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Lorenzo-Pouso AI, González-Palanca S, Palmeiro-Fernández G, Dominguez-Salgado JC, Pérez-Sayáns M, González-Veiga EJ, Caponio VCA, Daley EM. Parents' perspectives on dental team as advisors to promote HPV vaccination among Spanish adolescents. J Public Health Dent 2024; 84:147-153. [PMID: 38485512 DOI: 10.1111/jphd.12609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Human papillomavirus (HPV) is a prevalent sexually transmitted infection responsible for many anogenital and oropharyngeal cancers. Dental care providers have the potential to influence vaccine uptake, yet little is known about how patients perceive their role in HPV education and prevention. METHODS Parents of adolescents aged 9 to 17 years (n = 375) were recruited from Valdeorras District Hospital (Galicia, Spain) to investigate parents' attitudes concerning the involvement of dental care providers in discussions related to HPV. A survey was distributed to the participants, and 343 (91.5%) were included in the analysis. RESULTS In general, nearly half of the parents reported feeling comfortable regarding discussing HPV with their dentist. Participants described more comfort with dentists than with dental hygienists. Parents' comfort levels were influenced by various social determinants of health, including education level, marital status, geographic origin, and child vaccination status (p > 0.05). CONCLUSION Parents reported varying comfort levels when discussing HPV and its vaccine with dental professionals, displaying a preference for dentists. Dental settings have the potential to promote vaccination, but the existence of ongoing barriers needs to be addressed.
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Affiliation(s)
- Alejandro Ismael Lorenzo-Pouso
- Oral Medicine, Oral Surgery and Implantology Unit, Faculty of Medicine and Odontology, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), ORALRES Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Gerardo Palmeiro-Fernández
- Primary Health Care Unit, EOXI Ourense, Verín, and El Barco de Valdeorras, Galician Health Service, Ourense, Spain
| | | | - Mario Pérez-Sayáns
- Oral Medicine, Oral Surgery and Implantology Unit, Faculty of Medicine and Odontology, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), ORALRES Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Ellen M Daley
- College of Public Health, University of South Florida, Tampa, Florida, USA
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2
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Jit M, Cook AR. Informing Public Health Policies with Models for Disease Burden, Impact Evaluation, and Economic Evaluation. Annu Rev Public Health 2024; 45:133-150. [PMID: 37871140 DOI: 10.1146/annurev-publhealth-060222-025149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Conducting real-world public health experiments is often costly, time-consuming, and ethically challenging, so mathematical models have a long-standing history of being used to inform policy. Applications include estimating disease burden, performing economic evaluation of interventions, and responding to health emergencies such as pandemics. Models played a pivotal role during the COVID-19 pandemic, providing early detection of SARS-CoV-2's pandemic potential and informing subsequent public health measures. While models offer valuable policy insights, they often carry limitations, especially when they depend on assumptions and incomplete data. Striking a balance between accuracy and timely decision-making in rapidly evolving situations such as disease outbreaks is challenging. Modelers need to explore the extent to which their models deviate from representing the real world. The uncertainties inherent in models must be effectively communicated to policy makers and the public. As the field becomes increasingly influential, it needs to develop reporting standards that enable rigorous external scrutiny.
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Affiliation(s)
- Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom;
| | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- National University Health System, Singapore
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3
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Spencer JC, Spees LP, Biddell CB, Odebunmi OO, Ilyasova AA, Yanguela J, Lich KH, Mills SD, Higgins CR, Ozawa S, Wheeler SB. Inclusion of marginalized populations in HPV vaccine modeling: A systematic review. Prev Med 2024; 182:107941. [PMID: 38522627 PMCID: PMC11194695 DOI: 10.1016/j.ypmed.2024.107941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/26/2024] [Accepted: 03/21/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Models simulating the potential impacts of Human Papillomavirus (HPV) vaccine have been used globally to guide vaccination policies and programs. We sought to understand how and why marginalized populations have been incorporated into HPV vaccine simulation models. METHODS We conducted a systematic search of PubMed, CINAHL, Scopus, and Embase to identify studies using simulation models of HPV vaccination incorporating one or more marginalized population through stratification or subgroup analysis. We extracted data on study characteristics and described these overall and by included marginalized groups. RESULTS We identified 36 studies that met inclusion criteria, which modeled vaccination in 21 countries. Models included men who have sex with men (MSM; k = 16), stratification by HIV status (k = 9), race/ethnicity (k = 6), poverty (k = 5), rurality (k = 4), and female sex workers (k = 1). When evaluating for a marginalized group (k = 10), HPV vaccination was generally found to be cost-effective, including for MSM, individuals living with HIV, and rural populations. In studies evaluating equity in cancer prevention (k = 9), HPV vaccination generally advanced equity, but this was sensitive to differences in HPV vaccine uptake and use of absolute or relative measures of inequities. Only one study assessed the impact of an intervention promoting HPV vaccine uptake. DISCUSSION Incorporating marginalized populations into decision models can provide valuable insights to guide decision making and improve equity in cancer prevention. More research is needed to understand the equity impact of HPV vaccination on cancer outcomes among marginalized groups. Research should emphasize implementation - including identifying and evaluating specific interventions to increase HPV vaccine uptake.
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Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America.
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Olufeyisayo O Odebunmi
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Anna A Ilyasova
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Juan Yanguela
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Sarah D Mills
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Colleen R Higgins
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Sachiko Ozawa
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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4
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Tran J, Hathaway CL, Broshkevitch CJ, Palanee-Phillips T, Barnabas RV, Rao DW, Sharma M. Cost-effectiveness of single-visit cervical cancer screening in KwaZulu-Natal, South Africa: a model-based analysis accounting for the HIV epidemic. Front Oncol 2024; 14:1382599. [PMID: 38720798 PMCID: PMC11077327 DOI: 10.3389/fonc.2024.1382599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Women living with human immunodeficiency virus (WLHIV) face elevated risks of human papillomavirus (HPV) acquisition and cervical cancer (CC). Coverage of CC screening and treatment remains low in low-and-middle-income settings, reflecting resource challenges and loss to follow-up with current strategies. We estimated the health and economic impact of alternative scalable CC screening strategies in KwaZulu-Natal, South Africa, a region with high burden of CC and HIV. Methods We parameterized a dynamic compartmental model of HPV and HIV transmission and CC natural history to KwaZulu-Natal. Over 100 years, we simulated the status quo of a multi-visit screening and treatment strategy with cytology and colposcopy triage (South African standard of care) and six single-visit comparator scenarios with varying: 1) screening strategy (HPV DNA testing alone, with genotyping, or with automated visual evaluation triage, a new high-performance technology), 2) screening frequency (once-per-lifetime for all women, or repeated every 5 years for WLHIV and twice for women without HIV), and 3) loss to follow-up for treatment. Using the Ministry of Health perspective, we estimated costs associated with HPV vaccination, screening, and pre-cancer, CC, and HIV treatment. We quantified CC cases, deaths, and disability-adjusted life-years (DALYs) averted for each scenario. We discounted costs (2022 US dollars) and outcomes at 3% annually and calculated incremental cost-effectiveness ratios (ICERs). Results We projected 69,294 new CC cases and 43,950 CC-related deaths in the status quo scenario. HPV DNA testing achieved the greatest improvement in health outcomes, averting 9.4% of cases and 9.0% of deaths with one-time screening and 37.1% and 35.1%, respectively, with repeat screening. Compared to the cost of the status quo ($12.79 billion), repeat screening using HPV DNA genotyping had the greatest increase in costs. Repeat screening with HPV DNA testing was the most effective strategy below the willingness to pay threshold (ICER: $3,194/DALY averted). One-time screening with HPV DNA testing was also an efficient strategy (ICER: $1,398/DALY averted). Conclusions Repeat single-visit screening with HPV DNA testing was the optimal strategy simulated. Single-visit strategies with increased frequency for WLHIV may be cost-effective in KwaZulu-Natal and similar settings with high HIV and HPV prevalence.
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Affiliation(s)
- Jacinda Tran
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, United States
| | - Christine Lee Hathaway
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
| | - Cara Jill Broshkevitch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Ruanne Vanessa Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
- Division of Infectious Diseases, Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Darcy White Rao
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
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Hall MT, Simms KT, Murray JM, Keane A, Nguyen DTN, Caruana M, Lui G, Kelly H, Eckert LO, Santesso N, de Sanjose S, Swai EE, Rangaraj A, Owiredu MN, Gauvreau C, Demke O, Basu P, Arbyn M, Dalal S, Broutet N, Canfell K. Benefits and harms of cervical screening, triage and treatment strategies in women living with HIV. Nat Med 2023; 29:3059-3066. [PMID: 38087116 PMCID: PMC10719091 DOI: 10.1038/s41591-023-02601-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
To support a strategy to eliminate cervical cancer as a public health problem, the World Health Organisation (WHO) reviewed its guidelines for screening and treatment of cervical pre-cancerous lesions in 2021. Women living with HIV have 6-times the risk of cervical cancer compared to women in the general population, and we harnessed a model platform ('Policy1-Cervix-HIV') to evaluate the benefits and harms of a range of screening strategies for women living with HIV in Tanzania, a country with endemic HIV. Assuming 70% coverage, we found that 3-yearly primary HPV screening without triage would reduce age-standardised cervical cancer mortality rates by 72%, with a number needed to treat (NNT) of 38.7, to prevent a cervical cancer death. Triaging HPV positive women before treatment resulted in minimal loss of effectiveness and had more favorable NNTs (19.7-33.0). Screening using visual inspection with acetic acid (VIA) or cytology was less effective than primary HPV and, in the case of VIA, generated a far higher NNT of 107.5. These findings support the WHO 2021 recommendation that women living with HIV are screened with primary HPV testing in a screen-triage-and-treat approach starting at 25 years, with regular screening every 3-5 years.
