title: Cost-effectiveness and equity impacts of three HPV vaccination programmes for school-aged girls in New Zealand.
abstract: BACKGROUND
  As with many high-income countries, vaccination coverage against human papilloma virus (HPV) infection is not high in New Zealand (NZ) at 47% in school-aged girls for three doses. We estimate the health gains, net-cost and cost-effectiveness of the currently implemented HPV national vaccination programme of vaccination dispersed across schools and primary care, and two alternatives: school-based only (assumed coverage as per Australia: 73%), and mandatory school-based vaccination but with opt-out permitted (coverage 93%). We also generate estimates by social group (sex, ethnic and deprivation group).
  
  
  METHODS
  A Markov macro-simulation model was developed for 12-year-old girls and boys in 2011, with future health states of: cervical cancer, pre-cancer (CIN I-III), genital warts, and three other HPV-related cancers (oropharyngeal, anal, vulvar cancer). In each state health sector costs, including additional health sector costs from extra life, and quality-adjusted life years (QALYs) were accumulated.
  
  
  RESULTS
  The current HPV vaccination programme has an estimated cost-effectiveness of NZ$18,800/QALY gained (about US$9700/QALY gained using the OECD's purchasing power parities; 95% UI: US$6900 to $33,700) compared to the status quo in NZ prior to 2008 (no vaccination, screening alone). The incremental cost-effectiveness ratio (ICER) of an intensive school-based only programme of girls, compared to the current situation, was US$33,000/QALY gained. Mandatory vaccination appeared least cost-effective (ICER compared to school-based of US$117,000/QALY gained, but with wide 95% uncertainty limits from $56,000 to $220,000). All interventions generated more QALYs per 12-year-old for Māori (indigenous population) and people living in deprived areas (range 5-25% greater QALYs gained).
  
  
  CONCLUSIONS
  A more intensive school-only vaccination programme seems warranted. Reductions in vaccine price will greatly improve cost-effectiveness of all options, possibly making a law for mandatory vaccination optimal from a health sector perspective. All interventions could reduce ethnic and socioeconomic disparities in HPV-related disease.
authors.affiliation: Department of Public Health, University of Otago, Wellington, New Zealand. Electronic address: tony.blakely@otago.ac.nz.
authors.forename: Tony
authors.initials: T
authors.lastname: Blakely
authors.affiliation: Department of Public Health, University of Otago, Wellington, New Zealand.
authors.forename: Giorgi
authors.initials: G
authors.lastname: Kvizhinadze
authors.affiliation: MSc Programme in Health Economics, University of York, United Kingdom.
authors.forename: Tanja
authors.initials: T
authors.lastname: Karvonen
authors.affiliation: Department of Public Health, University of Otago, Wellington, New Zealand.
authors.forename: Amber L
authors.initials: AL
authors.lastname: Pearson
authors.affiliation: Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
authors.forename: Megan
authors.initials: M
authors.lastname: Smith
authors.affiliation: Department of Public Health, University of Otago, Wellington, New Zealand.
authors.forename: Nick
authors.initials: N
authors.lastname: Wilson
mesh_terms: D002648:Child; D003362:Cost-Benefit Analysis; D005006:Ethnicity; D005260:Female; D017048:Health Care Costs; D006801:Humans; D037141:Mandatory Programs / Q000191:economics; D008390:Markov Chains; D032541:Mass Vaccination / Q000191:economics*; D018803:Models, Economic; D009010:Monte Carlo Method; D009520:New Zealand; D030361:Papillomavirus Infections / Q000517:prevention & control*; D053918:Papillomavirus Vaccines / Q000008:administration & dosage / Q000191:economics*; D019057:Quality-Adjusted Life Years; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control
chemical_list: D053918:Papillomavirus Vaccines
keywords: Anogenital warts; Cervical cancer; Cost-effectiveness; Cost-utility analysis; Equity; HPV vaccination; Markov model; Māori health