Erste Erfahrungen zur Akzeptanz der HPV-Impfung

Cost-effectiveness of human papillomavirus vaccination in Germany

BACKGROUND

The aim of this study was to assess the cost-effectiveness of human papillomavirus (HPV) vaccination in addition to the current cervical cancer screening programme in Germany using a dynamic transmission model.

METHODS

Based on a mathematical model simulating the transmission dynamics and the natural history of HPV infection and associated diseases (cervical intraepithelial neoplasia, cervical cancer, and genital warts), we estimated the epidemiological and economic consequences of HPV vaccination with both the quadrivalent and bivalent vaccines. In our base case analysis, we assessed the cost-effectiveness of vaccinating 12-year-old girls with a 3-dose schedule. In sensitivity analysis, we also evaluated the use of a 2-dose schedule and assessed the impact of vaccinating boys.

RESULTS

From a health care payer perspective, incremental cost-effectiveness ratios (ICERs) of a 3-dose schedule were €34,249 per quality-adjusted life year (QALY) for the bivalent and €14,711 per QALY for the quadrivalent vaccine. Inclusion of indirect costs decreased ICERs by up to 40%. When adopting a health care payer perspective, ICERs of a 2-dose approach decreased to €19,450 per QALY for the bivalent and to €3645 per QALY for the quadrivalent vaccine. From a societal perspective, a 2-dose approach using the quadrivalent vaccine was a cost-saving strategy while using the bivalent vaccine resulted in an ICER of €13,248 per QALY. Irrespective of the perspective adopted, additional vaccination of boys resulted in ICERs exceeding €50,000 per QALY, except for scenarios with low coverage (20%) in girls.

CONCLUSIONS

Our model results suggest that routine HPV vaccination of 12-year-old girls with three doses is likely to be cost-effective in Germany. Due to the additional impact on genital warts, the quadrivalent vaccine appeared to be more cost-effective than the bivalent vaccine. A 2-dose schedule of the quadrivalent vaccine might even lead to cost savings when adopting a societal perspective. The cost-effectiveness of additional vaccination of boys was highly dependent on the coverage in girls.

[HPV vaccination coverage in German girls: results of the KiGGS study: first follow-up (KiGGS Wave 1)]

OBJECTIVES

In Germany, vaccination against HPV infection has been recommended for girls aged 12-17 years since 2007. The aim of this paper was to provide an overview of the current status and determinants of HPV vaccination uptake in Germany.

METHODS

Analyses included data from 14- to 17-year-old girls (n =1,337) of the German Health Interview and Examination Survey for Children and Adolescents - First Follow-up Survey (KiGGS Wave 1). Standardized telephone interviews included questions for girls on the number of HPV vaccine doses and visits to a gynecologist. Parents were asked about their socioeconomic status (SES) and the girls' participation in the J1 adolescent health check-up. Descriptive analyses of the HPV vaccination status with respect to social, demographic, and health-care utilization factors were performed. Factors associated with vaccination were identified and odds ratios (OR) were estimated by means of logistic regression analysis.

RESULTS

The prevalence of vaccination with at least one HPV vaccine dose was 52.6% (95% confidence interval 48.5-56.6). Three-dose HPV vaccination coverage was 39.5% (35.3-43.9). Vaccine uptake increased with age, was higher in girls with middle and low SES compared with high SES, with residence in eastern Germany, in those who had already seen a gynecologist, and who participated in the J1. Multivariable logistic regression revealed a twofold increased chance of being vaccinated for girls with middle SES (OR 1.9) compared with high-SES girls and for those who had yet seen a gynecologist (OR 2.1).

CONCLUSIONS

School-based vaccination programs and multi-tier vaccination campaigns have led to high vaccination rates in some European and non-European countries. In Germany, however, such high vaccination rates have not been achieved. To fully realize the potential of HPV vaccinations to reduce HPV-related cancer incidence at the population level, vaccination coverage in Germany must be increased. In absence of school-based vaccination programs, medical doctors should use each visit to check and complete the girl's vaccination status.

Estimating the long-term effects of HPV vaccination in Germany

In Germany, vaccination against the most oncogenic HPV types 16/18 is recommended by the Standing Committee on Vaccination (STIKO) for 12-17 year old girls since March 2007. We developed a dynamic mathematical model for the natural history and transmission of HPV infections to estimate the impact of vaccination on incidence and mortality of cervical cancer and its pre-stages, and on anogenital warts. We focused on an extensive model calibration to epidemiologic data for all stages of the natural history model as well as on a detailed implementation of cervical cancer screening modalities in Germany. Our model predicts first a substantial reduction of cervical cancer incidence and mortality over the next 30 years, which is mainly attributable to an increase in screening participation in the 1990s and not to HPV vaccination, followed by a further reduction attributable to vaccination. Over the next 100 years, HPV vaccination will prevent approximately 37% of cervical cancer cases even if vaccination coverage is only 50% (as currently observed in Germany). Consideration of cross-protection results in a further reduction of approximately 7% of all cervical cancer cases for the bivalent and about 5% for the quadrivalent vaccine in our model. Vaccination of boys was only reasonable if moderate to high vaccination coverage in girls was not achieved. Strategies should be implemented in Germany to increase HPV vaccination coverage among girls thereby making better use of the demonstrated benefits of the vaccine.

Human papillomavirus vaccine uptake, knowledge and attitude among 10th grade students in Berlin, Germany, 2010

PURPOSE

Since March 2007, the Standing Committee on Vaccination (STIKO) recommends HPV vaccination for all 12-17 y-old females in Germany. In the absence of an immunization register, we aimed at assessing HPV-vaccination coverage and knowledge among students in Berlin, the largest city in Germany, to identify factors influencing HPV-vaccine uptake.

METHODS

Self-administered questionnaires were distributed to 10th grade school students in 14 participating schools in Berlin to assess socio-demographic characteristics, knowledge, and statements on vaccinations. Vaccination records were reviewed. Multivariable statistical methods were applied to identify independent predictors for HPV-vaccine uptake among female participants.

RESULTS

Between September and December 2010, 442 students completed the questionnaire (mean age 15.1; range 14-19). In total 281/442 (63.6%) students specified HPV correctly as a sexually transmitted infection. Of 238 participating girls, 161 (67.6%) provided their vaccination records. Among these, 66 (41.0%) had received the recommended three HPV-vaccine doses. Reasons for being HPV-unvaccinated were reported by 65 girls: Dissuasion from parents (40.2%), dissuasion from their physician (18.5%), and concerns about side-effects (30.8%) (multiple choices possible). The odds of being vaccinated increased with age (Odds Ratio (OR) 2.19, 95% Confidence Interval (CI) 1.16, 4.15) and decreased with negative attitude toward vaccinations (OR = 0.33, 95%CI 0.13, 0.84).

CONCLUSIONS

HPV-vaccine uptake was low among school girls in Berlin. Both, physicians and parents were influential regarding their HPV-vaccination decision even though personal perceptions played an important role as well. School programs could be beneficial to improve knowledge related to HPV and vaccines, and to offer low-barrier access to HPV vaccination.