Is expanding HPV vaccination programs to include school-aged boys likely to be value-for-money: a cost-utility analysis in a country with an existing school-girl program

Prevalence of human papillomavirus in head and neck cancer patients in India: a systematic review and meta-analysis

BACKGROUND

Human papillomavirus (HPV) is increasingly recognized as a significant risk factor in the development of head and neck cancers (HNCs), with varying prevalence and impact. This study aims to systematically review and analyze the prevalence of HPV in HNCs in India, providing insights into regional variations.

METHODS

A comprehensive literature search was carried out using PubMed, Embase, and Web of Science up to November 10, 2023. Inclusion criteria focused on original research reporting HPV-positive cases among HNC patients in India. We used Nested-Knowledge software, for screening, and data extraction. The modified Newcastle-Ottawa Scale was used for quality assessment of included studies. We pooled the prevalence of HPV among HNC patients and performed a random-effects model meta-analysis using R software (version 4.3).

RESULTS

The search yielded 33 studies, encompassing 4654 HNC patients. The pooled prevalence of HPV infection was found to be 33% (95% CI: 25.8-42.6), with notable heterogeneity (I² = 95%). Analysis of subgroups according to geographical location indicated varying prevalence rates. Specifically, the prevalence was 47% (95% CI: 32.2-62.4) in the eastern regions and 19.8% (95% CI: 10.8-33.4) in the western regions. No evidence of publication bias was detected.

CONCLUSION

The observed considerable regional disparities on the prevalence of HPV in HNC patients in India emphasizes the need for integrated HPV vaccination and screening programs in public health strategies. The findings underline the necessity for further research to explore regional variations and treatment responses in HPV-associated HNCs, considering the impact of factors such as tobacco use and the potential benefits of HPV vaccination.

Accounting for Adverse Events Following Immunization in Economic Evaluation: Systematic Review of Economic Evaluations of Pediatric Vaccines Against Pneumococcus, Rotavirus, Human Papillomavirus, Meningococcus and Measles-Mumps-Rubella-Varicella

OBJECTIVES

Economic evaluations of vaccines should accurately represent all relevant economic and health consequences of vaccination, including losses due to adverse events following immunization (AEFI). We investigated to what extent economic evaluations of pediatric vaccines account for AEFI, which methods are used to do so and whether inclusion of AEFI is associated with study characteristics and the vaccine's safety profile.

METHODS

A systematic literature search (MEDLINE, EMBASE, Cochrane Systematic Reviews and Trials, Database of the Centre for Reviews and Dissemination of the University of York, EconPapers, Paediatric Economic Database Evaluation, Tufts New England Cost-Effectiveness Analysis Registry, Tufts New England Global Health CEA, International Network of Agencies for Health Technology Assessment Database) was performed for economic evaluations published between 2014 and 29 April 2021 (date of search) pertaining to the five groups of pediatric vaccines licensed in Europe and the United States since 1998: the human papillomavirus (HPV) vaccines, the meningococcal vaccines (MCV), the measles-mumps-rubella-varicella (MMRV) combination vaccines, the pneumococcal conjugate vaccines (PCV) and the rotavirus vaccines (RV). Rates of accounting for AEFI were calculated, stratified by study characteristics (e.g., region, publication year, journal impact factor, level of industry involvement) and triangulated with the vaccine's safety profile (Advisory Committee on Immunization Practices [ACIP] recommendations and information on safety-related product label changes). The studies accounting for AEFI were analyzed in terms of the methods used to account for both cost and effect implications of AEFI.

RESULTS

We identified 112 economic evaluations, of which 28 (25%) accounted for AEFI. This proportion was significantly higher for MMRV (80%, four out of five evaluations), MCV (61%, 11 out of 18 evaluations) and RV (60%, nine out of 15 evaluations) compared to HPV (6%, three out of 53 evaluations) and PCV (5%, one out of 21 evaluations). No other study characteristics were associated with a study's likelihood of accounting for AEFI. Vaccines for which AEFI were more frequently accounted for also had a higher frequency of label changes and a higher level of attention to AEFI in ACIP recommendations. Nine studies accounted for both the cost and health implications of AEFI, 18 studies considered only costs and one only health outcomes. While the cost impact was usually estimated based on routine billing data, the adverse health impact of AEFI was usually estimated based on assumptions.

