Cost-effectiveness analysis of introducing universal human papillomavirus vaccination of girls aged 11 years into the National Immunization Program in Brazil.
OBJECTIVE
To evaluate the impact and cost-effectiveness of introducing universal human papillomavirus (HPV) vaccination into the National Immunization Program (NIP) in Brazil.


METHODS
The Excel-based CERVIVAC decision support model was used to compare two strategies: (1) status quo (with current screening program) and (2) vaccination of a cohort of 11-year-old girls. National parameters for the epidemiology and costs of cervical cancer were estimated in depth. The estimates were based on data from the health information systems of the public health system, the PNAD 2008 national household survey, and relevant scientific literature on Brazil. Costs are expressed in 2008 United States dollars (US$), and a 5% discount rate is applied to both future costs and future health benefits.


RESULTS
Introducing the HPV vaccine would reduce the burden of disease. The model estimated there would be 229 deaths avoided and 6677 disability-adjusted life years (DALYs) averted in the vaccinated cohort. The incremental cost-effectiveness ratios (ICERs) per DALY averted from the perspectives of the government (US$ 7663), health system (US$ 7412), and society (US$ 7298) would be considered cost-effective, according to the parameters adopted by the World Health Organization. In the sensitivity analysis, the ICERs were most sensitive to variations in discount rate, disease burden, vaccine efficacy, and proportion of cervical cancer caused by types 16 and 18. However, universal HPV vaccination remained a cost-effective strategy in most variations of the key estimates.


CONCLUSIONS
Vaccine introduction could contribute additional benefits in controlling cervical cancer, but it requires large investments by the NIP. Among the essential conditions for attaining the expected favorable results are immunization program sustainability, equity in a population perspective, improvement of the screening program, and development of a surveillance system.
Department of Preventive Medicine, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455 - 2(o) andar Cerqueira César, 01246-903 São Paulo, SP, Brazil.
Hillegonda Maria Dutilh
HM
Novaes
Department of Preventive Medicine, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455 - 2(o) andar Cerqueira César, 01246-903 São Paulo, SP, Brazil. Electronic address: patricia.soarez@usp.br.
Patrícia Coelho
PC
de Soárez
Rio de Janeiro State University, Social Medicine Institute, Rio de Janeiro, RJ, Brazil.
Gulnar Azevedo
GA
Silva
Rio de Janeiro State University, Social Medicine Institute, Rio de Janeiro, RJ, Brazil.
Andreia
A
Ayres
Department of Collective Health, Institute of Tropical Pathology and Public Health, Federal University of Goias, Goiania, GO, Brazil.
Alexander
A
Itria
Leonor Mendes de Barros Maternity Hospital, Health State Secretariat, São Paulo, SP, Brazil.
Cristina Helena
CH
Rama
Clinic of Infectious and Parasitic Diseases, Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Enéas de Carvalho Aguiar, 455, 4(o) andar, sala 4028 Cerqueira César, 05403-000 São Paulo, SP, Brazil.
Ana Marli Christovam
AM
Sartori
Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Andrew D
AD
Clark
Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, United States.
Stephen
S
Resch
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001938:Brazil / Q000453:epidemiology; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D006291:Health Policy; D006801:Humans; D017589:Immunization Programs; D008875:Middle Aged; D015233:Models, Statistical; D030361:Papillomavirus Infections / Q000150:complications / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*; D053918:Papillomavirus Vaccines / Q000008:administration & dosage / Q000191:economics* / Q000276:immunology*; D002583:Uterine Cervical Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D014611:Vaccination / Q000191:economics* / Q000379:methods; D055815:Young Adult
D053918:Papillomavirus Vaccines
Cost effectiveness; Cost-benefit analysis; HPV vaccines; Papillomavirus vaccines; Uterine cancer; Uterine cervical neoplasms