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HPV vaccine may be more cost-effective with routine screening in girls
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Initial catch-up efforts of the HPV vaccine should be focused on vaccinating women younger than 21 years old, according to researchers from the Harvard School of Public Health.
Based on meta-analysis findings, the researchers suggested that the cost-effectiveness of the HPV vaccination also depends on universal screening of adolescent girls and the revision of current screening policies.
The researchers analyzed epidemiologic and demographic data on the HPV-16 and HPV-18 vaccinations in preadolescent girls (aged 12 years) and catch-up programs in older girls and women (aged to 18, 21 or 26 years).
Compared with the current screening practice, the cost-effectiveness ratio of vaccination in girls aged 12 years was $43,600 per quality-adjusted life-year gained, assuming the vaccine provided lifelong immunity.
Under the same assumption, the ratio of cost-effectiveness for a temporary catch-up program that included girls aged to 18 years was $97,300 per quality-adjusted life-year. In programs that included women aged to 21 years the ratio was $120,400 per quality-adjusted life-year and for those aged to 26 years the ratio was $152,700 per quality-adjusted life-year.
Assuming immunity decreased after 10 years, the cost of vaccination for preadolescent girls was more than $140,000 per quality-adjusted life-year, and the researchers reported a higher cost-effectiveness for screening alone in catch-up programs, compared with vaccination.
The researchers observed more favorable cost-effectiveness ratios when prevention of other health conditions was included or if screening was performed less frequently with more sensitive tests. If vaccinated girls were screened more regularly in adulthood, the cost-effectiveness ratios were less advantageous. – by Stacey L. Adams
N Engl J Med. 2008;359:821-832.
One big assumption the health economic folks are implying is that the HPV vaccine is going to require a 10-year booster dose, and I don't believe it is. The vaccine is formulated like the hepatitis B vaccine - it's made the same way, with the same kind of schedule and the same virus-like protein. And hepatitis B vaccine does not need a booster. Therefore, they need to emphasize the costs on the basis of no booster.
The economic values presented are consistent with other vaccines we give children and adolescents, as far as cost-effectiveness and quality-adjusted life-years for preadolescent girls. If we vaccinate at age 11 to12 years, that's when the cost-effectiveness is optimized, this makes perfect sense since these girls should have virtually no sexual or HPV exposure. That's the key to this vaccine: the younger you are (i.e. age 11 to 12), the better the vaccine is going to prevent its intended target - HPV infection.
According to the researchers, the vaccine is economically attractive for 11 to 12-year-olds. And for 13- to 18-year-olds it will cost up to $100,000 per quality-adjusted life-year, which is reasonable, they say. According to the researchers, after age 21, the vaccine becomes less cost-effective and may be harder to justify.
The risk for HPV infections are highest at ages 15 through 22 years. Fifty-five percent of all sexually active girls under age 20 (about 80%-90%) have had HPV exposure once they're sexually active and they'll be positive for HPV within three years. But in reality, according to the earlier future 1 and future 2 studies of HPV-4 vaccine, up to 85% of women from 16 to 25 years will still not be infected with vaccine strains of HPV-16 or HPV-18. So, this group will receive the same protection as the pre-pubertal girls. This is difficult to factor in to the calculations, thus I still believe we should continue to encourage these young women to receive a pre-cancer/cancer preventing vaccine, especially those women who are still single or divorced and highly likely to continue to be exposed.
Overall, this study presents more questions about how to best analyze the effectiveness of these HPV vaccines is in preventing the real economic implications, which are pap smears, repeat pap smears, colposcopy, biopsies and laser therapies or precancerous therapies.
– Stan Block, MD
Clinical Professor of Pediatrics
University of
Louisville, Kentucky