Systematic review of the cost-effectiveness of the vaccination against HPV in Brazil

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.

Model Comparisons of the Effectiveness and Cost-Effectiveness of Vaccination: A Systematic Review of the Literature

OBJECTIVES

To describe all published articles that have conducted comparisons of model-based effectiveness and cost-effectiveness results in the field of vaccination. Specific objectives were to 1) describe the methodologies used and 2) identify the strengths and limitations of the studies.

METHODS

We systematically searched MEDLINE and Embase databases for studies that compared predictions of effectiveness and cost-effectiveness of vaccination of two or more mathematical models. We categorized studies into two groups on the basis of their data source for comparison (previously published results or new simulation results) and performed a qualitative synthesis of study conclusions.

RESULTS

We identified 115 eligible articles (only 5% generated new simulations from the reviewed models) examining the effectiveness and cost-effectiveness of vaccination against 14 pathogens (69% of studies examined human papillomavirus, influenza, and/or pneumococcal vaccines). The goal of most of studies was to summarize evidence for vaccination policy decisions, and cost-effectiveness was the most frequent outcome examined. Only 33%, 25%, and 3% of studies followed a systematic approach to identify eligible studies, assessed the quality of studies, and performed a quantitative synthesis of results, respectively. A greater proportion of model comparisons using published studies followed a systematic approach to identify eligible studies and to assess their quality, whereas more studies using new simulations performed quantitative synthesis of results and identified drivers of model conclusions. Most comparative modeling studies concluded that vaccination was cost-effective.

CONCLUSIONS

Given the variability in methods used to conduct/report comparative modeling studies, guidelines are required to enhance their quality and transparency and to provide better tools for decision making.

Cost effectiveness of human papilloma virus vaccination in low and middle income countries: a systematic review of literature

INTRODUCTION

Low and middle income countries (LMICs) bear more than 50% of the current cervical cancer burden over the last decade with linkages to lack of HPV vaccination, high levels of poverty, illiteracy and nonexistent or poor screening programs. Governments of LMICs need enough convincing evidence that HPV vaccination will be more cost-effective in reducing the scourge of cervical cancer.

AREAS COVERED

A systematic review to identify suitable studies from MEDLINE(via PubMed), EMBASE and Electronic search through GOOGLE for original and review articles from 2007 to 2014 on cost-effectiveness of human papilloma virus vaccination of pre-adolescent girls in LMICs was conducted. A total of 19 full articles were finally selected and reviewed after screening out those not consistent with the inclusion and exclusion criteria.

EXPERT COMMENTARY

Most studies on cost-effectiveness of HPV vaccine in LMICs show that lowering cost of HPV vaccination with or without Pap smear screening is cost-effective in areas with high incidence of cervical cancer.

Cost Effectiveness of HPV Vaccination: A Systematic Review of Modelling Approaches

BACKGROUND

A large number of economic evaluations have been published that assess alternative possible human papillomavirus (HPV) vaccination strategies. Understanding differences in the modelling methodologies used in these studies is important to assess the accuracy, comparability and generalisability of their results.

OBJECTIVES

The aim of this review was to identify published economic models of HPV vaccination programmes and understand how characteristics of these studies vary by geographical area, date of publication and the policy question being addressed.

METHODS

We performed literature searches in MEDLINE, Embase, Econlit, The Health Economic Evaluations Database (HEED) and The National Health Service Economic Evaluation Database (NHS EED). From the 1189 unique studies retrieved, 65 studies were included for data extraction based on a priori eligibility criteria. Two authors independently reviewed these articles to determine eligibility for the final review. Data were extracted from the selected studies, focussing on six key structural or methodological themes covering different aspects of the model(s) used that may influence cost-effectiveness results.

RESULTS

More recently published studies tend to model a larger number of HPV strains, and include a larger number of HPV-associated diseases. Studies published in Europe and North America also tend to include a larger number of diseases and are more likely to incorporate the impact of herd immunity and to use more realistic assumptions around vaccine efficacy and coverage. Studies based on previous models often do not include sufficiently robust justifications as to the applicability of the adapted model to the new context.

CONCLUSIONS

The considerable between-study heterogeneity in economic evaluations of HPV vaccination programmes makes comparisons between studies difficult, as observed differences in cost effectiveness may be driven by differences in methodology as well as by variations in funding and delivery models and estimates of model parameters. Studies should consistently report not only all simplifying assumptions made but also the estimated impact of these assumptions on the cost-effectiveness results.