Cost-effectiveness analysis of a gender-neutral human papillomavirus vaccination program in the Netherlands

Background: Vaccinating girls against human papillomavirus (HPV) infection is a highly effective and cost-effective intervention to provide protection against HPV-induced cancers. Since vaccination coverage rates among girls is modest in the Netherlands, additional strategies should be implemented to improve the protection against HPV-related cancer. Here we assessed the benefits and cost-effectiveness of gender-neutral vaccination. Methods: We designed a static Markov model with a lifelong time horizon to simulate a cohort of 100,000 12-year-old Dutch boys. The model compares health and economic effects of HPV vaccination taking the current female vaccination coverage into consideration. HPV prevalence in boys was corrected for the predicted herd effects of the female programme in 2017. We extracted transition probabilities from peer-reviewed literature and previously constructed models. The robustness of the model was tested with multiple sensitivity analyses. Results: Vaccinating 30% of 100,000 12-year-old boys prevents 18, 13 and 25 cases of anal, penile, and oropharyngeal cancers in men, respectively. A total of 205 quality-adjusted life-years (QALYs) are saved by preventing cancer-related morbidity and mortality. Assuming a vaccine price of (sic)50 per dose, the incremental cost-effectiveness ratio (ICER) is (sic)17,907 per QALY. In addition, due to vaccine-induced herd effects, we estimated that 110 cases of cancer in females would be additionally prevented and 246 QALYs would be gained in the female cohort, bringing the total to 166 cancers prevented and 451 QALYs gained. Taking these additional benefits of boys' vaccination into account, the overall ICER was estimated at (sic)7310 per QALY gained. The model outcomes are most sensitive to variation in vaccine price, herd immunity from females and vaccine efficacy. Conclusions: Vaccination of boys, additional to girls, will prevent a relevant number of cancers in both boys and girls. Based on the current Dutch situation vaccination of HPV in boys is likely cost-effective. GSK Study identifier: HO-18-19169. (C) 2020 GlaxoSmithKline Biologicals S.A. Published by Elsevier Ltd

Equity in human papilloma virus vaccination uptake?:sexual behaviour, knowledge and demographics in a cross-sectional study in (un)vaccinated girls in the Netherlands

BACKGROUND: In the Netherlands, human papillomavirus (HPV) vaccination is part of a national program equally accessible for all girls invited for vaccination. To assess possible inequalities in vaccine uptake, we investigated differences between vaccinated and unvaccinated girls with regard to various characteristics, including education and ethnicity, (both associated with non-attendance to the national cervical screening program), sexual behaviour and knowledge of HPV. METHODS: In 2010, 19,939 nationwide randomly-selected 16–17 year-old girls (2009 vaccination campaign) were invited to fill out an online questionnaire. A knowledge scale score and multivariable analyses identified variables associated with vaccination status. RESULTS: 2989 (15%) of the selected girls participated (65% vaccinated, 35% unvaccinated). The participants were comparable with regard to education, ethnicity, most sexual risk behaviour and had similar knowledge scores on HPV transmission and vaccination. However, unvaccinated girls lived in more urbanised areas and were more likely to have a religious background. Irrespective of vaccination status, 81% of the girls were aware of the causal relationship between HPV and cervical cancer, but the awareness of the necessity of cervical screening despite being vaccinated was limited. CONCLUSIONS: HPV vaccine uptake was not associated with knowledge of HPV and with factors that are known to be associated with non-attendance to the cervical cancer screening program in the Netherlands. Furthermore, most sexual behaviour was not related to vaccination status meaning that teenage unvaccinated girls were not at a disproportionally higher risk of being exposed to HPV. Routine HPV vaccination may reduce the social inequity of prevention of cervical cancer

Cost-Effectiveness of Adolescent Pertussis Vaccination for The Netherlands: Using an Individual-Based Dynamic Model

