Human papillomavirus vaccination coverage, policies, and practical implementation across Europe

BACKGROUND

Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland.

METHODS

Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information.

RESULTS

Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9-15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51-70% in seven, 31-50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used.

CONCLUSION

According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.

Are the Two Human Papillomavirus Vaccines Really Similar? A Systematic Review of Available Evidence: Efficacy of the Two Vaccines against HPV

BACKGROUND

When the bivalent and the quadrivalent HPV vaccines were marketed they were presented as having comparable efficacy against cervical cancer. Differences between the vaccines are HPV types included and formulation of the adjuvant.

METHOD

A systematic review was conducted to assess the efficacy of the two vaccines against cervical cancer. Outcomes considered were CIN2+, CIN3+, and AIS.

RESULTS

Nine reports (38,419 women) were included. At enrollment mean age of women was 20 years, 90% had negative cytology, and 80% were seronegative and/or DNA negative for HPV 16 or 18 (naïve women). In the TVC-naïve, VE against CIN2+ was 58% (95% CI: 35, 72); heterogeneity was detected, VE being 65% (95% CI: 54, 74) for the bivalent and 43% (95% CI: 23, 57) for the quadrivalent. VE against CIN3+ was 78% (95% CI: <0, 97); heterogeneity was substantial, VE being 93% (95% CI: 77, 98) for the bivalent and 43% (95% CI: 12, 63) for the quadrivalent. VE in the TVC was much lower. No sufficient data were available on AIS.

CONCLUSIONS

In naïve girls bivalent vaccine shows higher efficacy, even if the number of events detected is low. In women already infected the benefit of the vaccination seems negligible.

Managing uncertainty: healthcare professionals' meanings regarding the HPV vaccine

BACKGROUND

New preventive technologies such as vaccines offer insight into psychological, social, and cultural landscapes. Providers have a key role in parents' decisions for vaccinating their children. Yet, perspectives from providers regarding the human papillomavirus (HPV) vaccine, or vaccination in general, are rarely sought

PURPOSE

Our objective in this paper is to understand how the HPV vaccine is perceived by health care providers and the multiple contextual meanings it elicits.

METHODS

We conducted interviews with 20 health care professionals in Bulgaria about their attitudes and practices related to HPV vaccination and their recommendations for policies. The verbatim-transcribed interviews were analyzed through narrative analysis, with a special focus on language.

RESULTS

We illustrate providers' contradictory and contextualized constructions of the vaccine and the narrative strategies they use to manage any uncertainty it elicits. These include being advocates and missionaries for preventive health, confirming their trust in the medical profession and professional organizations, challenging patients' concerns with rational explanations, normalizing the risk of medical innovations, and avoiding the sexual nature of HPV transmission.

CONCLUSIONS

The introduction of a vaccine to prevent HPV infection, and by implication, possibly cervical and other cancers, created hope, and at the same time, intensified confusion and uncertainty. Providers have been frustrated for years with the rising mortality from cervical cancer in Bulgaria, and their perceived powerlessness in affecting this. HPV vaccination, on the other hand, seems relatively simple and "taming uncertainty" positions them as instrumental in limiting (or even eliminating) morbidity and mortality in future generations.

Coverage of the English national human papillomavirus (HPV) immunisation programme among 12 to 17 year-old females by area-level deprivation score, England, 2008 to 2011

The English national human papillomavirus (HPV) immunisation programme has offered vaccination to girls aged 12 years at the start of each school year since September 2008. A catch-up programme has offered vaccination to girls up to 18 years. Delivery is predominantly school-based, with some general practitioner (GP)-based immunisation. The relationship between HPV immunisation coverage and deprivation (index of multiple deprivation, IMD) was assessed by geographical area (N=151) for each school year offered the HPV vaccine between 2008 to 2011 using the Spearman’s rank correlation coefficient, and compared to that for adequate cervical screening of women aged 25 to 49 years. Coverage at age 12 showed no significant association with IMD at the area-level (p=0.12). Within the catch-up years, there was some suggestion of higher deprivation being associated with lower coverage. This was not significant for girls offered immunisation under 16 years (in compulsory education) (p=0.09), but was more marked and statistically significant for older girls (p<0.0001). The proportion of women aged 25 to 49 years with an adequate cervical screen was negatively associated with deprivation (p<0.0001). School-based HPV immunisation delivery appears to be successfully reducing inequalities in cervical cancer control at area-level. However, the catch-up cohorts above the age of compulsory education may face increased inequality. Further investigation is needed into individual-level factors associated with coverage.