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Affiliation(s)
- Michaela T Hall
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia.
| | - Kate T Simms
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - John M Murray
- School of Mathematics and Statistics, University of New South Wales, Sydney, NSW, Australia
| | - Adam Keane
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Diep T N Nguyen
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Michael Caruana
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Gigi Lui
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Helen Kelly
- London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Linda O Eckert
- Department of Global Health and the Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, USA
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Silvia de Sanjose
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
- ISGlobal, Barcelona, Spain
| | - Edwin E Swai
- Universal Health Coverage and Life Course Cluster, World Health Organization, Dar es Salaam, Tanzania
| | - Ajay Rangaraj
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Morkor Newman Owiredu
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Cindy Gauvreau
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- SUCCESS Project, Expertise France, Paris, France
| | - Owen Demke
- Global Diagnostics, Clinton Health Access Initiative, Kigali, Rwanda
| | - Partha Basu
- Early Detection Prevention and Infections, International Agency for Research on Cancer, Lyon, France
| | - Marc Arbyn
- Cancer Epidemiology Unit, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Shona Dalal
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Karen Canfell
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
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Simms KT, Keane A, Nguyen DTN, Caruana M, Hall MT, Lui G, Gauvreau C, Demke O, Arbyn M, Basu P, Wentzensen N, Lauby-Secretan B, Ilbawi A, Hutubessy R, Almonte M, De Sanjosé S, Kelly H, Dalal S, Eckert LO, Santesso N, Broutet N, Canfell K. Benefits, harms and cost-effectiveness of cervical screening, triage and treatment strategies for women in the general population. Nat Med 2023; 29:3050-3058. [PMID: 38087115 PMCID: PMC10719104 DOI: 10.1038/s41591-023-02600-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/19/2023] [Indexed: 12/17/2023]
Abstract
In 2020, the World Health Organization (WHO) launched a strategy to eliminate cervical cancer as a public health problem. To support the strategy, the WHO published updated cervical screening guidelines in 2021. To inform this update, we used an established modeling platform, Policy1-Cervix, to evaluate the impact of seven primary screening scenarios across 78 low- and lower-middle-income countries (LMICs) for the general population of women. Assuming 70% coverage, we found that primary human papillomavirus (HPV) screening approaches were the most effective and cost-effective, reducing cervical cancer age-standardized mortality rates by 63-67% when offered every 5 years. Strategies involving triaging women before treatment (with 16/18 genotyping, cytology, visual inspection with acetic acid (VIA) or colposcopy) had close-to-similar effectiveness to HPV screening without triage and fewer pre-cancer treatments. Screening with VIA or cytology every 3 years was less effective and less cost-effective than HPV screening every 5 years. Furthermore, VIA generated more than double the number of pre-cancer treatments compared to HPV. In conclusion, primary HPV screening is the most effective, cost-effective and efficient cervical screening option in LMICs. These findings have directly informed WHO's updated cervical screening guidelines for the general population of women, which recommend primary HPV screening in a screen-and-treat or screen-triage-and-treat approach, starting from age 30 years with screening every 5 years or 10 years.
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Affiliation(s)
- Kate T Simms
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia.
| | - Adam Keane
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Diep Thi Ngoc Nguyen
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Caruana
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michaela T Hall
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Gigi Lui
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Cindy Gauvreau
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- SUCCESS Project, Expertise France, Paris, France
| | - Owen Demke
- Global Diagnostics, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium
| | - Partha Basu
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Beatrice Lauby-Secretan
- Evidence Synthesis and Classification Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Andre Ilbawi
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Maribel Almonte
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Silvia De Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
- ISGlobal, Barcelona, Spain
| | - Helen Kelly
- London School of Hygiene & Tropical Medicine, London, UK
| | - Shona Dalal
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Linda O Eckert
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Karen Canfell
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
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7
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M de Carvalho T, Man I, Georges D, Saraswati LR, Bhandari P, Kataria I, Siddiqui M, Muwonge R, Lucas E, Sankaranarayanan R, Basu P, Berkhof J, Bogaards JA, Baussano I. Health and economic effects of introducing single-dose or two-dose human papillomavirus vaccination in India. BMJ Glob Health 2023; 8:e012580. [PMID: 37931940 PMCID: PMC10632817 DOI: 10.1136/bmjgh-2023-012580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Cervical cancer is a major public health problem in India, where access to prevention programmes is low. The WHO-Strategic Advisory Group of Experts recently updated their recommendation for human papillomavirus (HPV) vaccination to include a single-dose option in addition to the two-dose option, which could make HPV vaccination programmes easier to implement and more affordable. METHODS We combined projections from a type-specific HPV transmission model and a cancer progression model to assess the health and economic effects of HPV vaccination at national and state level in India. The models used national and state-specific Indian demographic, epidemiological and cost data, and single-dose vaccine efficacy and immunogenicity data from the International Agency for Research on Cancer India vaccine trial with 10-year follow-up. We compared single-dose and two-dose HPV vaccination for a range of plausible scenarios regarding single-dose vaccine protection, coverage and catch-up. We used a healthcare sector payer perspective with a time horizon of 100 years. RESULTS Under the base-case scenario of lifelong protection of single-dose vaccination in 10-year-old girls with 90% coverage, the discounted incremental cost-effectiveness ratio (ICER) of nationwide vaccination relative to no vaccination was US$406 (₹INR30 000) per DALY (disability-adjusted life-years) averted. This lay below an opportunity-cost-based threshold of 30% Indian gross domestic product per capita in each Indian state (state-specific ICER range: US$67-US$593 per DALY averted). The ICER of two-dose vaccination versus no vaccination vaccination was US$1404 (₹INR104 000). The ICER of two-dose vaccination versus single-dose vaccination, assuming lower initial efficacy and waning of single-dose vaccination, was at least US$2282 (₹INR169 000) per DALY averted. CONCLUSIONS Nationwide introduction of single-dose HPV vaccination at age 10 in India is highly likely to be cost-effective whereas extending the number of doses from one to two would have a less favourable profile.
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Affiliation(s)
- Tiago M de Carvalho
- Department of Epidemiology and Data Science, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Irene Man
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Damien Georges
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Prince Bhandari
- Research Triangle Institute (RTI) International India, New Delhi, India
| | - Ishu Kataria
- Research Triangle Institute (RTI) International India, New Delhi, India
| | - Mariam Siddiqui
- Research Triangle Institute (RTI) International India, New Delhi, India
| | - Richard Muwonge
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Eric Lucas
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Partha Basu
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Johannes A Bogaards
- Department of Epidemiology and Data Science, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Iacopo Baussano
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
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8
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Bénard É, Drolet M, Laprise JF, Gingras G, Jit M, Boily MC, Bloem P, Brisson M. Potential population-level effectiveness of one-dose HPV vaccination in low-income and middle-income countries: a mathematical modelling analysis. Lancet Public Health 2023; 8:e788-e799. [PMID: 37777288 PMCID: PMC10557953 DOI: 10.1016/s2468-2667(23)00180-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Given the accumulating evidence that one-dose vaccination could provide high and sustained protection against human papillomavirus (HPV) infection and related diseases, we examined the population-level effectiveness and efficiency of one-dose HPV vaccination of girls compared with two-dose vaccination, using mathematical modelling. METHODS In this mathematical modelling study, we used HPV-ADVISE LMIC, an individual-based transmission-dynamic model independently calibrated to four epidemiologically diverse low-income and middle-income countries (LMICs; India, Nigeria, Uganda, and Viet Nam). We parameterised and calibrated the model using sexual behaviour and epidemiological data identified from international population-based datasets and the literature. All base-case vaccination scenarios start in 2023 with the nonavalent vaccine and assumed 80% vaccination coverage with one or two doses. We assumed that two doses of vaccine provide 100% efficacy against vaccine-type infections and a lifelong duration of protection. We examined a non-inferior vaccination scenario for one dose compared with two doses, pessimistic scenarios of lower one-dose vaccine efficacy (85%) or a shorter duration of protection (ie, 20 or 30 years), and the effectiveness of a mitigation scenario in which schedules would switch from one dose to two doses. We also did sensitivity analyses by varying vaccination coverage. We used three outcomes: the relative reduction in cervical cancer incidence, the number of cervical cancers averted, and the number of vaccine doses needed to prevent one cervical cancer. FINDINGS Assuming non-inferior vaccine characteristics for one dose compared with two doses, the model projections show that two-dose or one-dose routine vaccination of girls aged 9 years (with a multi-age cohort vaccination of girls aged 10-14 years) would avert 12·0 million (80% UI 9·5-14·5) cervical cancers in India, 4·7 million (3·4-5·8) in Nigeria, 2·3 million (1·9-2·6) in Uganda, and 0·4 million (0·2-0·5) in Viet Nam over 100 years. Under pessimistic assumptions of lower one-dose efficacy (85%) or a shorter duration of protection (ie, 30 years), one-dose routine vaccination would avert 69% (61-80) to 94% (92-96) of the cervical cancers averted with two-dose routine vaccination. However, when assuming a duration of protection of 20 years, one-dose routine vaccination would avert substantially fewer cervical cancers (ie, 35% [26-44] to 69% [65-71] of the cervical cancers averted with two-dose routine vaccination). A switch from one-dose to two-dose routine vaccination of girls aged 9 years, with a one-dose catch-up of girls aged 10-14 years, 5 years after the start of the vaccination programme, could mitigate potential losses in cervical cancer prevention from a short one-dose duration of protection (averting 92% [83-98] to 99% [97-100]) of the cervical cancers averted with two-dose routine vaccination). One-dose routine vaccination would result in fewer doses needed to prevent one cervical cancer than two-dose routine vaccination, even if the duration of protection is as low as 20 years. Finally, for countries with two-dose routine vaccination, adding one-dose multi-age cohort vaccination in the first year would provide similar benefits as a two-dose multi-age cohort vaccination, and would be more efficient even under the pessimistic assumptions of lower one-dose vaccine efficacy or duration of protection. INTERPRETATION One-dose routine vaccination could avert most of the cervical cancers averted with two-dose vaccination while being more efficient, provided the duration of one-dose protection is greater than 20-30 years (depending on the LMIC). The doses saved by introducing one-dose routine vaccination could offer the opportunity to vaccinate girls before they age out of the vaccination window of 9-14 years and, potentially, to vaccinate boys or older age groups. FUNDING Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Élodie Bénard
- Département de médecine sociale et préventive, Université Laval, Québec City, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec City, QC, Canada
| | - Mélanie Drolet
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC, Canada
| | | | - Guillaume Gingras
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC, Canada
| | - Mark Jit
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Marie-Claude Boily
- Département de médecine sociale et préventive, Université Laval, Québec City, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec City, QC, Canada; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Paul Bloem
- Life Course and Integration, Essential Programme on Immunization, Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Marc Brisson
- Département de médecine sociale et préventive, Université Laval, Québec City, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec City, QC, Canada; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
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Man I, Georges D, Sankaranarayanan R, Basu P, Baussano I. Building resilient cervical cancer prevention through gender-neutral HPV vaccination. eLife 2023; 12:e85735. [PMID: 37486822 PMCID: PMC10365835 DOI: 10.7554/elife.85735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/08/2023] [Indexed: 07/26/2023] Open
Abstract
The COVID-19 pandemic has disrupted HPV vaccination programmes worldwide. Using an agent-based model, EpiMetHeos, recently calibrated to Indian data, we illustrate how shifting from a girls-only (GO) to a gender-neutral (GN) vaccination strategy could improve the resilience of cervical cancer prevention against disruption of HPV vaccination. In the base case of 5-year disruption with no coverage, shifting from GO to GN strategy under 60% coverage (before disruption) would increase the resilience, in terms of cervical cancer cases still prevented in the disrupted birth cohorts per 100,000 girls born, by 2.8-fold from 107 to 302 cases, and by 2.2-fold from 209 to 464 cases under 90% coverage. Furthermore, shifting to GN vaccination helped in reaching the World Health Organization (WHO) elimination threshold. Under GO vaccination with 60% coverage, the age-standardised incidence rate of cervical cancer in India in the long term with vaccination decreased from 11.0 to 4.7 cases per 100,000 woman-years (above threshold), as compared to 2.8 cases (below threshold) under GN with 60% coverage and 2.4 cases (below threshold) under GN with 90% coverage. In conclusion, GN HPV vaccination is an effective strategy to improve the resilience to disruption of cancer prevention programmes and to enhance the progress towards cervical cancer elimination.