BACKGROUND: Despite widespread immunization programs, a clear increase in pertussis incidence is apparent in many developed countries during the last decades. Consequently, additional immunization strategies are considered to reduce the burden of disease. The aim of this study is to design an individual-based stochastic dynamic framework to model pertussis transmission in the population in order to predict the epidemiologic and economic consequences of the implementation of universal booster vaccination programs. Using this framework, we estimate the cost-effectiveness of universal adolescent pertussis booster vaccination at the age of 12 years in the Netherlands. METHODS/PRINCIPAL FINDINGS: We designed a discrete event simulation (DES) model to predict the epidemiological and economic consequences of implementing universal adolescent booster vaccination. We used national age-specific notification data over the period 1996-2000--corrected for underreporting--to calibrate the model assuming a steady state situation. Subsequently, booster vaccination was introduced. Input parameters of the model were derived from literature, national data sources (e.g. costing data, incidence and hospitalization data) and expert opinions. As there is no consensus on the duration of immunity acquired by natural infection, we considered two scenarios for this duration of protection (i.e. 8 and 15 years). In both scenarios, total pertussis incidence decreased as a result of adolescent vaccination. From a societal perspective, the cost-effectiveness was estimated at €4418/QALY (range: 3205-6364 € per QALY) and €6371/QALY (range: 4139-9549 € per QALY) for the 8- and 15-year protection scenarios, respectively. Sensitivity analyses revealed that the outcomes are most sensitive to the quality of life weights used for pertussis disease. CONCLUSIONS/SIGNIFICANCE: To our knowledge we designed the first individual-based dynamic framework to model pertussis transmission in the population. This study indicates that adolescent pertussis vaccination is likely to be a cost-effective intervention for The Netherlands. The model is suited to investigate further pertussis booster vaccination strategies

Cost-effectiveness of a male catch-up human papillomavirus vaccination program in the Netherlands

In the Netherlands, the Health Council has advised that the human papillomavirus (HPV) vaccination should be offered to both boys and girls. Additionally, boys and men up to the age of 26 years should be included in a catch-up program. In this study, we examine the cost-effectiveness of this HPV catch-up program. We used a static Markov model to estimate the amount of cancers prevented and the incremental cost-effectiveness ratio (ICER) for different scenarios. Vaccinating men from 12 until the age of 26 years would result in an average of 48 cancer cases prevented in every cohort (an estimated total of 720 cases), with an average ICER of €32,256. We found that the catch-up vaccination program results in a relevant number prevented cases against an acceptable cost-effectiveness ratio. Policymakers should take these findings into account when evaluating a gender-neutral HPV vaccination program in the Netherlands

Vaccination process of immunocompromised patients in the Netherlands: Current challenges and potential solutions

Introduction: Immunocompromised patients (ICP) have an increased risk for infectious diseases. Vaccines could help reduce this risk. However, ICP do not always receive or are reimbursed for the specific vaccinations on which they are dependent in the Netherlands. This research aims to gain insights into the current challenges in the vaccination process of ICP in the Netherlands. Moreover, it aims to explore potential solutions for these challenges and the ideal vaccination process. Methods: Twelve semi-structured interviews with relevant stakeholders were conducted. Partly based on the challenges found by the Council for Health and Society (RVS) and the Dutch National Health Care Institute (ZIN) an interview guide was developed. Results: Several newly emerged challenges were identified: fair reimbursement for the efforts of stakeholders; circular reasoning of vaccine reimbursement and guidelines; suboptimal translation from guidelines to practice and no smooth-running infrastructure. Most challenges corresponded with those stated by the RVS and ZIN. Affordability and knowledge deficit in healthcare providers and patients were the most important challenges. Rarely the same solutions were mentioned, and no ideal vaccination process emerged. Conclusions: The various challenges in the vaccination process of ICP in the Netherlands implies the difficulty to solve the problem. It is recommended to focus on solving the most important challenges. A potential solution is to adjust the GVS registration process to make it easier for the pharmaceutical industry to apply for reimbursement towards various high-risk groups. Additionally, vaccination should have a more prominent role in the education of healthcare providers. Furthermore, stakeholders need to cooperate more to solve the reimbursement and guidelines issue

Reviewing and piloting methods for decreasing discount rates; someone, somewhere in time.

