1. In this modeling study, the cost-effectiveness and number needed to vaccinate of mid-adult human papillomavirus (HPV) vaccination improved when limited to those at higher risk for acquiring HPV infection.

2. HPV vaccination of mid-adults was found to be significantly less cost-effective and required a higher number needed to vaccinate compared to the vaccination of persons 26 years of age and younger.

Evidence Rating Level: 2 (Good)

Study Rundown: Human papillomavirus (HPV) is a deoxyribonucleic acid (DNA) virus which is known to cause genital warts and various forms of cancer, including cervical and oropharyngeal. Since 2006, the United States Advisory Committee on Immunization Practices has recommended HPV vaccination for females between 9 and 26 years of age, with subsequent updates including males between 9 and 26 years of age. Following the approval of the 9-valent HPV vaccine for use through 45 years of age by the U.S. Food and Drug Administration, the Advisory Committee expanded its recommendation to include shared clinical decision making for HPV vaccination of “mid-adults,” women and men aged 27 through 45 years. While the population-level benefit of vaccinating mid-adults appears marginal, individual-level benefit in those who are at higher risk of acquiring HPV infections is uncertain. Hence, using an individual-based transmission dynamic modeling of HPV transmission and associated diseases, this study investigated the cost-effectiveness and utility of HPV vaccination in the mid-adult U.S. population at higher risk of infection. Overall, it found that the value of mid-adult HPV vaccination improved when limited to those at higher risk for acquiring HPV infection, including those with a greater number of sexual partners and those who have recently separated. Moreover, it showed that HPV vaccination of mid-adults was significantly less cost-effective and required a higher number needed to vaccination to prevent 1 HPV-related cancer case compared to the vaccination of persons 26 years of age and younger under all scenarios investigated. The model used in the study was limited by uncertainties in the natural progression of HPV infection to disease, and the results may not be generalizable to other countries with differing patterns of sexual behavior, screening participation, and disease prevalence. Overall, this study showed that, while mid-adult vaccination was much less effective than vaccination at younger age, those at higher risk within the older cohort may still benefit from catch-up vaccination.

Click to read the study in AIM

Relevant Reading: Effectiveness and cost-effectiveness of human papillomavirus vaccination through age 45 years in the United States

In-Depth [prospective cohort]: This model-based projection study utilized the United States version of HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation) to evaluate the cost-effectiveness and NNV of vaccinating the mid-adult U.S. population against HPV. HPV-ADVISE incorporated several components including demographic characteristics, sexual behavior and HPV transmission, type-specific natural progression of HPV disease, vaccination, screening and treatment, and health economic outcomes. In the base-case analysis, expansion of the HPV vaccination program to either include all mid-adults or mid-adults with higher risk of infection was compared to the current 9-valent HPV vaccination program including persons between 9 to 26 years of age in the United States. For the scenario involving mid-adults with higher levels of sexual activity, individuals who were expected to have more than 10 lifetime partners were vaccinated. For the scenario involving mid-adults who have just separated, vaccination was provided immediately following the termination of the relationship. The main outcomes included incremental cost-effectiveness ratios (ICERs) based on costs per quality-adjusted life years (QALY) gained and the number needed to vaccinate (NNV) to prevent 1 additional HPV-related cancer case. Expanding the vaccination program to all mid-adults, those with higher sexual activity, and those who have just separated was projected to cost an additional $2,005,000 (80% uncertainty interval [UI], $1,227,000 to >$10 million), $763,000 (80% UI, $447,000 to $2,946,000), and $1,164,000 (80% UI, $525,000 to $4,627,000) per QALY gained, respectively. The NNVs to prevent 1 additional cancer case were 7,670 (80% UI, 5,550 to 12,120), 3,190 (80% UI, 2,230 to 4,750), and 5,150 (80% UI, 3,800 to 8,250), respectively, compared to 223 (80% UI, 210 to 232) for the existing 9-valent program. In the sensitivity analysis, HPV vaccination of infrequently screened mid-adult women who have just separated and have higher sexual activity exhibited the lowest ICER ($86,000 per QALY gained) and NNV (470). In summary, this study demonstrates that the efficacy of HPV vaccination in mid-adults improved when selecting for those at higher risk of infection.

Image: PD

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