Is human papillomavirus screening preferable to current policies in vaccinated and unvaccinated women? A cost-effectiveness analysis

Objectives

Italy was the first European nation to offer free vaccination against human papillomavirus (HPV) types 16 and 18. The vaccination is actively encouraged and is available free of charge to 11-year-old girls. The introduction of new technologies such as HPV DNA testing and HPV vaccination requires cost-effectiveness analysis of cervical cancer strategies in Italy for both vaccinated and unvaccinated women.

Methods

A calibrated Markov model was developed to describe the natural history of HPV infection and cervical carcinogenesis. We performed a microsimulation generating the life histories of 10 million women. Changes in these life histories occur as consequences of prevention strategies. We estimated costs of screening activities using an activity-based costing analysis. We assessed lifetime risk due to cervical cancer, lifetime costs and quality-adjusted life-expectancy (QALE) for 18 scenarios. Strategies varied by screening interval (three and five years), primary and triage test (Pap test and HPV DNA test), and HPV 16 and 18 vaccination.

Results

The current screening policy (Pap test every three years) is more costly and less effective than HPV DNA test and Pap test triage every five years. For unvaccinated women an HPV DNA test every five years with a Pap test triage was cost-effective (ICER €5753/QALE). Vaccination followed by the same screening strategy was cost-effective (ICER €23,951/QALE) for women who are eligible to be vaccinated.

Conclusions

Our findings strongly support changing the Pap screening policy to the use of HPV DNA as a primary test with Pap test triage for both vaccinated and unvaccinated women.

A comparison of the use of economics in vaccine expert reviews

We reviewed how health economics has been included in the vaccine expert review processes in a sample of countries. We identified two kinds of review processes - those in which vaccines and drugs are assessed using a common process, and those in which vaccines are assessed within the infectious disease framework. In either process, the countries recommend that their national pharmaco-economic (i.e., guidelines developed for drugs) guidelines be used to conduct the studies, although the guidelines themselves differ between countries. As a result of these factors, the decision process and the study outcomes can differ between countries, but because the vaccine adoption process includes other criteria as well, economic factors will not necessarily alter the outcome.

Comparison of quality of internet pages on human papillomavirus immunization in Italian and in English

PURPOSE

Information available on the Internet about immunizations may influence parents' perception about human papillomavirus (HPV) immunization and their attitude toward vaccinating their daughters. We hypothesized that the quality of information on HPV available on the Internet may vary with language and with the level of knowledge of parents. To this end we compared the quality of a sample of Web pages in Italian with a sample of Web pages in English.

METHODS

Five reviewers assessed the quality of Web pages retrieved with popular search engines using criteria adapted from the Good Information Practice Essential Criteria for Vaccine Safety Web Sites recommended by the World Health Organization. Quality of Web pages was assessed in the domains of accessibility, credibility, content, and design. Scores in these domains were compared through nonparametric statistical tests.

RESULTS

We retrieved and reviewed 74 Web sites in Italian and 117 in English. Most retrieved Web pages (33.5%) were from private agencies. Median scores were higher in Web pages in English compared with those in Italian in the domain of accessibility (p < .01), credibility (p < .01), and content (p < .01). The highest credibility and content scores were those of Web pages from governmental agencies or universities. Accessibility scores were positively associated with content scores (p < .01) and with credibility scores (p < .01). A total of 16.2% of Web pages in Italian opposed HPV immunization compared with 6.0% of those in English (p < .05).

CONCLUSIONS

Quality of information and number of Web pages opposing HPV immunization may vary with the Web site language. High-quality Web pages on HPV, especially from public health agencies and universities, should be easily accessible and retrievable with common Web search engines.

