The Cost-Effectiveness of Quadrivalent Human Papillomavirus Vaccination in Indonesia

Detecting and genotyping high-risk human papillomavirus among male patients during 2015-2023 in Beijing, China

Few studies focused on human papillomavirus (HPV) in male patients. This study aimed to explore the detection rate and genotyping of HPV among male patients in Beijing to provide a reference for formulating prevention strategies for HPV infection. The cross-sectional study was conducted in Beijing Chaoyang Hospital from November 2015 to March 2023. It covered male patients from the urology and dermatology departments. Fifteen high-risk HPV genotypes were detected by the multiplex real-time polymerase chain reaction method. The overall detection rate of HPV was 25.19% (1288/5114, 95% confidence interval [CI] 24.00%-26.38%), of which the single infection rate was 16.99% (869/5114, 95% CI 15.97%-18.05%) and the co-infection rate was 8.19% (419/5114, 95% CI 7.46%-8.98%). The detection rate of HPV was 40.77% (521/1278), 35.58% (58/163), 32.69% (101/309), 31.91% (60/188), 12.63% (299/2367), and 32.35% (131/405) among male patients with balanitis, warts, rash, urethritis, prostatitis, and other urinary inflammation, respectively (P < 0.001). The top five HPV genotypes were HPV-52, HPV-58, HPV-16, HPV-51, and HPV-66. After the first positive HPV test, the proportion of male patients who turned negative was 22.47% within 3 months, 26.40% within 3-6 months, 24.72% within 6-12 months, 17.98% within 12-24 months, and 8.43% more than 24 months. The detection rate of HPV was high among male patients from the urology and dermatology departments in Beijing, which should be considered to develop HPV vaccines with better prevention effects.

Exploring Indonesian Primary Schoolgirls' Experiences of School-based HPV Vaccination, Knowledge of HPV Risks and Prevention, and Preferences for Cervical Cancer Education

OBJECTIVE

In 2016, Indonesia introduced its Human Papillomavirus (HPV) vaccination demonstration program for girls in grades 5 and 6 of primary school, to reduce cervical cancer (CC) burden in selected provinces and test the viability of nationwide vaccination. This study explored schoolgirls' experience of school-based HPV vaccination, their knowledge of HPV and HPV vaccination, and their preferences for cervical cancer (CC) education.

METHODS

An online survey was conducted with schoolgirls who experienced HPV vaccination between 2019 and 2021 through the demonstration program. Using purposive sampling, respondents were recruited through partnerships with primary public health centres and primary schools in Jakarta and Yogyakarta. Data analysis was conducted using Chi-square test, Independent-samples t-test, and one-way ANOVA.

RESULTS

One hundred and forty primary schoolgirls with a mean age of 12.2 years (SD = 0.70) completed the survey. Schools and mothers were identified as key actors in socialising children about important health information and as girls' preferred sources of information. The average summed score for girls' knowledge of HPV, the HPV vaccine, and CC after being vaccinated was 5.07 out of 10 (SD 0.23). Significant differences in the mean knowledge scores among participants with different preferences regarding CC education in school were observed.

CONCLUSION

While schoolgirls' experiences of HPV vaccination were largely positive, their knowledge of critical health information regarding HPV vaccination and CC prevention needs improving. Thus, it is necessary to provide parents, and school-based educators with culturally appropriate strategies and comprehensive evidence-based information about HPV vaccination and CC prevention more effectively to children.

Knowledge, attitudes, and practices among Indonesian urban communities regarding HPV infection, cervical cancer, and HPV vaccination

Background

Few studies explored Indonesian understanding of cervical cancer (CC) and the human papillomavirus (HPV) vaccination. We aimed to investigate the association between knowledge, attitudes, and practices (KAP) and socio-demographical influences related to HPV, CC, and vaccination among Indonesian urban citizens.

Methods

We conducted an online survey during March 2020-August 2021 using the Snowball sampling technique. The socio-demographic characteristic and KAP responses were collected via Google Forms from 400 respondents in Jakarta. The knowledge and attitudes were divided into HPV and CC (aspect 1) and HPV vaccination (aspect 2). Correlation between KAP scores was performed using Spearman’s test, and multiple logistic regression analyses were conducted to determine KAP predictors.

