title: Incremental cost-effectiveness evaluation of vaccinating girls against cervical cancer pre- and post-sexual debut in Belgium.
abstract: BACKGROUND
  Vaccination against human papillomavirus (HPV) to prevent cervical cancer (CC) primarily targets young girls before sexual debut and is cost-effective. We assessed whether vaccination with the HPV-16/18 AS04-adjuvanted vaccine added to screening remains cost-effective in females after sexual debut compared to screening alone in Belgium. The role of protection against non-HPV-16/18 was also investigated.
  
  
  METHODS
  A published Markov cohort model was adapted to Belgium. The model replicated the natural history of HPV infection, the effects of screening, and vaccination. Vaccine efficacy (VE) included non-HPV-16/18 protection based on the PATRICIA clinical trial data. Pre- and post-HPV exposure VE were differentiated. Lifetime vaccine protection was assumed. Input data were obtained from literature review, national databases and a Delphi panel. Costing was from a healthcare payer perspective. Costs were discounted at 3% and effects at 1.5%. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained and the number of lesions prevented with vaccination from age 12 to 40 was evaluated. The specific effect of non-HPV-16/18 protection was investigated. Univariate sensitivity analysis was performed on key variables.
  
  
  RESULTS
  The model estimated that vaccinating a cohort of 100,000 girls at age 12 would prevent 646 CC cases over a lifetime (102 non-HPV-16/18) with an ICER of €9171/QALY. Vaccinating at age 26 would prevent 340 CC cases (40 non-HPV-16/18) with an ICER of €17,348/QALY and vaccinating at age 40 would prevent 146 CC cases (17 non-HPV-16/18) with an ICER of €42,847/QALY. The ICER remained under the highly cost-effective threshold (1×GDP/capita) until age 33 years and under the cost-effective threshold (3×GDP/capita) beyond age 40.
  
  
  CONCLUSIONS
  Extending HPV vaccination to females post-sexual debut could lead to a substantial reduction in CC-related burden and would be cost-effective in Belgium.
authors.affiliation: Health Economics, GlaxoSmithKline Vaccines, Rue Fleming 20, B-1300 Wavre, Belgium. nadia.x.demarteau@gskbio.com
authors.forename: Nadia
authors.initials: N
authors.lastname: Demarteau
authors.forename: Georges
authors.initials: G
authors.lastname: Van Kriekinge
authors.forename: Philippe
authors.initials: P
authors.lastname: Simon
mesh_terms: D000276:Adjuvants, Immunologic / Q000191:economics; D000328:Adult; D000367:Age Factors; D000368:Aged; D001530:Belgium / Q000453:epidemiology; D002648:Child; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D056738:Cross Protection; D005260:Female; D052162:Human papillomavirus 16 / Q000472:pathogenicity; D052161:Human papillomavirus 18 / Q000472:pathogenicity; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D008962:Models, Theoretical; D030361:Papillomavirus Infections / Q000191:economics / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D002583:Uterine Cervical Neoplasms / Q000191:economics / Q000517:prevention & control* / Q000821:virology; D014611:Vaccination / Q000191:economics*
chemical_list: D000276:Adjuvants, Immunologic; D053918:Papillomavirus Vaccines
keywords: Adult; Belgium; CC; CIN; CIS; Cervical cancer; Cost-effectiveness; GDP; HPV; Human papillomavirus; ICER; QALY; TVC; VE; Vaccination; carcinoma in situ; cervical cancer; cervical intraepithelial neoplasia; gross domestic product; human papillomavirus; incremental cost-effectiveness ratio; quality-adjusted life-year; total vaccinated cohort; vaccine efficacy