DISCUSSION

Although (mild) AEFI were demonstrated for all five studied vaccines, only a quarter of reviewed studies accounted for these, mostly in an incomplete and inaccurate manner. We provide guidance on which methods to use to better quantify the impact of AEFI on both costs and health outcomes. Policymakers should be aware that the impact of AEFI on cost-effectiveness is likely to be underestimated in the majority of economic evaluations.

HPV vaccine for men: Where to? (Review)

Human papillomavirus (HPV) is one of the most widespread human pathogens. For a long time, it was treated as an opportunistic infection, but it is in actuality one of the most dangerous carcinogens. It is responsible for numerous malignancies: Cervical, penile, oropharyngeal, vaginal, vulvar and some anal neoplasia. The need for a long-term solution was evident and thus HPV vaccines were proven to be a viable solution. Women and men who have sex with men, and young men are included in the vaccination template. A thorough review using PubMed and other databases that included articles on vaccine templates and targeted male patients was carried out. After review of all of the studies conducted on this subject, there is a clear benefit for HPV vaccination for men. Yet, even with the introduction of a national vaccine program for HPV for women and girls in most developed countries, regarding the male vaccine program, few countries have established a national program. Still, a gender-neutral vaccine remains a controversial issue. It is important to monitor the impact of HPV vaccine in men and the benefits that occur, to inform and spread the results in order to implement this vaccine program worldwide. Any monitoring plan regarding the HPV vaccination must include HPV prevalence, anogenital warts, and anal cancer. The largest impact regarding the range of this type of vaccine is the surveillance of the specific targeted population. HPV vaccine is a very efficient immunization method. Women are obviously the first target, but there are still many contradictions regarding men. Most of the reasons reside in the cost-efficiency aspect, but there is still great debate regarding the most efficient vaccine in the male population.

Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK

BACKGROUND

Human papillomavirus (HPV) is the most widespread sexually transmitted infection worldwide. It causes several health consequences, in particular accounting for the majority of cervical cancer cases in women. In the United Kingdom, a vaccination campaign targeting 12-year-old girls started in 2008; this campaign has been successful, with high uptake and reduced HPV prevalence observed in vaccinated cohorts. Recently, attention has focused on vaccinating both sexes, due to HPV-related diseases in males (particularly for high-risk men who have sex with men) and an equity argument over equalising levels of protection.

METHODS

We constructed an epidemiological model for HPV transmission in the UK, accounting for nine of the most common HPV strains. We complemented this with an economic model to determine the likely health outcomes (healthcare costs and quality-adjusted life years) for individuals from the epidemiological model. We then tested vaccination with the three HPV vaccines currently available, vaccinating either girls alone or both sexes. For each strategy we calculated the threshold price per vaccine dose, i.e. the maximum amount paid for the added health benefits of vaccination to be worth the cost of each vaccine dose. We calculated results at 3.5% discounting, and also 1.5%, to consider the long-term health effects of HPV infection.

RESULTS

At 3.5% discounting, continuing to vaccinate girls remains highly cost-effective compared to halting vaccination, with threshold dose prices of £56-£108. Vaccination of girls and boys is less cost-effective (£25-£53). Compared to vaccinating girls only, adding boys to the programme is not cost-effective, with negative threshold prices (-£6 to -£3) due to the costs of administration. All threshold prices increase when using 1.5% discounting, and adding boys becomes cost-effective (£36-£47). These results are contingent on the UK's high vaccine uptake; for lower uptake rates, adding boys (at the same uptake rate) becomes more cost effective.

CONCLUSIONS

Vaccinating girls is extremely cost-effective compared with no vaccination, vaccinating both sexes is less so. Adding boys to an already successful girls-only programme has a low cost-effectiveness, as males have high protection through herd immunity. If future health effects are weighted more heavily, threshold prices increase and vaccination becomes cost-effective.