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Affiliation(s)
- Irene Man
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections BranchLyonFrance
| | - Damien Georges
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections BranchLyonFrance
| | | | - Partha Basu
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections BranchLyonFrance
| | - Iacopo Baussano
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections BranchLyonFrance
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10
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Gao M, Hu S, Zhao X, You T, Jit M, Liu Y, Qiao Y, Zhao F, Wang C. Health and economic impact of delaying large-scale HPV vaccination and screening implementation on cervical cancer in China: a modelling study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 36:100768. [PMID: 37547038 PMCID: PMC10398607 DOI: 10.1016/j.lanwpc.2023.100768] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/14/2023] [Accepted: 03/28/2023] [Indexed: 08/08/2023]
Abstract
Background Current uptake of HPV vaccination and screening in China is far below World Health Organization 2030 targets for cervical cancer elimination. We quantified health and economic losses of delaying large-scale HPV vaccination and screening implementation in China. Methods We used a previously validated transmission model to project lifetime health benefits, costs, effectiveness, and timeline for cervical cancer elimination of alternative scenarios, including combining HPV vaccination initiated from 2022 to 2030 with screening in different modalities and coverage increase rates, as well as screening alone. All women living or projected to be born in China during 2022-2100 were considered. We employed a societal perspective. Findings Regardless of vaccine type, immediate large-scale vaccination initiated in 2022 and achieving 70% coverage of HPV-based screening in 2030 (no-delay scenario) would be the least costly and most effective. Compared with the no-delay scenario, delaying vaccination by eight years would result in 434,000-543,000 additional cervical cancer cases, 138,000-178,000 deaths, and $2863-4437 million costs, and delay elimination by 9-10 years. Even with immediate vaccination, the gradual scale-up of LBC-based screening to 70% coverage in 2070 would result in 2,530,000-3,060,000 additional cases, 909,000-1,040,000 deaths, and $5098-5714 million costs compared with no-delay scenario, and could not achieve elimination if domestic 2vHPV or 4vHPV vaccines are used (4.09-4.21 cases per 100,000 woman in 2100). Interpretation Delaying large-scale HPV vaccination and/or high-performance screening implementation has detrimental consequences for cervical cancer morbidity, mortality, and expenditure. These findings should spur health authorities to expedite large-scale vaccine rollout and improve screening. Funding Bill & Melinda Gates Foundation (INV-031449 and INV-003174) and CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-004).
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Affiliation(s)
- Meng Gao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shangying Hu
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuelian Zhao
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingting You
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yang Liu
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Youlin Qiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fanghui Zhao
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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11
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Impact of including boys in the national school-based human papillomavirus vaccination programme in Singapore: A modelling-based cost-effectiveness analysis. Vaccine 2023; 41:1934-1942. [PMID: 36797100 DOI: 10.1016/j.vaccine.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Globally, gender-neutral Human Papillomavirus (HPV) vaccination programmes are gaining traction. Although cervical cancer remains the most prevalent, other HPV-related cancers are increasingly recognised as important, especially among men who have sex with men. We assessed if including adolescent boys in Singapore's school-based HPV vaccination programme is cost-effective from the healthcare perspective. We adapted a World Health Organization-supported model, Papillomavirus Rapid Interface for Modelling and Economics, and modelled the cost and quality-adjusted life years (QALY) associated with vaccinating 13-year-olds with the HPV vaccine. Cancer incidence and mortality rates were obtained from local sources and adjusted based on the expected direct and indirect vaccine protection for various population subgroups at an 80 % vaccine coverage. Moving to a gender-neutral vaccination programme with a bivalent or nonavalent vaccine could avert 30 (95 % uncertainty interval [UI]: 20-44) and 34 (95 % UI: 24-49) HPV-related cancers per birth cohort, respectively. At a 3 % discount rate, a gender-neutral vaccination programme is not cost-effective. However, with a 1.5 % discount rate, which puts more value on long-term health gains from vaccination, moving to a gender-neutral vaccination programme with the bivalent vaccine is likely cost-effective, with an incremental cost-effectiveness ratio of SGD$19 007 (95 % UI: 10 164-30 633) per QALY gained. The findings suggest the need to engage experts to examine, in detail, the cost-effectiveness of gender-neutral vaccination programmes in Singapore. Issues of drug licensing, feasibility, gender equity, global vaccine supplies, and the global trend towards disease elimination/eradication should also be considered. This model provides a simplified method for resource-strapped countries to gain a preliminary estimate of the cost-effectiveness of a gender-neutral HPV vaccination programme before investing resources for further research.
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12
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Shen M, Zou Z, Bao H, Fairley CK, Canfell K, Ong JJ, Hocking J, Chow EP, Zhuang G, Wang L, Zhang L. Cost-effectiveness of artificial intelligence-assisted liquid-based cytology testing for cervical cancer screening in China. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2023. [DOI: 10.1016/j.lanwpc.2023.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Choi HCW, Leung K, Chan KKL, Bai Y, Jit M, Wu JT. Maximizing the cost-effectiveness of cervical screening in the context of routine HPV vaccination by optimizing screening strategies with respect to vaccine uptake: a modeling analysis. BMC Med 2023; 21:48. [PMID: 36765349 PMCID: PMC9921628 DOI: 10.1186/s12916-023-02748-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Regarding primary and secondary cervical cancer prevention, the World Health Organization proposed the cervical cancer elimination strategy that requires countries to achieve 90% uptake of human papillomavirus (HPV) vaccines and 70% screening uptake. The optimal cervical screening strategy is likely different for unvaccinated and vaccinated cohorts upon national HPV immunization. However, health authorities typically only provide a one-size-fits-all recommendation for the general population. We aimed to evaluate the cost-effectiveness for determining the optimal screening strategies for vaccinated and unvaccinated cohorts. METHODS We considered the women population in Hong Kong which has a unique HPV infection and cervical cancer epidemiology compared to other regions in China and Asia. We used mathematical models which comprise a deterministic age-structured compartmental dynamic component and a stochastic individual-based cohort component to evaluate the cost-effectiveness of screening strategies for cervical screening. Following the recommendations in local guidelines in Hong Kong, we considered strategies that involved cytology, HPV testing, or co-testing as primary cervical screening. We also explored the impacts of adopting alternative de-intensified strategies for vaccinated cohorts. The 3-year cytology screening was used as the base comparator while no screening was also considered for vaccinated cohorts. Women's lifetime life years, quality-adjusted life years, and costs of screening and treatment were estimated from the societal perspective based on the year 2022 and were discounted by 3% annually. Incremental cost-effectiveness ratios (ICERs) were compared to a willingness to pay (WTP) threshold of one gross domestic product per capita (US $47,792). Probabilistic and one-way sensitivity analyses were conducted. RESULTS Among unvaccinated cohorts, the strategy that adds reflex HPV to triage mild cytology abnormality generated more life years saved than cytology-only screening and could be a cost-effective alternative. Among vaccinated cohorts, when vaccine uptake was 85% (based on the uptake in 2022), all guideline-based strategies (including the cytology-only screening) had ICERs above the WTP threshold when compared with no screening if the vaccine-induced protection duration was 20 years or longer. Under the same conditions, HPV testing with genotyping triage had ICERs (compared with no screening) below the WTP threshold if the routine screening interval was lengthened to 10 and 15 years or screening was initiated at ages 30 and 35 years. CONCLUSIONS HPV testing is a cost-effective alternative to cytology for vaccinated cohorts, and the associated optimal screening frequency depends on vaccine uptake. Health authorities should optimize screening recommendations by accounting for population vaccine uptake.
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Affiliation(s)
- Horace C W Choi
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China. .,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China.
| | - Kathy Leung
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Karen K L Chan
- Department of Obstetrics and Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yuan Bai
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Mark Jit
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Modelling and Economics Unit, Public Health England, London, UK
| | - Joseph T Wu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
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14
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You T, Zhao X, Hu S, Gao M, Liu Y, Zhang Y, Qiao Y, Jit M, Zhao F. Optimal allocation strategies for HPV vaccination introduction and expansion in China accommodated to different supply and dose schedule scenarios: A modelling study. EClinicalMedicine 2023; 56:101789. [PMID: 36618898 PMCID: PMC9813696 DOI: 10.1016/j.eclinm.2022.101789] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A key barrier to cervical cancer elimination in China is low human papillomavirus (HPV) vaccine uptake, which is limited by supply constraints, high prices, and restriction to two/three-dose schedule. We explored optimal vaccination strategies for maximizing health and economic benefits accommodated to different supply and dose schedules. METHODS We evaluated different HPV vaccine strategies under 4 scenarios with different assumptions about vaccine availability and dose schedules. Each strategy involved different vaccine types, target ages, and modes of delivery. We used a previously validated transmission model to assess the health impact (cervical cancer cases averted), efficiency (number of doses needed to be given to prevent one case of cervical cancer [NND]), and value for money (incremental cost-effectiveness ratio [ICER] and return on investment [ROI]) of different strategies in Chinese females over a 100-year time horizon. All costs are expressed in 2021 dollars. We adopted a societal perspective and discounted quality-adjusted life-years (QALYs), costs and benefits by 3% annually for cost-effectiveness analysis and ROI calculation. FINDINGS In a supply-constrained and on-label use scenario, compared with no vaccination, two-dose routine vaccination of 14-year-olds would be the optimal, cost-saving strategy for a future national program (NNDs: 150-220, net cost saving: $15 164 million-$22 034 million, ROIs: 7-14, depending on vaccine type). If the one-dose schedule recommended by WHO is permitted in China, then reallocating the second dose from the routine cohorts to add a catch-up vaccination at 20-year-olds would be the most efficient strategy (NNDs: 73-107), and would be cost-saving compared with routine one-dose vaccination only (net cost saving: $4127 million-$6035 million, ROIs: 19-37). When supply constraints are lifted, scaling up vaccination in older females to 26 years could further expand the health benefits and still be cost-saving compared to maintaining the optimal vaccination strategy in the supply-constrained context. INTERPRETATION Our study provides timely evidence for the current and future HPV vaccination strategy planning in China, and may also be of value to other countries with supply and dose restrictions. FUNDING Bill & Melinda Gates Foundation; CAMS Innovation Fund for Medical Sciences (CIFMS).
