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

An Umbrella Review of the Cost Effectiveness of Human Papillomavirus Vaccines

BACKGROUND AND OBJECTIVES

Although many systematic reviews for the human papillomavirus vaccines cost effectiveness have been published, they vary in perspectives, methods, and quality. We aimed to condense systematically such evidence to facilitate locating, processing, and learning, not only about the consensus of findings but also how models were built and their evolution over time and across settings.

METHODS

We conducted an umbrella review of cost-effectiveness studies for human papillomavirus vaccines using three databases (PubMed, Embase, and Cochrane). Based on their objectives, we classified studies into three groups (human papillomavirus vaccines cost effectiveness, model characteristics, and all-type vaccines, including human papillomavirus vaccines). We used the AMTAR2 to assess the quality of the studies. Additionally, we provided a summary of study findings, discussions, and evidence gaps in the literature.

RESULTS

Though most studies were critically low quality and had a low quality of reporting, the human papillomavirus vaccine was consistently cost effective in young girls and men who have sex with men. Stratified analyses by rated quality did not change the results. The quality assessment of the reviews did not necessarily reflect the quality assessment of underlying studies. The human papillomavirus vaccine models became more complex over time, capturing more realistic disease transmission with different human papillomavirus strains and herd immunities.

CONCLUSIONS

Additional evidence is needed for vulnerable populations (e.g., childhood cancer survivors) who are at high risk for human papillomavirus vaccine-related cancers and, therefore, may be more cost effective when receiving human papillomavirus vaccines. Quantifying human papillomavirus vaccine cost effectiveness via meta-analyses is feasible if investigators can increase the homogeneity of their populations.

A cross-sectional survey of parental attitudes towards Human papillomavirus vaccination exclusion categories in Brazil

BACKGROUND

In 1988, Brazil established a constitutional right to health and universal access to health care for all Brazilians through the creation of the Unified Health System (SUS). As part of its efforts to fulfill this right, the quadrivalent Human papillomavirus (HPV) vaccine was introduced into the national immunization program in 2014. The non-discriminatory provision of healthcare goods, facilities, and services is a fundamental part of the right to health. Yet HPV vaccination was limited to females aged 9-13, despite the universal nature of SUS and scientific support for the vaccination of males and older females. The purpose of this cross-sectional study was to describe parental attitudes regarding age- and gender-based HPV vaccination exclusions, as well as parental knowledge of HPV and the HPV vaccine.

METHODS

Data were gathered from parents with children aged 9-17 in a health post located in the municipality of Mauá (São Paulo, Brazil) through interviewer-administered questionnaires. We analyzed attitudes regarding HPV vaccination and its eligibility guidelines by comparing parents of HPV vaccine eligible and ineligible children.

RESULTS

In this low-income population, the majority of the 219 parents surveyed supported the inclusion of males and females over 13 into the HPV vaccination program; support for the non-discriminatory provision of the HPV vaccine was high among parents - especially if financially accessible. Additionally, there were high levels of knowledge and positive parental attitudes regarding HPV vaccination safety and efficacy among both parent groups suggesting information accessibility - a key component of the right to health and informed decision-making.

CONCLUSIONS

Support for the expansion of HPV vaccination for excluded populations exists, and is not based on current eligibility, or differential knowledge and attitudes about the vaccine. Moving forward, careful consideration of gender- based eligibility for vaccination, informed decision-making, and the importance of community participation in health policy development and implementation may be gleaned from the case of Brazil and beyond.