Pricing of HPV vaccines in European tender-based settings

BACKGROUND

Vaccine price is one of the most influential parameters in economic evaluations of HPV vaccination programmes. Vaccine tendering is a cost-containment method widely used by national or regional health authorities, but information on tender-based HPV vaccine prices is scarce.

METHODS

Procurement notices and awards for the HPV vaccines, published from January 2007 until January 2018, were systematically retrieved from the online platform for public procurement in Europe. Information was collected from national or regional tenders organized for publicly funded preadolescent vaccination programmes against HPV. The influence of variables on the vaccine price was estimated by means of a mixed-effects model.

FINDINGS

Prices were collected from 178 procurements announced in 15 European countries. The average price per dose for the first-generation HPV vaccines decreased from €101.8 (95% CI 91.3-114) in 2007 to €28.4 (22.6-33.5) in 2017, whereas the average dose price of the 9-valent vaccine in 2016-2017 was €49.1 (38.0-66.8). Unit prices were, respectively, €7.5 (4.4-10.6) and €34.4 (27.4-41.4) higher for the 4-valent and 9-valent vaccines than for the 2-valent vaccine. Contract volume and duration, level of procurement (region or country), per capita GDP and number of offers received had a significant effect on vaccine price.

INTERPRETATION

HPV vaccine procurement is widely used across Europe. The fourfold decrease in the average tender-based prices compared to list prices confirms the potential of tendering as an efficient cost-containment strategy, thereby expanding the indications for cost-effective HPV vaccination to previously ineligible target groups.

Who Will Benefit From Expanding HPV Vaccination Programs to Boys?

Indications for human papillomavirus vaccination programs are expanding to boys. However, the rationale behind their inclusion is often not clear. Using a Bayesian synthesis framework and assuming equal vaccine coverage in both sexes, we assessed how the incremental number of cancer cases prevented and life-years gained from boys’ vaccination are distributed between women, heterosexual men, and men who have sex with men (MSM). Below 60% coverage, at least 50% of the gains from boys’ vaccination was attributable to cervical cancer prevention, whereas at 80% coverage, 50% of the gains was attributable to women, 15% to heterosexual men, and 35% to MSM. Above 90% coverage, 85–100% of the gains from boys’ vaccination was attributable to anal and oropharyngeal cancer prevention, mainly in MSM. Sex-neutral vaccination can be advocated on grounds of bolstering herd protection to women and directly protecting men, particularly MSM, with the clinical significance of either argument determined by the coverage.

Present challenges in cervical cancer prevention: Answers from cost-effectiveness analyses

Simulation models are commonly used to address important health policy issues that cannot be explored through experimental studies. These models are especially useful to determine a set of strategies that result in a good value for money (cost-effectiveness). Several mathematical models simulating the natural history of HPV and related diseases, especially cervical cancer, have been developed to calculate a relative effectiveness and cost-effectiveness of HPV vaccination and cervical cancer screening interventions. Virtually all cost-effectiveness analyses identify HPV vaccination programmes for preadolescent girls to be cost-effective, even for relatively low vaccination coverage rates. Routine vaccination of preadolescent girls is the primary target population for HPV vaccination as it shows to provide the greatest health impact. Cost-effectiveness analyses assessing other vaccine target groups are less conclusive. Adding additional age-cohorts would accelerate health benefits in some years, although cost-effectiveness becomes less favourable as age at vaccination increases. Including men in HPV vaccination programmes may be a less efficient strategy if done at the expense of female vaccination coverage for reducing the burden of HPV in the population. However, as the HPV vaccine price decreases, the cost-effectiveness of universal vaccination improves, becoming equally as efficient as female-only vaccination. Vaccine price is a decisive factor in the cost-effectiveness analyses. The lower the price, the greater the likelihood that vaccination groups other than the primary target would be considered cost-effective.