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Affiliation(s)
- Tingting You
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuelian Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shangying Hu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng Gao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Liu
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Yong Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Youlin Qiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of Hong Kong, Hong Kong SAR, China
| | - Fanghui Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Corresponding author. 17 South Panjiayuan Lane, PO Box 2258, Beijing, 100021, China.
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Meites E, Wilkin TJ, Markowitz LE. Review of human papillomavirus (HPV) burden and HPV vaccination for gay, bisexual, and other men who have sex with men and transgender women in the United States. Hum Vaccin Immunother 2022; 18:2016007. [PMID: 35294325 PMCID: PMC8993076 DOI: 10.1080/21645515.2021.2016007] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Gay, bisexual, and other men who have sex with men (MSM) and transgender women, particularly those who are living with HIV, are disproportionately affected by human papillomavirus (HPV). For this narrative review of HPV health outcomes and vaccination for gay, bisexual, and other MSM and transgender women in the United States, we highlighted 71 publications regarding 1) burden of HPV infections and related diseases; 2) HPV vaccine efficacy; 3) HPV vaccination recommendations; 4) HPV vaccination coverage; 5) real-world vaccine effectiveness and health impacts; and 6) HPV vaccination acceptability. Vaccination is effective at reducing HPV infections among MSM; in the United States, routine HPV vaccination is recommended for all adolescents at age 11-12 years and for all persons through age 26 years. Efforts are ongoing to increase vaccination coverage and monitor health impacts of vaccination. Increasing vaccination coverage before sexual exposure to HPV is expected to reduce the burden of HPV-related disease.
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Affiliation(s)
- Elissa Meites
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Timothy J Wilkin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA
| | - Lauri E Markowitz
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Bénard É, Drolet M, Laprise JF, Jit M, Prem K, Boily MC, Brisson M. Potential benefit of extended dose schedules of human papillomavirus vaccination in the context of scarce resources and COVID-19 disruptions in low-income and middle-income countries: a mathematical modelling analysis. Lancet Glob Health 2022; 11:e48-e58. [PMID: 36521952 PMCID: PMC9764452 DOI: 10.1016/s2214-109x(22)00475-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 10/13/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The WHO Strategic Advisory Group of Experts recommended that an extended interval of 3-5 years between the two doses of the human papillomavirus (HPV) vaccine could be considered to alleviate vaccine supply shortages. However, three concerns have limited the introduction of extended schedules: girls could be infected between the two doses, the vaccination coverage for the second dose could be lower at ages 13-14 years than at ages 9-10 years, and identifying girls vaccinated with a first dose to give them the second dose could be difficult. Using mathematical modelling, we examined the potential effect of these concerns on the population-level impact and efficiency of extended dose HPV vaccination schedules. METHODS We used HPV-ADVISE, an individual-based, transmission-dynamic model of multitype HPV infection and disease, calibrated to country-specific data for four low-income and middle-income countries (India, Viet Nam, Uganda, and Nigeria). For the extended dose scenarios, we varied the vaccination coverage of the second dose among girls previously vaccinated, the one-dose vaccine efficacy, and the one-dose vaccine duration of protection. We also examined a strategy in which girls aged 14 years were vaccinated irrespective of their previous vaccination status. We used a scenario of girls-only two-dose vaccination at age 9 years (vaccine=9 valent, vaccine-type efficacy=100%, duration of protection=lifetime, and coverage=80%) as our comparator. We estimated two outcomes: the relative reduction in the age-standardised cervical cancer incidence (population-level impact) and the number of cervical cancers averted per 100 000 doses (efficiency). FINDINGS Our model projected substantial reductions in cervical cancer incidence over 100 years with the two-dose schedule (79-86% depending on the country), compared with no vaccination. Projections for the 5-year extended schedule, in which the second dose is given only to girls previously vaccinated at age 9 years, were similar to the current two-dose schedule, unless vaccination coverage of the second dose is very low (reductions in cervical cancer incidence of 71-78% assuming 30% coverage at age 14 years among girls vaccinated at age 9 years). However, when the dose at age 14 years is given to girls irrespective of vaccination status and assuming high vaccination coverage, the model projected a substantially greater reduction in cervical cancer incidence compared with the current two-dose schedule (reductions in cervical cancer incidence of 86-93% assuming 70% coverage at age 14 years, irrespective of vaccination status). Efficiency of the extended schedule was greater than the two-dose schedule, even with a drop in vaccination coverage. INTERPRETATION The three concerns are unlikely to have a substantial effect on the population-level impact of extended dose schedules. Hence, extended dose schedules will likely provide similar cervical cancer reductions as two-dose schedules, while reducing the number of doses required in the short-term, providing a more efficient use of scarce resources, and offering a 5-year time window to reassess the necessity of the second dose. FUNDING WHO, Canadian Institute of Health Research Foundation, Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, and Bill & Melinda Gates Foundation.
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Affiliation(s)
- Élodie Bénard
- Département de médecine sociale et préventive, Université Laval, QC, Canada,Centre de recherche du CHU de Québec, Université Laval, QC, Canada
| | - Mélanie Drolet
- Centre de recherche du CHU de Québec, Université Laval, QC, Canada
| | | | - Mark Jit
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK,School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kiesha Prem
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Marie-Claude Boily
- Département de médecine sociale et préventive, Université Laval, QC, Canada,Centre de recherche du CHU de Québec, Université Laval, QC, Canada,MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Marc Brisson
- Département de médecine sociale et préventive, Université Laval, QC, Canada; Centre de recherche du CHU de Québec, Université Laval, QC, Canada; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
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17
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Jansen EEL, de Kok IMCM, Kaljouw S, Demirel E, de Koning HJ, Hontelez JAC. Rapid elimination of cervical cancer while maintaining the harms and benefits ratio of cervical cancer screening: a modelling study. BMC Med 2022; 20:433. [PMID: 36352410 PMCID: PMC9645325 DOI: 10.1186/s12916-022-02631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) vaccination and intensifying screening expedite cervical cancer (CC) elimination, yet also deteriorate the balance between harms and benefits of screening. We aimed to find screening strategies that eliminate CC rapidly but maintain an acceptable harms-benefits ratio of screening. METHODS Two microsimulation models (STDSIM and MISCAN) were applied to simulate HPV transmission and CC screening for the Dutch female population between 2022 and 2100. We estimated the CC elimination year and harms-benefits ratios of screening for 228 unique scenarios varying in vaccination (coverage and vaccine type) and screening (coverage and number of lifetime invitations in vaccinated cohorts). The acceptable harms-benefits ratio was defined as the number of women needed to refer (NNR) to prevent one CC death under the current programme for unvaccinated cohorts (82.17). RESULTS Under current vaccination conditions (bivalent vaccine, 55% coverage in girls, 27.5% coverage in boys), maintaining current screening conditions is projected to eliminate CC by 2042, but increases the present NNR with 41%. Reducing the number of lifetime screens from presently five to three and increasing screening coverage (61% to 70%) would prevent an increase in harms and only delay elimination by 1 year. Scaling vaccination coverage to 90% in boys and girls with the nonavalent vaccine is estimated to eliminate CC by 2040 under current screening conditions, but exceeds the acceptable NNR with 23%. Here, changing from five to two lifetime screens would keep the NNR acceptable without delaying CC elimination. CONCLUSIONS De-intensifying CC screening in vaccinated cohorts leads to little or no delay in CC elimination while it substantially reduces the harms of screening. Therefore, de-intensifying CC screening in vaccinated cohorts should be considered to ensure acceptable harms-benefits ratios on the road to CC elimination.
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Affiliation(s)
- Erik E L Jansen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Inge M C M de Kok
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sylvia Kaljouw
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erhan Demirel
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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18
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Man I, Georges D, de Carvalho TM, Ray Saraswati L, Bhandari P, Kataria I, Siddiqui M, Muwonge R, Lucas E, Berkhof J, Sankaranarayanan R, Bogaards JA, Basu P, Baussano I. Evidence-based impact projections of single-dose human papillomavirus vaccination in India: a modelling study. Lancet Oncol 2022; 23:1419-1429. [PMID: 36174583 PMCID: PMC9622421 DOI: 10.1016/s1470-2045(22)00543-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the high burden of cervical cancer, access to preventive measures remains low in India. A single-dose immunisation schedule could facilitate the scale-up of human papillomavirus (HPV) vaccination, contributing to global elimination of cervical cancer. We projected the effect of single-dose quadrivalent HPV vaccination in India in comparison with no vaccination or to a two-dose schedule. METHODS In this modelling study, we adapted an HPV transmission model (EpiMetHeos) to Indian data on sexual behaviour (from the Demographic and Health Survey and the Indian National AIDS Control Organisation), HPV prevalence data (from two local surveys, from the states of Tamil Nadu and West Bengal), and cervical cancer incidence data (from Cancer Incidence in Five Continents for the period 2008-12 [volume XI], and the Indian National Centre for Disease Informatics and Research for the period 2012-16). Using the model, we projected the nationwide and state-specific effect of HPV vaccination on HPV prevalence and cervical cancer incidence, and lifetime risk of cervical cancer, for 100 years after the introduction of vaccination or in the first 50 vaccinated birth cohorts. Projections were derived under a two-dose vaccination scenario assuming life-long protection and under a single-dose vaccination scenario with protection duration assumptions derived from International Agency for Research on Cancer (IARC) India vaccine trial data, in combination with different vaccination coverages and catch-up vaccination age ranges. We used two thresholds to define cervical cancer elimination: an age-standardised incidence rate of less than 4 cases per 100 000 woman-years, and standardised lifetime risk of less than 250 cases per 100 000 women born. FINDINGS Assuming vaccination in girls aged 10 years, with 90% coverage, and life-long protection by two-dose or single-dose schedule, HPV vaccination could reduce the prevalence of HPV16 and HPV18 infection by 97% (80% UI 96-99) in 50 years, and the lifetime risk of cervical cancer by 71-78% from 1067 cases per 100 000 women born under a no vaccination scenario to 311 (80% UI 284-339) cases per 100 000 women born in the short term and 233 (219-252) cases per 100 000 women born in the long term in vaccinated cohorts. Under this scenario, we projected that the age-standardised incidence rate threshold for elimination could be met across India (range across Indian states: 1·6 cases [80% UI 1·5-1·7] to 4·0 cases [3·8-4·4] per 100 000 woman-years), while the complementary threshold based on standardised lifetime risk was attainable in 17 (68%) of 25 states, but not nationwide (range across Indian states: 207 cases [80% UI 194-223] to 477 cases [447-514] per 100 000 women born). Under the considered assumptions of waning vaccine protection, single-dose vaccination was projected to have a 21-100% higher per-dose efficiency than two-dose vaccination. Single-dose vaccination with catch-up for girls and women aged 11-20 years was more impactful than two-dose vaccination without catch-up, with reduction of 39-65% versus 38% in lifetime risk of cervical cancer across the ten catch-up birth cohorts and the first ten routine vaccination birth cohorts. INTERPRETATION Our evidence-based projections suggest that scaling up cervical cancer prevention through single-dose HPV vaccination could substantially reduce cervical cancer burden in India. FUNDING The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Irene Man
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France.
