title: A cost-utility analysis of cervical cancer screening and human papillomavirus vaccination in the Philippines.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Health Philippines, Pharmaceutical Division, 3/F Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003, Manila, Philippines. rum.secretariat@gmail.com.
authors.forename: Anna Melissa
authors.initials: AM
authors.lastname: Guerrero
authors.affiliation: Department of Health Philippines, Pharmaceutical Division, 3/F Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003, Manila, Philippines. rum.secretariat@gmail.com.
authors.forename: Anne Julienne
authors.initials: AJ
authors.lastname: Genuino
authors.affiliation: Product Team for Special Benefits, Philippine Health Insurance Corporation, Pasig, 1603, Philippines. rum.secretariat@gmail.com.
authors.forename: Melanie
authors.initials: M
authors.lastname: Santillan
authors.affiliation: Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, 11000, Thailand. naiyana.p@hitap.net.
authors.forename: Naiyana
authors.initials: N
authors.lastname: Praditsitthikorn
authors.affiliation: Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, 11000, Thailand. varit.c@hitap.net.
authors.forename: Varit
authors.initials: V
authors.lastname: Chantarastapornchit
authors.affiliation: Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, 11000, Thailand. yot.t@hitap.net.
authors.forename: Yot
authors.initials: Y
authors.lastname: Teerawattananon
authors.affiliation: Institution of Clinical Epidemiology, University of the Philippines, Manila, 1000, Philippines. issa.alejandria@gmail.com.
authors.forename: Marissa
authors.initials: M
authors.lastname: Alejandria
authors.affiliation: Obstetrics and Gynecology, Philippine General Hospital, Manila, 1000, Philippines. obonco@yahoo.com.
authors.forename: Jean Anne
authors.initials: JA
authors.lastname: Toral
mesh_terms: D000293:Adolescent; D000328:Adult; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics; D005260:Female; D006801:Humans; D008329:Managed Care Programs / Q000191:economics; D008875:Middle Aged; D065006:Papanicolaou Test / Q000191:economics; D030361:Papillomavirus Infections / Q000191:economics* / Q000517:prevention & control*; D053918:Papillomavirus Vaccines / Q000008:administration & dosage / Q000191:economics*; D010679:Philippines / Q000208:ethnology; D002583:Uterine Cervical Neoplasms / Q000191:economics* / Q000517:prevention & control*; D014611:Vaccination / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D053918:Papillomavirus Vaccines