Should human papillomavirus vaccination target women over age 26, heterosexual men and men who have sex with men? A targeted literature review of cost-effectiveness

BACKGROUND

Human papillomavirus (HPV) vaccination for young women up to age 26 is highly cost-effective and has been implemented in 65 countries globally. We investigate the cost-effectiveness for HPV vaccination program in older women (age > 26 years), heterosexual men and men who have sex with men (MSM).

METHOD

A targeted literature review was conducted on PubMed for publications between January 2000 and January 2017 according to the PRISMA guidelines. We included English-language articles that reported the incremental cost-effectiveness ratio (ICER) of HPV vaccination programs for women over age 26, heterosexual men, and MSM and identified the underlying factors for its cost-effectiveness.

RESULTS

We included 36 relevant articles (six, 26 and four in older women, heterosexual men and MSM, respectively) from 17 countries (12 high-income (HICs) and five low- and middle-income (LMICs) countries). Most (4/6) studies in women over age 26 did not show cost-effectiveness ($65,000-192,000/QALY gained). Two showed cost-effectiveness, but only when the vaccine cost was largely subsidised and protection to non-naïve women was also considered. Sixteen of 26 studies in heterosexual men were cost-effective (ICER = $19,600-52,800/QALY gained in HICs; $49-5,860/QALY gained in LMICs). Nonavalent vaccines, a low vaccine price, fewer required doses, and a long vaccine protection period were key drivers for cost-effectiveness. In contrast, all four studies on MSM consistently reported cost-effectiveness (ICER = $15,000-$43,000/QALY gained), particularly in MSM age < 40 years and those who were HIV-positive. Countries' vaccination coverage did not significantly correlate with its per-capita Gross National Income.

CONCLUSION

Targeted HPV vaccination for MSM should be next priority in HPV prevention after having established a solid girls vaccination programme. Vaccination for heterosexual men should be considered when 2-dose 4vHPV/9vHPV vaccines become available with a reduced price, whereas targeted vaccination for women over age 26 is unlikely to be cost-effective.

Cost-effectiveness of sex-neutral HPV-vaccination in Sweden, accounting for herd-immunity and sexual behaviour

INTRODUCTION

The aim was to assess cost-effectiveness of expanding the Swedish HPV-vaccination program to include preadolescent boys, by comparing health-effects and costs of HPV-related disease, with a sex-neutral vaccination program versus only vaccinating girls.

METHODS

We used a dynamic compartmental model to simulate the burden of HPV16/18-related disease in Sweden, accounting for indirect effects of vaccination through herd-immunity. The model accounted for sexual behaviour, such as age preferences and men who have sex with men. The main outcome was number of individuals with HPV-related cancers (cervical, genital, anal and oropharyngeal cancer) and cervical intraepithelial neoplasia (CIN). Costs included in the analysis were those incurred when treating HPV-related cancer and CIN, production losses during sick-leave, and acquisition and administration of vaccine. Health effects were measured as quality-adjusted life years (QALY). The time horizon was set to 100 years, and both effects and costs were discounted by 3% annually. Health effects and costs were accumulated over the time horizon and used to create an incremental cost-effectiveness ratio.

RESULTS

A sex-neutral vaccination program would reduce HPV-related cancer and CIN, both due to direct effects among vaccinated as well as through herd-immunity, further decreasing HPV-related cancer burden annually by around 60 cases among men and women respectively in steady-state. The cost per gained QALY was estimated to 40,000 euro. Applying the procurement price of 2017, sex-neutral vaccination was dominant.

CONCLUSION

Introducing a sex-neutral HPV-vaccination program would be good value for money also in Sweden where there this 80% coverage in the current HPV-vaccination program for preadolescent girls. The cost-effectiveness of a sex-neutral program is highly dependent on the price of the vaccine, the lower the price the more favourable it is to also vaccinate boys.

Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review

INTRODUCTION

Vaccine herd effects are the indirect protection that vaccinated persons provide to those who remain susceptible to infection, due to the reduced transmission of infections. Herd effects have been an important part of the discourse on how to best implement human papillomavirus (HPV) vaccines and prevent HPV-related diseases.