| | - Damien Georges
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Tiago M de Carvalho
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, Netherlands; Amsterdam Public Health, Amsterdam, Netherlands
| | | | | | - Ishu Kataria
- Center for Global Noncommunicable Diseases, RTI International, New Delhi, India
| | | | - Richard Muwonge
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Eric Lucas
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Johannes Berkhof
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, Netherlands; Amsterdam Public Health, Amsterdam, Netherlands
| | | | - Johannes A Bogaards
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, Netherlands; Amsterdam Public Health, Amsterdam, Netherlands
| | - Partha Basu
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Iacopo Baussano
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
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19
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Iskandar R, Taghavi K, Low N, Bramer WM, Egger M, Rohner E. Mathematical Models for Evaluating Effectiveness and Cost-Effectiveness of Cervical Cancer Control Policies in Populations Including Women Living With Human Immunodeficiency Virus: A Scoping Review. Value Health Reg Issues 2022; 32:39-46. [PMID: 36063639 PMCID: PMC9979336 DOI: 10.1016/j.vhri.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/07/2022] [Accepted: 07/23/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Mathematical modeling is increasingly used to inform cervical cancer control policies, and model-based evaluations of such policies in women living with human immunodeficiency virus (HIV) are an emerging research area. We did a scoping review of published literature to identify research gaps and inform future work in this field. METHODS We systematically searched literature up to April 2022 and included mathematical modeling studies evaluating the effectiveness or cost-effectiveness of cervical cancer prevention strategies in populations including women living with HIV. We extracted information on prevention strategies and modeling approaches. RESULTS We screened 1504 records and included 22 studies, almost half of which focused on South Africa. We found substantial between-study heterogeneity in terms of strategies assessed and modeling approaches used. Fourteen studies evaluated cervical cancer screening strategies, 7 studies assessed human papillomavirus vaccination (with or without screening), and 1 study evaluated the impact of HIV control measures on cervical cancer incidence and mortality. Thirteen conducted cost-effectiveness analyses. Markov cohort state-transition models were used most commonly (n = 12). Most studies (n = 17) modeled the effect of HIV by creating HIV-related health states. Thirteen studies performed model calibration, but 11 did not report the calibration methods used. Only 1 study stated that model code was available upon request. CONCLUSIONS Few model-based evaluations of cervical cancer control strategies have specifically considered women living with HIV. Improvements in model transparency, by sharing information and making model code publicly available, could facilitate the utility of these evaluations for other high disease-burden countries, where they are needed for assisting policy makers.
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Affiliation(s)
- Rowan Iskandar
- Center of Excellence in Decision-Analytic Modeling and Health Economics Research, sitem-insel, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Katayoun Taghavi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Wichor M Bramer
- Medical Library, Erasmus MC, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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20
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Herrick T, Thomson KA, Shin M, Gannon S, Tsu V, de Sanjosé S. Acting on the call for cervical cancer elimination: Planning tools for low- and middle- income countries to increase the coverage and effectiveness of screening and treatment. BMC Health Serv Res 2022; 22:1246. [PMID: 36241993 PMCID: PMC9563118 DOI: 10.1186/s12913-022-08423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Accessible planning tools tailored for low-and middle-income countries can assist decision makers in comparing implementation of different cervical cancer screening approaches and treatment delivery scenarios in settings with high cervical cancer burden. Methods The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and compare the accuracy of screening approaches, what treatment equipment to procure, and how best to deploy treatment equipment in a given country. The CPPT compares four screening approaches: 1) visual inspection with acetic acid (VIA), 2) HPV testing, 3) HPV testing followed by a VIA triage, and 4) HPV testing followed by an enhanced triage test. Accuracy of screening outcomes (e.g., true positives, false positives) is based on published sensitivity and specificity of tests to detect cervical precancerous lesions. The CPPT compares five scenarios for deploying ablative treatment equipment: 1) cervical precancer equipment at every location a woman is screened (single visit approach), 2) equipment only at a hospital level, 3) a single unit of equipment in each district, 4) allowing two districts to share a single unit of equipment, and 5) equipment placed at select district hospitals paired with mobile outreach. Users can customize the CPPT by adjusting pre-populated baseline values and assumptions, including population estimates, screening age range, screening frequency, HPV and HIV prevalence, supply costs, and health facility details. Results The CPPT generates data tables and graphs that compare the results of implementing each of the four screening and five treatment scenarios disaggregated by HIV status. Outputs include the number and outcomes of women screened, cost of each screening approach, provider time and cost saved by implementing self-sampling for HPV testing, number of women treated, treatment equipment needed by type, and the financial and economic costs for each equipment deployment scenario. Conclusion The CPPT provides practical information and data to compare tradeoffs of patient access and screening accuracy as well as efficient utilization of equipment, skilled personnel, and financial resources. Country decision makers can use outputs from the CPPT to guide the scale-up of cervical cancer screening and treatment while optimizing limited resources.
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Affiliation(s)
- Tara Herrick
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA.
| | - Kerry A Thomson
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA.
| | - Michelle Shin
- Department of Global Health, University of Washington, Seattle, USA
| | - Sarah Gannon
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA
| | - Vivien Tsu
- Department of Global Health, University of Washington, Seattle, USA
| | - Silvia de Sanjosé
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA
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21
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Mello ALDN, Zancan P. Isoquinolines alkaloids and cancer metabolism: Pathways and targets to novel chemotherapy. Chem Biol Drug Des 2022; 99:944-956. [PMID: 35322534 DOI: 10.1111/cbdd.14043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/15/2022] [Accepted: 03/20/2022] [Indexed: 12/24/2022]
Abstract
Cancer is one of the main causes of death in the world. This is a complex disease where the development of resistance to chemotherapy is frequent driving the search for new anticancer compounds. In this sense, isoquinolines have gained attention in the past few years. This review aims to highlight the new advances related to the use of isoquinolines compounds against cancer cells, and we point out targets for their anti-tumor action. Isoquinolines are compounds found in plants that are important for their protection. In cancer, many representatives of this class of compounds have demonstrated their efficacy against cancer by acting on cancer metabolism, such as triggering cell death, reducing pro-survival protein expression, inducing ROS production, inhibiting pro-survival cell signaling pathways, among other effects. The mechanisms triggered by isoquinolines in cancer cells represent robust anticancer strategies, which support that this class of compounds are strong candidates for cancer treatment.
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Affiliation(s)
- Angélica Lauria do Nascimento Mello
- Laboratório de Oncobiologia Molecular (LabOMol), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Zancan
- Laboratório de Oncobiologia Molecular (LabOMol), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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22
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Keane A, Ng CW, Simms KT, Nguyen D, Woo YL, Saville M, Canfell K. The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost-effectiveness of human papillomavirus screening with self-collection and digital registry support. Int J Cancer 2021; 149:1997-2009. [PMID: 34363620 PMCID: PMC9291320 DOI: 10.1002/ijc.33759] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/06/2021] [Accepted: 07/27/2021] [Indexed: 11/19/2022]
Abstract
The WHO has launched a global strategy to eliminate cervical cancer through the scale‐up of human papillomavirus (HPV) vaccination, cervical screening, and cervical cancer treatment. Malaysia has achieved high‐coverage HPV vaccination since 2010, but coverage of the existing cytology‐based program remains low. Pilot studies found HPV self‐sampling was acceptable and effective, with high follow‐up rates when a digital registry was used, and recently the Malaysian Government announced plans for a national HPV‐based screening program. We therefore evaluated the impact of primary HPV screening with self‐collection in Malaysia in the context of Malaysia's existing vaccination program. We used the “Policy1‐Cervix” modeling platform to assess health outcomes, cost‐effectiveness, resource use and cervical cancer elimination timing (the year when cervical cancer rates reach four cases per 100 000 women) of implementing primary HPV testing with self‐collection, assuming 70% routine‐screening coverage could be achieved. Based on available data, we assumed that compliance with follow‐up was 90% when a digital registry was used, but that compliance with follow‐up would be 50‐75% without the use of a digital registry. We found that the current vaccination program would prevent 27 000 to 32 200 cervical cancer cases and 11 700 to 14 000 deaths by 2070. HPV testing with a digital registry was cost‐effective (CER = $US 6953‐7549 < $US 11 373[<1×GDP per capita]) and could prevent an additional 15 900 to 17 800 cases and 9700 to 10 600 deaths by 2070, expediting national elimination by 11 to 20 years, to 2055 to 2059. If HPV screening were implemented without a digital registry, there would be 1800 to 4900 fewer deaths averted by 2070 and the program would be less cost‐effective. These results underline the importance of HPV testing as a key elimination pillar in Malaysia.
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Affiliation(s)
- Adam Keane
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chiu Wan Ng
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kate T Simms
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Diep Nguyen
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Yin Ling Woo
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Karen Canfell
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, Faculty of Medicine, UNSW, Sydney, Australia
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23
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Zawadzki RS, Gong CL, Cho SK, Schnitzer JE, Zawadzki NK, Hay JW, Drabo EF. Where Do We Go From Here? A Framework for Using Susceptible-Infectious-Recovered Models for Policy Making in Emerging Infectious Diseases. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:917-924. [PMID: 34243834 PMCID: PMC8110035 DOI: 10.1016/j.jval.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Throughout the coronavirus disease 2019 pandemic, susceptible-infectious-recovered (SIR) modeling has been the preeminent modeling method to inform policy making worldwide. Nevertheless, the usefulness of such models has been subject to controversy. An evolution in the epidemiological modeling field is urgently needed, beginning with an agreed-upon set of modeling standards for policy recommendations. The objective of this article is to propose a set of modeling standards to support policy decision making. METHODS We identify and describe 5 broad standards: transparency, heterogeneity, calibration and validation, cost-benefit analysis, and model obsolescence and recalibration. We give methodological recommendations and provide examples in the literature that employ these standards well. We also develop and demonstrate a modeling practices checklist using existing coronavirus disease 2019 literature that can be employed by readers, authors, and reviewers to evaluate and compare policy modeling literature along our formulated standards. RESULTS We graded 16 articles using our checklist. On average, the articles met 6.81 of our 19 categories (36.7%). No articles contained any cost-benefit analyses and few were adequately transparent. CONCLUSIONS There is significant room for improvement in modeling pandemic policy. Issues often arise from a lack of transparency, poor modeling assumptions, lack of a system-wide perspective in modeling, and lack of flexibility in the academic system to rapidly iterate modeling as new information becomes available. In anticipation of future challenges, we encourage the modeling community at large to contribute toward the refinement and consensus of a shared set of standards for infectious disease policy modeling.
