the vaccine-induced type-specific incidence reduction was lowered to 99%, one screen during lifetime was cost-effective even in addition to 13-valent vaccination. In conclusion, in a cohort of HPV16/18 vaccinated women, four rounds of HPV DNA screening is cost-effective. One screen during lifetime remains cost-effective in addition to broad spectrum vaccination offering protection against many high-risk HPV types.     

Parental acceptance of human papillomavirus (HPV) vaccination in Indonesia: a cross-sectional study

Background

Cervical cancer ranks the second most frequent cancer in Indonesian women. In Indonesia, human papillomavirus (HPV) vaccine acceptance has not been studied before.

Objective

To determine parental HPV vaccine acceptance in Indonesia, and factors that influence their decision. Factors include sociodemographic factors, knowledge of HPV, HPV vaccination and cervical cancer, health beliefs about cervical cancer, and attitudes towards vaccination in general.

Methods

746 parents, with at least 1 daughter aged 0-14, were interviewed using questionnaires based on published and adjusted interviews. Interviews were done in sub district public health centers, general governmental hospitals, and via house-visits, in 5 Indonesian provinces.

Results

Parental HPV vaccine acceptance was 96.1%. Logistic regression revealed that age, beliefs regarding cervical cancer, and attitudes towards vaccination in general were significantly associated with HPV vaccine acceptance. Of the participants, 66.0%, 16.6%, and 15.8% had heard about cervical cancer, HPV, and HPV vaccination respectively. The mean total knowledge score was 1.91(Standard Deviation 2.31) on a 0-8 scale. Health beliefs about cervical cancer and attitudes towards vaccination in general were positive. Participants named the high cost of the vaccine, fear for side-effects, and chosen vaccination locations as possible barriers towards HPV vaccine implementation.

Discussion

Parental HPV vaccine acceptance is high, but knowledge about HPV and cervical cancer is low. During HPV vaccination programs, focus should not only be on providing information, but also on existing beliefs and attitudes towards cervical cancer and vaccination in general. If HPV vaccination programs were to be implemented in Indonesia, the indicated barriers should be taken into account.     

Planning for human papillomavirus (HPV) vaccination in sub-Saharan Africa: A modeling-based approach

Background

Human papillomavirus (HPV) vaccines have the potential to reduce cervical cancer incidence and mortality, particularly in the parts of the developing world that bear the greatest burden of disease. This research sought to predict the impact and cost-effectiveness of an HPV vaccination program in an example low-resource country with a high burden of cervical cancer: Mali, West Africa.

Methods

Novel compartmental mathematical models projected the impact of adolescent HPV vaccination in urban and rural areas of Mali. The models accounted for two high-risk vaccine-types: HPV 16 and 18. We then attached comprehensive real cost and cost-effectiveness estimates.

Results

Our models predict that HPV vaccination in Mali will reduce cervical cancer burden by a factor roughly equal to vaccine coverage. A point vaccination program was simulated in a cohort of 333,146 urban and 588,982 rural Malian women, age 10–14. Vaccination of 50% of girls reduced the peak prevalence of HPV 16/18 to 5.0% in the urban setting and 9.6% in the rural setting, down from 11.7% and 22.0%, respectively, with no vaccination. The 50% vaccination scenario averted 1145 cervical cancer deaths in the urban group and 2742 in the rural group. The cost per discounted life-year saved in this scenario was 1030 US dollars (urban) and 725 dollars (rural). The cost per life-year saved was higher at 90% coverage, but was still in the range of a “cost-effective” public health intervention.

Conclusions

This research yielded the most comprehensive real cost estimates of HPV vaccination yet published for sub-Saharan Africa. Our models indicate that HPV vaccination in Mali will be cost-effective when introduced. To maximize the benefit using limited resources, vaccination programs may begin with a target coverage of about 50%. We anticipate that costs of reaching late adopters after the First Vaccinated Wave of vaccination will be higher, but worthwhile.