AREAS COVERED

In this paper, we review the theory of HPV vaccine herd effects derived from mathematical models, give an account of observed HPV vaccine herd effects worldwide, and examine the implications of vaccine herd effects for future cervical cancer screening efforts.

EXPERT COMMENTARY

HPV vaccine herd effects improve the cost-effectiveness of vaccinating preadolescent girls, but contribute to making gender-neutral vaccination less economically efficient. Vaccination coverage and sexual mixing patterns by age are strong determinants of herd effects. Many countries worldwide are starting to observe reductions in HPV-related outcomes likely attributable to herd effects, most notably declining anogenital warts in young men, and declining HPV-16/18 infection prevalence in young unvaccinated women. Policy makers making recommendations for cervical cancer screening will have to consider HPV vaccination coverage and herd effects, as these will affect the positive predictive value of screening and the risk of cervical cancer in unvaccinated women.

Using Facebook to Recruit Young Australian Men Into a Cross-Sectional Human Papillomavirus Study

Background

Young men can be difficult to engage in health research using traditional methods of recruitment. Social networking sites are increasingly being used to recruit participants into health research, due to their cost effectiveness, overall generalizability, and wide reach.

Objective

The aim of this study was to determine the feasibility of using Facebook to recruit young Australian men into a human papillomavirus (HPV) prevalence study.

Methods

We recruited male permanent residents of Australia, aged 18 to 35 years, into the HPV in Young Males (HYM) study through targeted advertising placed on Facebook. Consenting participants completed an online questionnaire and provided a self-collected penile swab for HPV DNA detection and genotyping. We compared sociodemographic characteristics of the study population with those of the general Australian male population, based on Australian 2011 census data.

Results

Between February 2015 and February 2017, targeted Facebook advertisements reached 1,523,239 men, resulting in 41,811 clicks through to the study website, with 1072 (2.56%) converting to lodgment of an expression of interest. Of these, 681 (63.53%) provided written informed consent and 535 (78.6% of recruited participants) completed all the study requirements. Reasons for participating in the study included altruism, past history of HPV, gaining more knowledge about HPV or the vaccine, working in the health industry, and the monetary compensation. The average advertising cost per completed study participant was Aus $48. Compared with the census population, HYM study participants were more likely to be Australian born (P<.001), be from Victoria (P=.003) or the Australian Capital Territory (P=.004), reside in a major city (P<.001), and have completed undergraduate (P<.001) or postgraduate education (P<.001). HYM study participants were less likely to report being a current smoker (P=.03), but were more likely to identify as bisexual or homosexual (294/529, 55.6%, P<.001), than the general population.

Conclusions

Using Facebook is a feasible and efficient strategy for the recruitment of men from across Australia for HPV testing. This method could be used for monitoring the impact of HPV vaccination. Additional targeting may achieve a sample that is broadly demographically representative of the Australian population. Future research should explore how the sexual risk behavior characteristics of populations recruited through Facebook compare with those of traditional recruitment methods.

Inclusion of the value of herd immunity in economic evaluations of vaccines. A systematic review of methods used

OBJECTIVE

The objectives of this review were to identify vaccine economic evaluations that include herd immunity and describe the methodological approaches used.

METHODS

We used Kim and Goldie's search strategy from a systematic review (1976-2007) of modelling approaches used in vaccine economic evaluations and additionally searched PubMed/MEDLINE and Embase for 2007-2015. Studies were classified according to modelling approach used. Methods for estimating herd immunity effects were described, in particular for the static models.

RESULTS

We identified 625 economic evaluations of vaccines against human-transmissible diseases from 1976 to 2015. Of these, 172 (28%) included herd immunity. While 4% of studies included herd immunity in 2001, 53% of those published in 2015 did this. Pneumococcal, human papilloma and rotavirus vaccines represented the majority of studies (63%) considering herd immunity. Ninety-five of the 172 studies utilised a static model, 59 applied a dynamic model, eight a hybrid model and ten did not clearly state which method was used. Relatively crude methods and assumptions were used in the majority of the static model studies.