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Affiliation(s)
- Roy S Zawadzki
- Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Cynthia L Gong
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Sang K Cho
- College of Pharmacy, University of Houston, Houston, TX, USA
| | - Jan E Schnitzer
- Proteogenomics Research Institute for Systems Medicine (PRISM), San Diego, CA, USA
| | - Nadine K Zawadzki
- Schaeffer Center for Health Policy & Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Joel W Hay
- Schaeffer Center for Health Policy & Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Emmanuel F Drabo
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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24
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Devine A, Vahanian A, Sawadogo B, Zan S, Bocoum FY, Kelly H, Gilham C, Nagot N, Ong JJ, Legood R, Meda N, Miners A, Mayaud P. Costs and cost-effectiveness of cervical cancer screening strategies in women living with HIV in Burkina Faso: The HPV in Africa Research Partnership (HARP) study. PLoS One 2021; 16:e0248832. [PMID: 33765011 PMCID: PMC7993811 DOI: 10.1371/journal.pone.0248832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction This study estimated the costs and incremental cost per case detected of screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) attending HIV clinics in Burkina Faso. Methods The direct healthcare provider costs of screening tests (visual inspection with acetic acid (VIA), VIA combined visual inspection with Lugol’s iodine (VIA/VILI), cytology and a rapid HPV DNA test (careHPV)) and confirmatory tests (colposcopy, directed biopsy and systematic four-quadrant (4Q) biopsy) were collected alongside the HPV in Africa Research Partnership (HARP) study. A model was developed for a hypothetical cohort of 1000 WLHIV using data on CIN2+ prevalence and the sensitivity of the screening tests. Costs are reported in USD (2019). Results The study enrolled 554 WLHIV with median age 36 years (inter-quartile range, 31–41) and CIN2+ prevalence of 5.8%. The average cost per screening test ranged from US$3.2 for VIA to US$24.8 for cytology. Compared to VIA alone, the incremental cost per CIN2+ case detected was US$48 for VIA/VILI and US$814 for careHPV. Despite higher costs, careHPV was more sensitive for CIN2+ cases detected compared to VIA/VILI (97% and 56%, respectively). The cost of colposcopy was US$6.6 per person while directed biopsy was US$33.0 and 4Q biopsy was US$48.0. Conclusion Depending on the willingness to pay for the detection of a case of cervical cancer, decision makers in Burkina Faso can consider a variety of cervical cancer screening strategies for WLHIV. While careHPV is more costly, it has the potential to be cost-effective depending on the willingness to pay threshold. Future research should explore the lifetime costs and benefits of cervical cancer screening to enable comparisons with interventions for other diseases.
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Affiliation(s)
- Angela Devine
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
- * E-mail:
| | - Alice Vahanian
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bernard Sawadogo
- Centre de Recherche Internationale pour la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Souleymane Zan
- Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Fadima Yaya Bocoum
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Helen Kelly
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Clare Gilham
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicolas Nagot
- Pathogenesis and control of chronic infections, INSERM, Etablissement Francais du Sang, University of Montpellier, Montpellier, France
| | - Jason J. Ong
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rosa Legood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicolas Meda
- Centre de Recherche Internationale pour la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Alec Miners
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philippe Mayaud
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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25
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Phua LC, Choi HCW, Wu J, Jit M, Low J, Ng K, Pearce F, Hall C, Abdul Aziz MI. Cost-effectiveness analysis of the nonavalent human papillomavirus vaccine for the prevention of cervical cancer in Singapore. Vaccine 2021; 39:2255-2263. [PMID: 33744050 DOI: 10.1016/j.vaccine.2021.03.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The nonavalent human papillomavirus (HPV) vaccine has been shown to extend protection against oncogenic HPV types 31/33/45/52/58 (HPV-OV) not covered by the bivalent and quadrivalent HPV vaccines. Besides its clinical benefit, evidence on the economic value of the nonavalent vaccine is required to inform local vaccination strategies and funding decisions. This study evaluated the cost-effectiveness of replacing the bivalent vaccine with the nonavalent vaccine in the national school-based HPV vaccination programme in Singapore. METHODS An existing age-structured dynamic transmission model coupled with stochastic individual-based simulations was adapted to project the health and economic impact of vaccinating 13-year-old girls with two doses of the nonavalent or bivalent HPV vaccines in Singapore. Direct costs (in Singapore dollars, S$) were obtained from public healthcare institutions in Singapore, while health state utilities were sourced from the literature. Incremental cost-effectiveness ratios (ICERs) were estimated over a lifetime horizon, from a healthcare system perspective. Probabilistic sensitivity analysis was performed to obtain the ICERs and corresponding variations across variable uncertainty. Particularly, this study tested the scenarios of lifelong and 20-year vaccine-induced protection, assumed 96.0% and 22.3% cross-protection against HPV-OV by nonavalent and bivalent vaccines respectively, and fixed vaccine prices per dose at S$188 for nonavalent and S$61.50 for bivalent vaccines. RESULTS Compared with the bivalent vaccine, the use of the nonavalent vaccine was associated with an ICER of S$61,629 per quality-adjusted life year gained in the base case. The result was robust across a range of plausible input values, and to assumptions regarding the duration of vaccine protection. CONCLUSION Given the high ICER, the nonavalent vaccine is unlikely to represent a cost-effective option compared with the bivalent vaccine for school-based HPV vaccination of 13-year old female students in Singapore. Substantial price reductions would be required to justify its inclusion in the school-based programme in the future.
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Affiliation(s)
- Lee Cheng Phua
- Agency for Care Effectiveness, Ministry of Health, Singapore
| | - Horace C W Choi
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Joseph Wu
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region; WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
| | - Mark Jit
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey Low
- Gynaecologic Oncology, National University Cancer Institute, National University Hospital, Singapore
| | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore
| | - Fiona Pearce
- Agency for Care Effectiveness, Ministry of Health, Singapore
| | - Cameron Hall
- Agency for Care Effectiveness, Ministry of Health, Singapore
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Kim JJ, Simms KT, Killen J, Smith MA, Burger EA, Sy S, Regan C, Canfell K. Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: A cost-effectiveness analysis. PLoS Med 2021; 18:e1003534. [PMID: 33705382 PMCID: PMC7951902 DOI: 10.1371/journal.pmed.1003534] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 01/07/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A nonavalent human papillomavirus (HPV) vaccine has been licensed for use in women and men up to age 45 years in the United States. The cost-effectiveness of HPV vaccination for women and men aged 30 to 45 years in the context of cervical cancer screening practice was evaluated to inform national guidelines. METHODS AND FINDINGS We utilized 2 independent HPV microsimulation models to evaluate the cost-effectiveness of extending the upper age limit of HPV vaccination in women (from age 26 years) and men (from age 21 years) up to age 30, 35, 40, or 45 years. The models were empirically calibrated to reflect the burden of HPV and related cancers in the US population and used standardized inputs regarding historical and future vaccination uptake, vaccine efficacy, cervical cancer screening, and costs. Disease outcomes included cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancers, as well as genital warts. Both models projected higher costs and greater health benefits as the upper age limit of HPV vaccination increased. Strategies of vaccinating females and males up to ages 30, 35, and 40 years were found to be less cost-effective than vaccinating up to age 45 years, which had an incremental cost-effectiveness ratio (ICER) greater than a commonly accepted upper threshold of $200,000 per quality-adjusted life year (QALY) gained. When including all HPV-related outcomes, the ICER for vaccinating up to age 45 years ranged from $315,700 to $440,600 per QALY gained. Assumptions regarding cervical screening compliance, vaccine costs, and the natural history of noncervical HPV-related cancers had major impacts on the cost-effectiveness of the vaccination strategies. Key limitations of the study were related to uncertainties in the data used to inform the models, including the timing of vaccine impact on noncervical cancers and vaccine efficacy at older ages. CONCLUSIONS Our results from 2 independent models suggest that HPV vaccination for adult women and men aged 30 to 45 years is unlikely to represent good value for money in the US.
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Affiliation(s)
- Jane J. Kim
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Kate T. Simms
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - James Killen
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia
| | - Megan A. Smith
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Emily A. Burger
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Stephen Sy
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Catherine Regan
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Karen Canfell
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
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Health economic evaluation of primary human papillomavirus screening in urban populations in China. Cancer Epidemiol 2020; 70:101861. [PMID: 33310688 DOI: 10.1016/j.canep.2020.101861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/02/2020] [Accepted: 11/15/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND On Nov 17, 2020, WHO launched a global initiative to accelerate the elimination of cervical cancer through the implementation of HPV vaccination, cervical cancer screening and treatment for precancer and cancer. China has the largest burden of cervical cancer in the world, but only has a national cervical cancer screening program in rural areas since 2009. Here, we aimed to evaluate the effectiveness and cost-effectiveness of cervical cancer screening in urban China, using Shenzhen City as an example. METHODS We use an extensively validated platform ('Policy1-Cervix'), calibrated to data from Shenzhen city and Guandong Province. We evaluated a range of strategies that have previously been implemented as pilot studies in China, or recommended as guidelines within China and globally, spanning primary HPV, cytology and co-testing strategies. We additionally considered alternate triaging methods, age ranges and screening intervals, resulting in 19 algorithms in total. RESULTS Of the 19 strategies considered, the most effective approach involved primary HPV testing. At 3- to 10-yearly intervals, primary HPV testing reduced the age-standardized cancer mortality rate by 37-71 %. The most cost-effective strategy was 5-yearly primary HPV testing with partial genotyping triage for ages 25-65, discharging to 10-yearly screening for low-risk women (ICER = US$7191/QALYS using 2018 costs; willingness-to-pay threshold<1xGDP [US$9771]). This strategy gave an incidence and mortality reduction of 56 % and 63 %, respectively. This remained the most cost-effective strategy under most conditions in sensitivity analysis. CONCLUSION Primary HPV testing would be cost-effective in Shenzhen and could more than halve cervical cancer incidence rates to 6 per 100,000 over the long term. In order to achieve rates below 4 per 100,000, the elimination threshold set by the World Health Organization, vaccination will likely also be necessary.