Results

Indonesian urban citizens in Jakarta were found to have poor knowledge in individual aspects of the inquiry but moderate knowledge overall, good attitude in inquiry both in each aspect and overall, and unsatisfying practices. Overall, in the general population, men, and women respectively: 50.8%, 32.4%, and 53.6% had good knowledge; 82.0%, 75.2%, and 84.4% expressed positive attitude; and 30.3%, 15.2%, and 35.6% applied favorable practice regarding questions inquired. Knowledge was weakly correlated towards attitude (ρ = 0.385) but moderately correlated with practice (ρ = 0.485); attitude was moderately correlated with practice (ρ = 0.577), all results: p<0.001. Significant odds ratio (OR) for predictors to good knowledge were female sex (OR = 2.99), higher education (OR = 2.91), and higher mother’s education (OR = 2.15). Factors related to positive attitudes were higher mother’s education (OR = 4.13), younger age (OR = 1.86), and better results in the knowledge inquiries (OR = 2.96). Factors that suggested better practices were female sex (OR = 2.33), being employed (OR = 1.68), excellent knowledge scores (OR = 4.56), and positive attitudes expressions (OR = 8.05). Having done one vaccination dose and intention to receive vaccines were significantly influenced by good KAP.

Conclusions

KAP had inter-association to successful CC and HPV prevention programs, and socio-demographical characteristics are critical to influencing better KAP.

The cost-effectiveness of bivalent, quadrivalent, and nine-valent HPV vaccination in Asia: a systematic review

PURPOSE

The aim of this study was to systematically review the cost-effectiveness of HPV vaccination in Asia.

METHODS

We performed a systematic review of papers indexed in PubMed, Scopus, and Web of Science covering the period from 1 January 2000 to 13 August 2020.

RESULTS

Sixteen studies were included in the review. Half of them (8 studies) evaluated the cost-effectiveness of HPV vaccination in high-income countries and regions (HICs) while the other eight studies were set in low- and middle-income countries and regions (LMICs). In HICs, the implementation of bivalent, quadrivalent and nine-valent HPV vaccination was all shown to be cost-effective. Most studies (7/8) also showed that it was cost-effective to implement bivalent, quadrivalent, and nine-valent HPV vaccines in LMICs. However, one study concluded that it was not cost-effective to implement bivalent HPV vaccination in Thailand.

CONCLUSION

In general, the implementation of bivalent, quadrivalent and nine-valent HPV vaccination for adolescent girls was cost-effective in both high-income countries and regions and low- and middle-income countries and regions in Asia. Policy makers in HICs could consider expanding the target vaccinated population, while for LMICs it is essential to reduce HPV vaccine price to a level at which the implementation of HPV vaccination is cost-effective.

The patent buyout price for human papilloma virus (HPV) vaccine and the ratio of R&D costs to the patent value

Human papillomavirus (HPV) is responsible for almost all of the 570,000 new cases of cervical cancer and approximately 311,000 deaths per year. HPV vaccination is an integral component of the World Health Organization’s (WHO) global strategy to fight the disease. However, high vaccine prices enforced through patent protection are limiting vaccine expansion, particularly in low- and middle-income countries. By limiting market power, patent buyouts could reduce vaccine prices and raise HPV vaccination rates while keeping innovation incentives. We estimate the global patent buyout price as the present discounted value (PDV) of the future profit stream over the remaining patent length for Merck’s HPV vaccines (Gardasil-4 and 9), which hold 87% of the global HPV vaccine market, in the range of US$ 15.6–27.7 billion (in 2018 US$). The estimated PDV of the profit stream since market introduction amounts to US$ 17.8–42.8 billion and the estimated R&D cost to US$ 1.05–1.21 billion. Thus, we arrive at a ratio of R&D costs to the patent value of the order of 2.5–6.8%. We relate this figure to typical estimates of the probability of success (POS) for clinical trials of vaccines to discuss if patent protection provides Merck with extraordinarily strong price setting power.

Economic evaluation of human papillomavirus vaccination in the Global South: a systematic review

OBJECTIVES

Many reviews have been conducted on the economic evaluation of the HPV vaccine in global north countries. But there is a dearth of such reviews in the Global South countries. Hence, this systematic review aims to summarize studies done in these countries.