CONCLUSION

The proportion of economic evaluations using a dynamic model has increased in recent years. However, 55% of the included studies used a static model for estimating herd immunity. Values from a static model can only be considered reliable if high quality surveillance data are incorporated into the analysis. Without this, the results are questionable and they should only be included in sensitivity analysis.

A Multiple Streams analysis of the decisions to fund gender-neutral HPV vaccination in Canada

In Canada, the human papillomavirus (HPV) vaccine is licensed and recommended for females and males. Although all Canadian jurisdictions fund school-based HPV vaccine programs for girls, only six jurisdictions fund school-based HPV vaccination for boys. The research aimed to analyze the factors that underpin government decisions to fund HPV vaccine for boys using a theoretical policy model, Kingdon's Multiple Streams framework. This approach assesses policy development by examining three concurrent, but independent, streams that guide analysis: Problem Stream, Policy Stream, and Politics Stream. Analysis from the Problem Stream highlights that males are affected by HPV-related diseases and are involved in transmitting HPV infection to their sexual partners. Policy Stream analysis makes clear that while the inclusion of males in HPV vaccine programs is suitable, equitable, and acceptable; there is debate regarding cost-effectiveness. Politics Stream analysis identifies the perspectives of six different stakeholder groups and highlights the contribution of government officials at the provincial and territorial level. Kingdon's Multiple Streams framework helps clarify the opportunities and barriers for HPV vaccine policy change. This analysis identified that the interpretation of cost-effectiveness models and advocacy of stakeholders such as citizen-advocates and HPV-affected politicians have been particularly important in galvanizing policy change.

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

BACKGROUND

The protective (herd) effect of the selective vaccination of pubertal girls against human papillomavirus (HPV) implies a high probability that one of the two partners involved in intercourse is immunised, hence preventing the other from this sexually transmitted infection. The dynamic transmission models used to inform immunisation policy should include consideration of sexual behaviours and population mixing in order to demonstrate an ecological validity, whereby the scenarios modelled remain faithful to the real-life social and cultural context. The primary aim of this review is to test the ecological validity of the universal HPV vaccination cost-effectiveness modelling available in the published literature.

METHODS

The research protocol related to this systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016034145). Eight published economic evaluations were reviewed.

RESULTS

None of the studies showed due consideration of the complexities of human sexual behaviour and the impact this may have on the transmission of HPV.

DISCUSSION

Our findings indicate that all the included models might be affected by a different degree of ecological bias, which implies an inability to reflect the natural demographic and behavioural trends in their outcomes and, consequently, to accurately inform public healthcare policy. In particular, ecological bias have the effect to over-estimate the preference-based outcomes of selective immunisation. A relatively small (15-20%) over-estimation of quality-adjusted life years (QALYs) gained with selective immunisation programmes could induce a significant error in the estimate of cost-effectiveness of universal immunisation, by inflating its incremental cost effectiveness ratio (ICER) beyond the acceptability threshold. The results modelled here demonstrate the limitations of the cost-effectiveness studies for HPV vaccination, and highlight the concern that public healthcare policy might have been built upon incomplete studies.

Young Hungarian Students' Knowledge about HPV and Their Attitude Toward HPV Vaccination

(1) Background: Hungarys's estimated cervical cancer mortality was 6.9/100,000 in 2012, above the average of the EU27 countries (3.7/100,000) in the same year. Since 2014, the bivalent HPV vaccine has been offered to schoolgirls aged 12-13. (2) Methods: We conducted a cross-sectional study among 1022 high school seniors (492 girls, 530 boys) in 19 randomly selected schools in Budapest. Our anonymous questionnaire contained 54 items: basic socio-demographic data, knowledge about HPV infection/cervical cancer and HPV vaccination. (3) Results: 54.9% knew that HPV caused cervical cancer, and 52.1% identified HPV as an STD. Knowledge of risk factors such as promiscuity (46.9%) and early sexual activity (15.6%) was low, but higher than that of further HPV-induced diseases: genital warts (in females 9.9%, in males 9%), anal cancer (in females 2.2%, in males 1.9%), penile cancer (9.4%), and vulvar cancer (7.8%). A percentage of 14.6% feared getting infected, and 35.7% supported compulsory HPV vaccination. A percentage of 51.2% would have their future children vaccinated-significantly more girls than boys. (4) Conclusion: Our results support the findings of previous studies about young adults' HPV-related knowledge, which was poor, especially regarding pathologies in men. Despite the low level of awareness, the students' attitude was mostly positive when asked about vaccinating their future children.