There has been substantial debate on the need for decreasing discounting for monetary and health gains in economic evaluations. Next to the discussion on differential discounting, a way to identify the need for such discounting strategies is through eliciting the time preferences for monetary and health outcomes. In this article, the authors investigate the perceived time preference for money and health gains through a pilot survey on Dutch university students using methods on functional forms previously suggested. Formal objectives of the study were to review such existing methods and to pilot them on a convenience sample using a questionnaire designed for this specific purpose. Indeed, a negative relation between the time of delay and the variance of the discounting rate for all models was observed. This study was intended as a pilot for a large-scale population-based investigation using the findings from this pilot on wording of the questionnaire, interpretation, scope and analytic framework

Cost-Utility Analysis of Human Papillomavirus Vaccination and Cervical Screening on Cervical Cancer Patient in Indonesia

BACKGROUND: Although cervical cancer is a preventable disease, the clinical and economic burdens of cervical cancer are still substantial issues in Indonesia. OBJECTIVES: The main purpose of this study was to model the costs, clinical benefits, and cost-utility of both visual inspection with acetic acid (VIA) screening alone and human papillomavirus (HPV) vaccination in addition to VIA screening in Indonesia. METHODS: We developed a population-based Markov model, consisting of three health states (susceptible, cervical cancer, and death), to assess future costs, health effects, and the cost-utility of cervical cancer prevention strategies in Indonesia. We followed a cohort of 100,000 females 12 to 100 years old and compared VIA screening alone with the addition of HPV vaccination on top of the screening to "no intervention." RESULTS: The implementation of VIA screening alone and in combination with HPV vaccination would reduce the cervical cancer incidence by 7.9% and 58.5%, corresponding to 25 and 98 deaths avoided within the cohort of 100,000, respectively. We also estimated that HPV vaccination combined with VIA screening apparently yielded a lower incremental cost-effectiveness ratio at international dollar 1863/quality-adjusted life-year (QALY), compared with VIA screening alone (I$3126/QALY). Both strategies could however be definitely labeled as very cost-effective interventions, based on a threshold suggested by the World Health Organization. The incremental cost-effectiveness ratio was sensitive to the discount rate, cervical cancer treatment costs, and quality of life as part of the QALY. CONCLUSIONS: The addition of HPV vaccination on top of VIA screening could be a cost-effective strategy in Indonesia even if relatively conservative assumptions are applied. This population-based model can be considered as an essential tool to inform decision makers on designing optimal strategies for cervical cancer prevention in Indonesia

Until Which Age Should Women Be Vaccinated Against HPV Infection? Recommendation Based on Cost-effectiveness Analyses

Introduction. Cervical cancer is caused by infection with human papillomavirus (HPV). Several countries have implemented vaccination programs against HPV for teenage girls before sexual debut. However, recent clinical trials have demonstrated that vaccination of older women is highly effective as well. Accordingly, it has been suggested that these older women should also be offered vaccination. Here, the cost-effectiveness of HPV vaccination for older women was assessed. Methods. A Markov model was used to estimate age-specific health benefits and cost savings of HPV vaccination for women 12-50 years of age, in the Netherlands. Sensitivity analyses were performed to test the robustness of the outcomes. State-of-the-art health-economic methods were used, and international health-economic guidelines were followed. Results. HPV vaccination is highly cost-effective for girls aged 12-16 years. Remarkably, cost-effectiveness only slowly declines with increasing age of the vaccinees up to 25 years. Indeed, substantial health benefits can be obtained by vaccinating women in this age group at acceptable costs. Beyond this age, cost-effectiveness of HPV-vaccination rapidly declines. Conclusions. Not only HPV vaccination of girls before sexual debut is a highly effective and cost-effective strategy for prevention of cervical cancer, but also vaccination of women until the age of 25 years is generally cost-effective