METHODS

Four databases PubMed, Embase, Cochrane Library, and Google Scholar from 2009 to 2019 were searched for economic evaluations on HPV vaccination in the Global South countries. PRISMA guidelines were followed to include full-text articles. 40 original articles were shortlisted for full-text review.

RESULTS

Studies had varied models, assumptions, and results according to different scenarios. Most studies concluded HPV vaccination to be cost-effective under varied scenarios and vaccine cost was the most influential parameter affecting the sensitivity analyses, consequently incremental cost-effectiveness ratio. A wide range in the cost-effectiveness ratio was observed in the included studies due to different study settings, populations, and inconsistencies in modeling practices (variations in methodological approaches).

CONCLUSIONS

This review suggests the introduction of HPV vaccination alone or in combination with screening according to different countries. The price of the vaccine should be economical and funds for the vaccine should be provided by public sector firms.

Landscape of vaccine access and health technology assessment role in decision-making process in ASEAN countries

Over the past few years, many innovative vaccines became available that offer protection for diseases which have never been prevented before. While there are several factors that could have an impact on access, the use of health technology assessment (HTA) undoubtedly is also one of the contributing factors. Objectives: To explore the landscape of vaccine access and the role of HTA in new vaccine adoption in Association of Southeast Asian Nations (ASEAN) countries. Results: A great deal of progress has been made in terms of access to new and innovation vaccine in the region. Variation in access to these vaccines comparing between countries, however, is still observed. The use of HTA in supporting new vaccine adoption is still in an early stage especially in Gavi, the Vaccine Alliance-eligible countries. Conclusions: Improving the use of HTA evidences to support decision making could accelerate the efficient adoption of new vaccine in ASEAN region.

Can the prophylactic quadrivalent HPV vaccine be used as a therapeutic agent in women with CIN? A randomized trial

Background

Human papillomavirus (HPV) is one of the most significant risk factors for cervical cancer. The HPV vaccine has a very significant impact on the incidence of cervical cancer. The present study aimed to investigate the impact of prophylactic quadrivalent HPV vaccine in the treatment of women with cervical intraepithelial neoplasia (CIN 1–3).

Methods

This randomized controlled trial was conducted in the Shahid Sadoughi University of Medical Sciences (SSUMS), Yazd, Iran, from October 2011 to November 2015 in women with histologically confirmed residual/recurrent CIN 1 or high-grade CIN (CIN 2–3). Eligible women were assigned randomly to an intervention and a control group. Women in the intervention group were given HPV vaccinations while those in the control group were not. Participants were followed up for 24 months. Primary and secondary outcomes, and adverse effects of the treatment in the two groups were compared using Student’s t test, the chi-square test, or Fisher’s exact test. P values < 0.05 or less were considered statistically significant.

Results

Three-hundred and twelve women were randomized to the two groups; the data of 138 in the intervention group and 104 in the control group were analyzed. The mean age of the women was 32.59 ± 4.85 years. Differences in age, marital status, and grades of CIN weren’t significant between the two groups. At the end of the two-year follow-up period, the number of women with CIN 2–3 in the intervention and control groups was reduced by 75% (from 93 to 23) versus 40% (from 69 to 41). The efficacy of the HPV vaccine in women with CIN 1–3 was 58.7% (p = 0.018). No serious adverse effects related to the vaccines were reported.

Conclusions

The prophylactic quadrivalent HPV vaccine after treatment may have a therapeutic effect in women with residual/recurrent CIN 1 or high-grade CIN (CIN 2–3).

Trial registration

Iranian Registry of Clinical Trials, IRCT20190603043801N1. Registered 24 July 2019 – Retrospectively registered, http://www.irct.ir/user/trial/40017/view

A Qualitative Study of Parental Knowledge and Perceptions of Human Papillomavirus and Cervical Cancer Prevention in Rural Central Java, Indonesia: Understanding Community Readiness for Prevention Interventions

Background:

Cervical cancer (CC) is a leading cause of cancer deaths among Indonesian women. Pilot prevention programs, including human papillomavirus (HPV) vaccination for young adolescent girls, and cervical screening for women, have been implemented. However, many communities are yet to receive these interventions, nor targeted education regarding CC prevention. This study explored community readiness and acceptance of HPV vaccination and CC screening, as well as knowledge and perceptions of HPV and CC, to determine facilitators and barriers to upscaling CC prevention in rural Central Java.