Psychosocial determinants of parental human papillomavirus (HPV) vaccine decision-making for sons: Methodological challenges and initial results of a pan-Canadian longitudinal study

Background

HPV vaccination decision-making is a complex process that is influenced by multiple psychosocial determinants. Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand where Canadian parents were situated in the HPV vaccine decision-making process for their son, how they changed over time and which psychosocial determinants were relevant for this process.

Methods

We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline (T1, February 2014) and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.

Results

At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.

Conclusions

HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users.

The whole story: a systematic review of economic evaluations of HPV vaccination including non-cervical HPV-associated diseases

INTRODUCTION

Many economic evaluations of HPV vaccination have been published, but most have focused on the prevention of cervical disease as a primary health outcome. The cost-effectiveness of vaccination is likely to be underestimated if not all HPV-associated diseases are taken into account. In this review, we assess the influence of non-cervical HPV-associated diseases on the incremental cost-effectiveness ratio (ICER) of preadolescent HPV vaccination. Areas covered: We systematically searched the literature and identified 18 studies that included non-cervical diseases in the estimates of cost-effectiveness of HPV-vaccination. When taking other HPV-related diseases into account compared to not including such other diseases, the mean ICERs were 2.85 times more favorable for girls only vaccination and 3.89 times for gender neutral vaccination. Expert commentary: Including non-cervical diseases in economic evaluations of HPV vaccination programs makes it more likely that the ICER falls beneath accepted cost-effectiveness thresholds and therefore increases the scope for gender neutral vaccination.

Extending the Human Papillomavirus Vaccination Programme to Include Males in High-Income Countries: A Systematic Review of the Cost-Effectiveness Studies

BACKGROUND AND OBJECTIVES

Giving the human papillomavirus (HPV) vaccination to females has been shown to be cost-effective in most countries. The epidemiological evidence and economic burden of HPV-related diseases have gradually been shown to be gender neutral. Randomized clinical trials report high efficacy, immunogenicity and safety of the HPV vaccine in males aged 16-26 years. Some pioneering countries extended their HPV vaccination programme to include males, regardless of the cost-effectiveness analysis results. Nevertheless, decision makers need evidence provided by modelling and economic studies to justify the funding of mass vaccination. This systematic review aims to assess the cost-effectiveness of extending the HPV vaccination programme to include males living in high-income countries.

METHODS

A systematic review of the cost-effectiveness analyses of HPV vaccination in males was performed. Data were extracted and analysed using a checklist adapted from the Consolidated Health Economic Evaluation Reporting Standards Statement.

RESULTS

Seventeen studies and 12 underlying mathematical models were identified. Model filiation showed evolution in time from aggregate models (static and dynamic) to individual-based models. When considering the health outcomes HPV vaccines are licensed for, regardless of modelling approaches and assumptions, extending vaccinations to males is rarely found to be cost-effective in heterosexual populations. Cost-effectiveness ratios become more attractive when all HPV-related diseases are considered and when vaccine coverage in females is below 40%.

CONCLUSION

Targeted vaccination of men who have sex with men (MSM) seems to be the best cost-effectiveness option. The feasibility of this strategy is still an open question, since early identification of this specific population remains difficult.

Update on the new 9-valent vaccine for human papillomavirus prevention

OBJECTIVE

To provide family physicians with information on the efficacy, safety, public health effects, and cost-effectiveness of the 9-valent human papillomavirus (HPV) vaccine.

QUALITY OF EVIDENCE

Relevant publications in PubMed up to May 2015 were reviewed and analyzed. Most evidence cited is level I (randomized controlled trials and meta-analyses) or level II (cross-sectional, case-control, and epidemiologic studies). Government reports and recommendations are also referenced.