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Slayton RB, O’Hagan JJ, Barnes S, Rhea S, Hilscher R, Rubin M, Lofgren E, Singh B, Segre A, Paul P. Modeling Infectious Diseases in Healthcare Network (MInD-Healthcare) Framework for Describing and Reporting Multidrug-resistant Organism and Healthcare-Associated Infections Agent-based Modeling Methods. Clin Infect Dis 2020; 71:2527-2532. [PMID: 32155235 PMCID: PMC7871347 DOI: 10.1093/cid/ciaa234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/04/2020] [Indexed: 01/13/2023] Open
Abstract
Mathematical modeling of healthcare-associated infections and multidrug-resistant organisms improves our understanding of pathogen transmission dynamics and provides a framework for evaluating prevention strategies. One way of improving the communication among modelers is by providing a standardized way of describing and reporting models, thereby instilling confidence in the reproducibility and generalizability of such models. We updated the Overview, Design concepts, and Details protocol developed by Grimm et al [11] for describing agent-based models (ABMs) to better align with elements commonly included in healthcare-related ABMs. The Modeling Infectious Diseases in Healthcare Network (MInD-Healthcare) framework includes the following 9 key elements: (1) Purpose and scope; (2) Entities, state variables, and scales; (3) Initialization; (4) Process overview and scheduling; (5) Input data; (6) Agent interactions and organism transmission; (7) Stochasticity; (8) Submodels; and (9) Model verification, calibration, and validation. Our objective is that this framework will improve the quality of evidence generated utilizing these models.
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Affiliation(s)
- Rachel B. Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Justin J. O’Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sean Barnes
- Robert H. Smith School of Business, University of Maryland, College Park, MD, USA
| | - Sarah Rhea
- RTI International, Research Triangle Park, NC, USA
| | | | - Michael Rubin
- Division of Epidemiology, University of Utah School Medicine, Salt Lake City, Utah, USA
| | - Eric Lofgren
- Washington State University, Pullman, Washington, USA
| | - Brajendra Singh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alberto Segre
- Department of Computer Science, University of Iowa, Iowa City, Iowa, USA
| | - Prabasaj Paul
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Smith MA, Hall MT, Saville M, Brotherton JML, Simms KT, Lew JB, Bateson D, Skinner SR, Kelaher M, Canfell K. Could HPV Testing on Self-collected Samples Be Routinely Used in an Organized Cervical Screening Program? A Modeled Analysis. Cancer Epidemiol Biomarkers Prev 2020; 30:268-277. [PMID: 33219163 DOI: 10.1158/1055-9965.epi-20-0998] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/10/2020] [Accepted: 11/17/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cervical screening on self-collected samples has mainly been considered for targeted use in underscreened women. Updated evidence supports equivalent sensitivity of PCR-based human papillomavirus (HPV) testing on self-collected and clinician-collected samples. METHODS Using a well-established model, we compared the lifetime impact on cancer diagnoses and deaths resulting from cervical screening using self-collected samples only, with and without the existing restriction in Australia to women aged 30+ years and ≥2 years overdue, compared with the mainstream program of 5-yearly HPV screening on clinician-collected samples starting at 25 years of age. We conservatively assumed sensitivity of HPV testing on self-collected relative to clinician-collected samples was 0.98. Outcomes were estimated either in the context of HPV vaccination ("routinely vaccinated cohorts;" uptake as in Australia) or in the absence of HPV vaccination ("unvaccinated cohorts"). RESULTS In unvaccinated cohorts, the health benefits of increased participation from self-collection outweighed the worst case (2%) loss of relative test sensitivity even if only 15% of women, who would not otherwise attend, used it ("additional uptake"). In routinely vaccinated cohorts, population-wide self-collection could be marginally (0.2%-1.0%) less effective at 15% additional uptake but 6.2% to 12.4% more effective at 50% additional uptake. Most (56.6%-65.0%) of the loss in effectiveness in the restricted self-collection pathway in Australia results from the requirement to be 2 or more years overdue. CONCLUSIONS Even under pessimistic assumptions, any potential loss in test sensitivity from self-collection is likely outweighed by improved program effectiveness resulting from feasible levels of increased uptake. IMPACT Consideration could be given to offering self-collection more widely, potentially as an equal choice for women.See related commentary by Lim, p. 245.
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Affiliation(s)
- Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia. .,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Michaela T Hall
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.,School of Mathematics and Statistics, UNSW, Sydney, New South Wales, Australia
| | - Marion Saville
- VCS Foundation, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia M L Brotherton
- VCS Population Health, VCS Foundation, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Deborah Bateson
- Family Planning NSW, Sydney, New South Wales, Australia.,Discipline of Obstetrics, Gynaecology & Neonatology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - S Rachel Skinner
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,Children's Hospital Westmead, Westmead, New South Wales, Australia
| | - Margaret Kelaher
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, UNSW, Sydney, New South Wales, Australia
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Qendri V, Bogaards JA, Baussano I, Lazzarato F, Vänskä S, Berkhof J. The cost-effectiveness profile of sex-neutral HPV immunisation in European tender-based settings: a model-based assessment. Lancet Public Health 2020; 5:e592-e603. [PMID: 33120045 DOI: 10.1016/s2468-2667(20)30209-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND In many European countries, human papillomavirus (HPV) vaccine uptake among girls has remained below target levels, supporting the scope for vaccination of boys. We aimed to investigate if sex-neutral HPV vaccination can be considered cost-effective compared with girls-only vaccination at uptake levels equal to those among girls and under tender-based vaccination costs achieved throughout Europe. METHODS We investigated the cost-effectiveness of sex-neutral HPV vaccination in European tender-based settings. We applied a Bayesian synthesis framework for health economic evaluation to 11 countries (Austria, Belgium, Croatia, Estonia, Italy, Latvia, the Netherlands, Poland, Slovenia, Spain, and Sweden), accommodating country-specific information on key epidemiological and economic parameters, and on current HPV vaccination programmes. We used projections from three independently developed HPV transmission models to tailor region-specific herd effects. The main outcome measures in the comparison of sex-neutral with girls-only vaccination were cancer cases prevented and incremental cost-effectiveness ratios (ICERs), defined as the cost in international dollars (I$) per life-year gained. FINDINGS The total number of cancer cases to be prevented by vaccinating girls at currently realised vaccine uptake varied from 318 (95% CI 197-405) per cohort of 200 000 preadolescents (100 000 girls plus 100 000 boys) in Croatia (under 20% uptake of the 9-valent vaccine) to 1904 (1741-2101) in Estonia (under 70% uptake of the 9-valent vaccine). Vaccinating boys at equal coverage increased these respective numbers by 168 (95% CI 121-213) in Croatia and 467 (391-587) in Estonia. Sex-neutral vaccination was likely to be cost-effective, with ICERs of sex-neutral compared with girls-only vaccination varying from I$4300 per life-year gained in Latvia (95% credibility interval 3450-5160; 40% uptake) to I$25 720 per life-year gained in Spain (21 380-30 330; 80% uptake). At uniform 80% uptake, a favourable cost-effectiveness profile was retained for most of the countries investigated (Austria, Belgium, Italy, Latvia, the Netherlands, Slovenia, Spain, and Sweden). INTERPRETATION Sex-neutral HPV vaccination is economically attractive in European tender-based settings. However, tendering mechanisms need to ensure that vaccination of boys will remain cost-effective at high vaccine uptake rates. FUNDING European Commission 7th Framework Programme and WHO.
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Affiliation(s)
- Venetia Qendri
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands.
| | - Johannes A Bogaards
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands; Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | | | - Fulvio Lazzarato
- Unit of Cancer Epidemiology, AOU Cittá della Salute e della Scienza, Hospital of Turin, Turin, Italy
| | - Simopekka Vänskä
- Infectious Disease Control and Vaccination Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
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Zou Z, Fairley CK, Ong JJ, Hocking J, Canfell K, Ma X, Chow EPF, Xu X, Zhang L, Zhuang G. Domestic HPV vaccine price and economic returns for cervical cancer prevention in China: a cost-effectiveness analysis. LANCET GLOBAL HEALTH 2020; 8:e1335-e1344. [PMID: 32971056 DOI: 10.1016/s2214-109x(20)30277-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 05/25/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Coinciding with the release of the first Chinese domestic human papillomavirus (HPV) vaccine Cecolin in 2019, and the substantial advancements in cervical cancer screening technology, we aimed to evaluate the cost-effectiveness of the combined strategies of cervical cancer screening programmes and universal vaccination of girls (aged 9-14 years) with Cecolin in China. METHODS We did a cost-effectiveness analysis in China, in which we developed a Markov model of cervical cancer to evaluate the incremental cost-effectiveness ratios of 61 intervention strategies, including a combination of various screening methods at different frequencies with and without vaccination, and also vaccination alone, from a health-care system perspective. We did univariate and probabilistic sensitivity analyses to assess the robustness of the model's findings. FINDINGS Compared with no intervention, various combined screening and vaccination strategies would incur an additional cost of US$6 157 000-22 146 000 and result in 691-970 quality-adjusted life-years (QALYs) gained in a designated cohort of 100 000 girls aged 9-14 years over a lifetime. With a willingness-to-pay threshold of three times the Chinese per-capita gross domestic product (GDP), careHPV screening (a rapid HPV test) once every 5 years with vaccination would be the most cost-effective strategy with an incremental cost-effectiveness ratio of $21 799 per QALY compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier, and the probability of it being cost-effective (44%) outperformed other strategies. Strategies that combined screening and vaccination would be more cost-effective than screening alone strategies when the vaccination cost was less than $50 for two doses, even with a lower willingness-to-pay of one times the per-capita GDP. INTERPRETATION careHPV screening once every 5 years with vaccination is the most cost-effective strategy for cervical cancer prevention in China. A reduction in the domestic HPV vaccine price is necessary to ascertain a good economic return for the future vaccination programme. The findings provide important evidence that informs health policies for cervical cancer prevention in China. FUNDING National Natural Science Foundation of China.
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Affiliation(s)
- Zhuoru Zou
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Christopher K Fairley
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Monash University, Melbourne, VIC, Australia
| | - Jason J Ong
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Monash University, Melbourne, VIC, Australia
| | - Jane Hocking
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China; Sexual Health Unit, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, VIC, Australia
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia; School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Xiaomeng Ma
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Monash University, Melbourne, VIC, Australia; Sexual Health Unit, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, VIC, Australia
| | - Xianglong Xu
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Monash University, Melbourne, VIC, Australia
| | - Lei Zhang
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Monash University, Melbourne, VIC, Australia; Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China.
| | - Guihua Zhuang
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China.