EUROGIN 2008 roadmap on cervical cancer prevention

The EUROGIN 2008 Roadmap represents a continuing effort to provide updated information on primary and secondary prevention of cervical cancer. The report addresses several areas including the progress made toward global implementation of currently licensed human papillomavirus (HPV) vaccines, the possibilities and value of future-generation HPV vaccines, endpoints under consideration for evaluation of candidate HPV vaccines, and monitoring impact of HPV vaccination programmes that can be implemented within developed and less-developed countries. For the sake of completeness, a short update on the evolution of HPV testing in primary screening programmes at present and after HPV vaccine introduction has also been included. The report is available on the EUROGIN website (www.eurogin.com).

Medical societies' recommendations for immunization with Human Papillomavirus vaccine and disclosure of conflicts of interests

OBJECTIVE

To review the recommendations on Human Papillomavirus (HPV) vaccination issued by different medical societies, as well as disclosures of any conflict of interests regarding such recommendations.

METHODS

The search for recommendations was mainly conducted through the Internet, together with a bibliography search on Pubmed (November 2008). The countries were selected to encompass a broad range of healthcare systems and income levels.

RESULTS

In all, 18 documents were identified: 4 from the U.S., 5 from Canada, and 1 from France (all 10 in favor of recommending vaccination), 5 from Spain (3 in favor of vaccination and 2 recommending no vaccination until further evidence of the vaccine effectiveness to prevent cervical cancer becomes available), 2 from Argentina (one in favor of vaccination and another pointing to the missing information on the vaccine's cost-effectiveness), and 1 from Chile (recommending no vaccination until more information becomes available). Only two documents disclose specific conflicts of interests for authors (American Cancer Society and Chilean Working Group on HPV). One of the Canadian documents did not include any conflict of interest statement, although Merck and GSK are listed among the sponsors.

CONCLUSIONS

Disclosure of conflicts of interest in documents where medical societies issue recommendations on HPV vaccination is very unusual. However, lack of disclosure is more frequent (near twice) when recommendations are in favor of the vaccination.

Economic evaluations of massive HPV vaccination: within-study and between study variations in incremental cost per QALY gained

OBJECTIVE

We describe the heterogeneity of the estimates of the incremental cost per quality-adjusted year of life (QALY) within and between cost-utility studies of the human papillomavirus (HPV) vaccine.

METHOD

We searched for articles in English published in peer-reviewed journals that perform cost-utility analyses to evaluate the addition of HPV vaccine to 12-year-old girls to existing cervical cancer screening practices. Fifteen studies were selected according to our inclusion and exclusion criteria.

RESULTS

There are large within-study variations in estimates of the cost per QALY gained. The most influential source of uncertainty is the duration of the vaccine protection. Between-study variations are mainly due to three causes: methodological differences, assumptions, and local conditions in the application area. We find large variations between studies for a given country.

DISCUSSION

Economic evaluation models are increasingly sophisticated, but scientific treatment of epidemiological and market uncertainty does not compensate for the lack of basic information.

CONCLUSIONS

The large disparities in cost per QALY estimates of massive vaccination programs around the world may be attributed to several critical sources (unavoidable and avoidable) of uncertainty. An asset of economic evaluation is the ability to highlight the areas of research that could be undertaken to reduce uncertainty.

New paradigms in cervical cancer prevention: opportunities and risks

Testing for the DNA of high-risk types of papilloma virus (HPV) is more sensitive than cytology in detecting pre-cancerous lesions. One of the main advantages will be the possibility of applying prolonged screening intervals. However adequate screening protocols (age of start and stop, screening intervals, management of HPV positive women) need to be applied in order to avoid over-referral to colposcopy and over-treatment and to maintain sustainable costs. Further follow-up of running trials and research on molecular markers will better define these parameters. The new situation will require organised screening programmes with rigorous protocols and monitoring. This will be even more needed when women vaccinated for HPV 16 and 18 will be screened. Research on how to best screen vaccinated women is a priority. This paper proposes an overview of the plausible impact of new technologies in cervical cancer screening in the near future and in the vaccinated cohorts.