MAIN MESSAGE

The 9-valent HPV vaccine, which protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58, is safe and effective and will further reduce the incidence of HPV infection, as well as HPV-related cancers. It can also indirectly protect unvaccinated individuals through herd immunity. With an effective vaccination program, most cervical cancers can be prevented. Analyses show that the cost-effectiveness of the 9-valent HPV vaccine in female patients is comparable to the original quadrivalent HPV vaccine (which protects against HPV types 6, 11, 16, and 18) currently in use. However, the usefulness of vaccinating male patients with the 9-valent HPV vaccine needs further investigation.

CONCLUSION

The 9-valent HPV vaccine offers more protection against HPV than the quadrivalent HPV vaccine does and is as safe. Analysis of cost-effectiveness favours its use, at least in adolescent girls. Therefore, physicians should recommend the 9-valent HPV vaccine to patients instead of the quadrivalent HPV vaccine.

Prophylactic HPV vaccination: past, present, and future

Human papillomavirus (HPV) is the necessary cause of cervical cancer, the fourth most common cancer and cause of cancer-related death in females worldwide. HPV also causes anal, vaginal, vulvar, penile, and oropharyngeal cancer. Prophylactic HPV vaccines based on recombinantly expressed virus-like particles have been developed. Two first-generation, U.S. Food and Drug Administration (FDA)-approved vaccines prevent infections and disease caused by HPV16 and HPV18, the two HPV genotypes that cause approximately 70% of cervical cancer, and one of these vaccines also prevents HPV6 and HPV11, the two HPV genotypes that cause 90% of genital warts. A next-generation vaccine, recently approved by the U.S. FDA, targets HPV16, HPV18, and five additional HPV genotypes that together causes approximately 90% of cervical cancer as well as HPV6 and HPV11. In clinical trials, these vaccines have shown high levels of efficacy against disease and infections caused by the targeted HPV genotypes in adolescent females and males and older females. Data indicate population effectiveness, and therefore cost effectiveness, is highest in HPV-naive young females prior to becoming sexually active. Countries that implemented HPV vaccination before 2010 have already experienced decreases in population prevalence of targeted HPV genotypes and related anogenital diseases in women and via herd protection in heterosexual men. Importantly, after more than 100 million doses given worldwide, HPV vaccination has demonstrated an excellent safety profile. With demonstrated efficacy, cost-effectiveness, and safety, universal HPV vaccination of all young, adolescent women, and with available resources at least high-risk groups of men, should be a global health priority. Failure to do so will result in millions of women dying from avertable cervical cancers, especially in low- and middle-income countries, and many thousands of women and men dying from other HPV-related cancers.

Trends in head and neck cancers in England from 1995 to 2011 and projections up to 2025

BACKGROUND

The magnitude of the growing burden of oropharyngeal cancers (OPC), a sub-set of head and neck cancers (HNC), is unknown in England.

METHODS

Data were extracted from population-based cancer registries in England. The burden of HNC overall and by anatomic site was described from 1995 to 2011. Projections of future rates up to 2025 were estimated using flexible age-period-cohort modelling.

RESULTS

HNC increased by 59% between 1995 and 2011 in England. Projections indicate that the number of HNC cases will increase by 55% from 2011, totalling 11,748 new cases in 2025, ranking HNC as the sixth most common cancer. Of the anatomic sites, OPC is projected to account for 35% of HNC with the largest rate increase (annual percentage change, +7.3% for men and +6.2% for women between 2011 and 2025), predominantly affecting males <60years. This projected burden is equivalent to a 239% increase in number of OPC cases. Incidence of the oral cavity, salivary glands and palate are projected to rise at lower rates, whereas rates of the nasopharynx, hypopharynx and larynx remain relatively stable or decreasing.

CONCLUSION

The substantial recent and predicted future significant increase in OPC highlights the need for prioritising the provision of cancer services for the considerable burden of OPC patients and survivors and cancer control strategies.