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Burger EA, Smith MA, Killen J, Sy S, Simms KT, Canfell K, Kim JJ. Projected time to elimination of cervical cancer in the USA: a comparative modelling study. LANCET PUBLIC HEALTH 2020; 5:e213-e222. [DOI: 10.1016/s2468-2667(20)30006-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 12/27/2022]
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Impact of HPV vaccine hesitancy on cervical cancer in Japan: a modelling study. LANCET PUBLIC HEALTH 2020; 5:e223-e234. [DOI: 10.1016/s2468-2667(20)30010-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/16/2019] [Accepted: 01/17/2020] [Indexed: 12/13/2022]
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Malone C, Barnabas RV, Buist DSM, Tiro JA, Winer RL. Cost-effectiveness studies of HPV self-sampling: A systematic review. Prev Med 2020; 132:105953. [PMID: 31911163 PMCID: PMC7219564 DOI: 10.1016/j.ypmed.2019.105953] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
HPV self-sampling (HPV-SS) can increase cervical cancer screening participation by addressing barriers in high- and low- and middle-income settings. Successful implementation of HPV-SS programs will depend on understanding potential costs and health effects. Our objectives were to summarize the methods and results of published HPV-SS cost and cost-effectiveness studies, present implications of these results for HPV-SS program implementation, and identify knowledge gaps. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. One reviewer searched online databases for articles published through June 12, 2019, identified eligible studies, and extracted data; a second reviewer checked extracted data for accuracy. Eligible studies used an economic model to compare HPV-SS outreach strategies to standard-of-care tests. Of 16 eligible studies, 14 reported HPV-SS could be a cost-effective strategy. Studies differed in model type, HPV-SS delivery methods, triage strategies for positive results, and target populations. Most (9/16) modeled HPV-SS in European screening programs, 6/16 targeted women who were underscreened for cervical cancer, and 5/16 modeled HPV-SS in low- and middle-income countries. The most commonly identified driver of HPV-SS cost-effectiveness was the level of increase in cervical cancer screening attendance. Lower HPV-SS material and testing costs, higher sensitivity to detect cervical precancer, and longer duration of underscreening among HPV-SS users were also associated with increased cost-effectiveness. Future HPV-SS models in high-income settings should explore the effect of widespread vaccination and new triage strategies such as partial HPV genotyping. Knowledge gaps remain about the cost-effectiveness of HPV-SS in low- and middle-income settings.
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Affiliation(s)
- Colin Malone
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA.
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Box 359931, 325 9th Ave, Seattle, WA 98104, USA.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Rachel L Winer
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA; Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
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Brisson M, Kim JJ, Canfell K, Drolet M, Gingras G, Burger EA, Martin D, Simms KT, Bénard É, Boily MC, Sy S, Regan C, Keane A, Caruana M, Nguyen DTN, Smith MA, Laprise JF, Jit M, Alary M, Bray F, Fidarova E, Elsheikh F, Bloem PJN, Broutet N, Hutubessy R. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet 2020; 395:575-590. [PMID: 32007141 PMCID: PMC7043009 DOI: 10.1016/s0140-6736(20)30068-4] [Citation(s) in RCA: 375] [Impact Index Per Article: 93.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/20/2019] [Accepted: 01/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. METHODS The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. FINDINGS Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4-19·8) to 2·1 (2·0-2·6) cases per 100 000 women-years over the next century (89·4% [86·2-90·1] reduction), and to avert 61·0 million (60·5-63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6-1·6) cases per 100 000 women-years (96·7% [91·3-96·7] reduction) and averted an extra 12·1 million (9·5-13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination. INTERPRETATION Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden. FUNDING WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec-Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.
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Affiliation(s)
- Marc Brisson
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mélanie Drolet
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Guillaume Gingras
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Emily A Burger
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Dave Martin
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Élodie Bénard
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Marie-Claude Boily
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Catherine Regan
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Adam Keane
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Michael Caruana
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Diep T N Nguyen
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Mark Jit
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK; Modelling and Economics Unit, Public Health England, London, UK; School of Public Health, University of Hong Kong, Hong Kong, China
| | - Michel Alary
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; Institut national de santé publique du Québec, Québec, QC, Canada
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Elena Fidarova
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Fayad Elsheikh
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Paul J N Bloem
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, Burger EA, Martin D, Nguyen DTN, Bénard É, Sy S, Regan C, Drolet M, Gingras G, Laprise JF, Torode J, Smith MA, Fidarova E, Trapani D, Bray F, Ilbawi A, Broutet N, Hutubessy R. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet 2020; 395:591-603. [PMID: 32007142 PMCID: PMC7043006 DOI: 10.1016/s0140-6736(20)30157-4] [Citation(s) in RCA: 284] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/07/2020] [Accepted: 01/20/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100 000 women and includes 2030 triple-intervention coverage targets for scale-up of human papillomavirus (HPV) vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%. We assessed the impact of achieving the 90-70-90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. We also assessed the potential for the elimination initiative to support target 3.4 of the UN Sustainable Development Goals (SDGs)-a one-third reduction in premature mortality from non-communicable diseases by 2030. METHODS The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC) involves three independent, dynamic models of HPV infection, cervical carcinogenesis, screening, and precancer and invasive cancer treatment. Reductions in age-standardised rates of cervical cancer mortality in 78 low-income and lower-middle-income countries (LMICs) were estimated for three core scenarios: girls-only vaccination at age 9 years with catch-up for girls aged 10-14 years; girls-only vaccination plus once-lifetime screening and cancer treatment scale-up; and girls-only vaccination plus twice-lifetime screening and cancer treatment scale-up. Vaccination was assumed to provide 100% lifetime protection against infections with HPV types 16, 18, 31, 33, 45, 52, and 58, and to scale up to 90% coverage in 2020. Cervical screening involved HPV testing at age 35 years, or at ages 35 years and 45 years, with scale-up to 45% coverage by 2023, 70% by 2030, and 90% by 2045, and we assumed that 50% of women with invasive cervical cancer would receive appropriate surgery, radiotherapy, and chemotherapy by 2023, which would increase to 90% by 2030. We summarised results using the median (range) of model predictions. FINDINGS In 2020, the estimated cervical cancer mortality rate across all 78 LMICs was 13·2 (range 12·9-14·1) per 100 000 women. Compared to the status quo, by 2030, vaccination alone would have minimal impact on cervical cancer mortality, leading to a 0·1% (0·1-0·5) reduction, but additionally scaling up twice-lifetime screening and cancer treatment would reduce mortality by 34·2% (23·3-37·8), averting 300 000 (300 000-400 000) deaths by 2030 (with similar results for once-lifetime screening). By 2070, scaling up vaccination alone would reduce mortality by 61·7% (61·4-66·1), averting 4·8 million (4·1-4·8) deaths. By 2070, additionally scaling up screening and cancer treatment would reduce mortality by 88·9% (84·0-89·3), averting 13·3 million (13·1-13·6) deaths (with once-lifetime screening), or by 92·3% (88·4-93·0), averting 14·6 million (14·1-14·6) deaths (with twice-lifetime screening). By 2120, vaccination alone would reduce mortality by 89·5% (86·6-89·9), averting 45·8 million (44·7-46·4) deaths. By 2120, additionally scaling up screening and cancer treatment would reduce mortality by 97·9% (95·0-98·0), averting 60·8 million (60·2-61·2) deaths (with once-lifetime screening), or by 98·6% (96·5-98·6), averting 62·6 million (62·1-62·8) deaths (with twice-lifetime screening). With the WHO triple-intervention strategy, over the next 10 years, about half (48% [45-55]) of deaths averted would be in sub-Saharan Africa and almost a third (32% [29-34]) would be in South Asia; over the next 100 years, almost 90% of deaths averted would be in these regions. For premature deaths (age 30-69 years), the WHO triple-intervention strategy would result in rate reductions of 33·9% (24·4-37·9) by 2030, 96·2% (94·3-96·8) by 2070, and 98·6% (96·9-98·8) by 2120. INTERPRETATION These findings emphasise the importance of acting immediately on three fronts to scale up vaccination, screening, and treatment for pre-invasive and invasive cervical cancer. In the next 10 years, a one-third reduction in the rate of premature mortality from cervical cancer in LMICs is possible, contributing to the realisation of the 2030 UN SDGs. Over the next century, successful implementation of the WHO elimination strategy would reduce cervical cancer mortality by almost 99% and save more than 62 million women's lives. FUNDING WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Germany Federal Ministry of Health, National Health and Medical Research Council Australia, Centre for Research Excellence in Cervical Cancer Control, Canadian Institute of Health Research, Compute Canada, and Fonds de recherche du Québec-Santé.
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Affiliation(s)
- Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Jane J Kim
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Marc Brisson
- Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Adam Keane
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Michael Caruana
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Emily A Burger
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Dave Martin
- Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Diep T N Nguyen
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Élodie Bénard
- Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Stephen Sy
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Catherine Regan
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Mélanie Drolet
- Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Guillaume Gingras
- Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | | | - Julie Torode
- Union for International Cancer Control, Geneva, Switzerland
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Elena Fidarova
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Dario Trapani
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Andre Ilbawi
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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Campos NG, Alfaro K, Maza M, Sy S, Melendez M, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Alonzo TA, Castle PE, Felix JC, Cremer M, Kim JJ. The cost-effectiveness of human papillomavirus self-collection among cervical cancer screening non-attenders in El Salvador. Prev Med 2020; 131:105931. [PMID: 31765712 DOI: 10.1016/j.ypmed.2019.105931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/17/2023]
Abstract
Cervical cancer screening with human papillomavirus (HPV) DNA testing has been incorporated into El Salvador's national guidelines. The feasibility of home-based HPV self-collection among women who do not attend screening at the clinic (i.e., non-attenders) has been demonstrated, but cost-effectiveness has not been evaluated. Using cost and compliance data from El Salvador, we informed a mathematical microsimulation model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis from the societal perspective. We estimated the reduction in cervical cancer risk, lifetime cost per woman (2017 US$), life expectancy, and incremental cost-effectiveness ratio (ICER, 2017 US$ per year of life saved [YLS]) of a program with home-based self-collection of HPV (facilitated by health promoters) for the 18% of women reluctant to screen at the clinic. The model was calibrated to epidemiologic data from El Salvador. We evaluated health and economic outcomes of the self-collection intervention for women aged 30 to 59 years, alone and in concert with clinic-based HPV provider-collection. Home-based self-collection of HPV was projected to reduce population cervical cancer risk by 14% and cost $1210 per YLS compared to no screening. An integrated program reaching 99% coverage with both provider- and home-based self-collection of HPV reduced cancer risk by 74% (compared to no screening), and cost $1210 per YLS compared to provider-collection alone. Self-collection facilitated by health promoters is a cost-effective strategy for increasing screening uptake in El Salvador.
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Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA.
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Stephen Sy
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Mario Melendez
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Rachel Masch
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Montserrat Soler
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, USA
| | - Todd A Alonzo
- University of Southern California, 222 East Huntington Drive, Suite 100, Monrovia, CA 91016, USA
| | | | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, USA
| | - Miriam Cremer
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA; Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
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