Changing inequalities in cervical cancer: modeling the impact of vaccine uptake, vaccine herd effects, and cervical cancer screening in the post-vaccination era.
BACKGROUND
Inequalities in cervical cancer may be increased following mass vaccination against the human papillomavirus (HPV) if girls with low vaccine uptake also have low future participation in cervical cancer screening. We evaluated how vaccine uptake distribution affects inequalities in squamous cell carcinoma (SCC) incidence between groups with different screening participation.


METHODS
We used an individual-based transmission dynamic model of HPV infection and disease (HPV-ADVISE). Females were stratified by routine screening frequency. We modeled the impact of vaccination on SCC incidence rate differences (absolute inequality) and incidence rate ratios (relative inequality) between women who have routine screening intervals of <5 years (frequently screened), ≥5 years (underscreened), and who are never screened. We compared simulations with uniform vaccine uptake with scenarios with unequal vaccine uptake, in which never and underscreened women have lower vaccine uptake than frequently screened women.


RESULTS
Absolute SCC inequalities between groups with different screening rates were predicted to decrease after vaccination, even when women with the lowest screening participation had the lowest vaccine uptake. Herd effects helped reduce absolute inequalities when vaccine uptake was unequal. Conversely, relative SCC inequalities remained unchanged or increased after vaccination. Results were robust to different overall vaccination coverages and sexual mixing scenarios.


CONCLUSIONS
Though mass HPV vaccination is predicted to substantially decrease SCC incidence rates, never screened women will still have the highest disease burden after vaccination.


CONCLUSIONS
To reduce both absolute and relative SCC inequalities, public health initiatives will need to address inequalities in both vaccine uptake and in cervical cancer screening participation.
Département de médecine sociale et préventive, Université Laval, Québec City, Québec, Canada. Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec City, Québec, Canada.
Talía
T
Malagón
Département de médecine sociale et préventive, Université Laval, Québec City, Québec, Canada. Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec City, Québec, Canada.
Mélanie
M
Drolet
Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom.
Marie-Claude
MC
Boily
Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec City, Québec, Canada.
Jean-François
JF
Laprise
Département de médecine sociale et préventive, Université Laval, Québec City, Québec, Canada. Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec City, Québec, Canada. Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom. marc.brisson@uresp.ulaval.ca.
Marc
M
Brisson
D055088:Early Detection of Cancer; D005260:Female; D006801:Humans; D015994:Incidence; D030361:Papillomavirus Infections / Q000821:virology*; D053918:Papillomavirus Vaccines / Q000276:immunology*; D012959:Socioeconomic Factors; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D014611:Vaccination
D053918:Papillomavirus Vaccines