Methods:

Qualitative data collection in October 2015 consisted of four focus group discussions with married women and men, and 22 semi-structured interviews with married women. All 57 participants, 39 women and 15 men, lived in Purworejo Regency in rural Central Java.

Results:

Most participants had no knowledge of HPV or the causal link between HPV and CC. However, most participants were supportive of vaccinating their children against HPV. Most participants had heard of cervical cancer, although understandings of symptoms and causes were very poor. Less than half of the women interviewed had undergone CC screening. Multiple barriers to screening were reported, including: a dislike of pelvic exams; embarrassment at being screened by a male doctor; anxiety over the cost; fearing a positive result; and being asymptomatic and thus not perceiving the need for screening.

Conclusions:

Extensive community education about HPV and CC, targeting women and men, adolescents, health workers and teachers, is crucial to support the introduction of the HPV Demonstration Program and the upscaling of CC screening. Low incomes among rural families underline the need for the HPV vaccine to be provided free within the National Immunization Program, and for CC screening to be free at primary health clinics.

Prevalence and distribution of HPV types in genital warts in Xi'an, China: a prospective study

OBJECTIVES

To characterise the prevalence and distribution of human papillomavirus (HPV) types in genital warts in Xi'an, China.

METHODS

This prospective study was conducted in Shaanxi Provincial Institute for Skin Disease and STD Control (SPISSC) between September 2014 and April 2017. Genital wart samples were obtained from 879 patients, including 512 men and 367 women. HPV genotyping was performed by using an automatic nucleic acid hybridisation system.

RESULTS

Of the 879 patients with genital warts, the detectable rates of low-risk, high-risk and total HPV types were 45.4%, 34.5% and 57.8%, respectively. The detectable rate of low-risk HPV types (45.4%) was significantly higher than that of high-risk HPV types (34.5%) (χ2=21.85, p<0.01). The detectable rate of low-risk HPV types of men (52.3%) was significantly higher than that of women (35.7%) (χ2=23.90, p<0.01). The detectable rates of one HPV type infection and two and three or more HPV type coinfections were 26.1%, 17.5% and 14.2%, respectively. HPV6 (24.9%), HPV11 (17.9%), HPV52 (9.9%) and HPV16 (7.3%) were the four most common HPV types.

CONCLUSIONS

The results of this study suggest that low-risk HPV types are major pathogens of genital warts, but high-risk HPV type infections and multiple HPV type coinfections are also common in genital warts. HPV6, 11, 52 and 16 are the four most common HPV types in genital wart in Xi'an, China.

Post Marketing Surveillance Study of 2nd Dose Quadrivalent Human Papilloma Virus Vaccine in Elementary School Children in Jakarta, Indonesia: Safety Result and Implementation of School-Based HPV Immunization Program

Objective:

Quadrivalent human papillomavirus (QHPV) vaccine has been advised for routine vaccination of pre-adolescent girls globally, and a two-dose QHPV vaccination schedule has been introduced in Indonesia to vaccinate 5^th and 6^th grade elementary school female students. This post-marketing surveillance study evaluated the possible adverse events following immunization with the two-dose QHPV vaccine in Indonesia.

Methods:

Girls studying in grade 6 of five designated elementary schools in Jakarta, receiving their 2^nd dose of QHPV vaccine and provided informed consent (represented by their parents), were included in the study. Students who had received other immunizations either simultaneously or <1 month ago were excluded. Local and systemic reactions noted at 30 min, and 72 h to 28th day, after the immunization were recorded using a Children Symptom Dairy Card/Kartu Harian Anak Sekolah (KHAS/Student Daily Card).

Results:

A total of 500 students from 20 schools were included. No serious adverse events were reported during the study period. Fever (systemic reaction) of mild intensity was noted in 1.6 % (n=8) of participants, which subsided after day 6. Local reactions such as pain, redness and swelling were noted in 59.6% (n=295), 23.6% (n=118), and 17.2% (n=86) of participants, respectively. These resolved without any intervention in majority of the cases after day 5.

Conclusion:

These results along with the safety data from the pre-licensure clinical trials confirm the favorable safety profile of QHPV vaccine in pre-adolescent girls. The school-based two-dose QHPV immunization program in Indonesia is a safe and effective strategy for optimizing HPV vaccine coverage among pre-adolescent girls.