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01.12.2015 | Research article | Ausgabe 1/2015 Open Access

BMC Public Health 1/2015

A cost-utility analysis of cervical cancer screening and human papillomavirus vaccination in the Philippines

Zeitschrift:
BMC Public Health > Ausgabe 1/2015
Autoren:
Anna Melissa Guerrero, Anne Julienne Genuino, Melanie Santillan, Naiyana Praditsitthikorn, Varit Chantarastapornchit, Yot Teerawattananon, Marissa Alejandria, Jean Anne Toral
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12889-015-2046-1) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

NP and YT designed the model. NP, YT and VC provided technical expertise on the use of the model and ensured the overall quality of the study. AMG, AJG, MA, JAT and MS collected the data. AJG constructed the tables and figures of the data. AMG and AJG performed the analysis, interpreted the data and results and drafted the initial manuscript. All authors contributed to the final draft of the manuscript.

Abstract

Background

Cervical cancer is the second leading cause of cancer cases and deaths among Filipino women because of inadequate access to screening and treatment services.  This study aims to evaluate the health and economic benefits of HPV vaccination and its combination with different screening strategies to find the most optimal preventive strategy in the Philippines.

Methods

A cost-utility analysis was conducted using an existing semi-Markov model to evaluate different screening (i.e., Pap smear, visual inspection with acetic acid) and vaccination strategies against HPV infection implemented alone or as part of a combination strategy at different coverage scenarios. The model was run using country-specific epidemiologic, cost and clinical parameters from a health system perspective. Sensitivity analysis was performed for vaccine efficacy, duration of protection and costs of vaccination, screening and treatment.

Results

Across all coverage scenarios, VIA has been shown to be a dominant and cost-saving screening strategy with incremental cost-effectiveness ratio (ICER) ranging from dominant to Php 61,059 (1443 USD) per QALY gained. VIA can reduce cervical cancer cases and deaths by 25 %. Pap smear screening was found to be not cost-effective due to its high cost in the Philippines. Adding HPV vaccination at a cost of 54 USD per vaccinated girl on top of VIA screening was found to be potentially cost-effective using a threshold of 1 GDP per capita (i.e., Php 120,000 or 2835 USD/ QALY) with the most favorable assumption of providing lifelong immunity against high-risk oncogenic HPV types 16/18. The highest incremental QALY gain was achieved with 80 % coverage of the combined strategy of VIA at 35 to 45 years old done every five years following vaccination at 11 years of age with an ICER of Php 33,126 (783 USD). This strategy may result in a two-thirds reduction in cervical cancer burden. HPV vaccination is not cost-effective when vaccine protection lasts for less than 20 years.

Conclusion

High VIA coverage targeting women aged 35–45 years old at five-year intervals is the most efficient and cost-saving strategy in reducing cervical cancer burden in the Philippines. Adding a vaccination program at high coverage among 11-year-old girls is potentially cost-effective in the Philippines assuming a life-long duration of vaccine efficacy.
Zusatzmaterial
Additional file 1: Distribution HPV types among Filipino women with normal cytology and with invasive cervical cancer. The figure shows the percentage share of different HPV types among Filipino women with normal cytology and with invasive cervical cancer.
12889_2015_2046_MOESM1_ESM.pdf
Additional file 2: Cost and health outcomes of competing strategies at different scenarios and screening 2-A: 8 % screening and 20 % vaccinationcoveragescoverage scenario 2-B: at 80 % screening and 20 % vaccination coveragescoverage scenario 2-C: 8 % screening and 80 % vaccination coveragescoverage scenario 2-D: 80 % screening and 80 % vaccination coveragescoverage scenario. For each coverage scenario, we identified optimal approaches defined as those having the lowest incremental cost-effectiveness ratios (ICERs) calculated as the additional cost of the incremental benefit of one strategy compared to the next less costly strategy.
12889_2015_2046_MOESM2_ESM.docx
Additional file 3: Cost-effectiveness of HPV vaccination at different start ages of vaccination and frequency of booster doses. The figure shows the different ICERs achieved with different assumptions on introducing vaccination starting at 11, 13, 20, and 25 years old and with varying frequency of booster doses every 0, 10, 15 and 20- years.
12889_2015_2046_MOESM3_ESM.pdf
Additional file 4: Vaccine ceiling price per dose at varying frequency of booster doses and duration of protection. The table identifies the cost-effective price per dose of the vaccine at varying frequency of booster doses and duration of protection.
12889_2015_2046_MOESM4_ESM.docx
Additional file 5: One-way sensitivity analysis. The tornado plot describes influential parameters that significantly affect changes in ICERs at 80 % coverage of VIA at 35–55 years old done every five years versus 80 % VIA at 35–55 years old done every five years and 20 % vaccination coverage at11 years old with lifetime protection.
12889_2015_2046_MOESM5_ESM.pdf
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