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Following is a list of published articles and reviews regarding Pneumococcal conjugate vaccinations' economic impact and cost effectiveness in the Latin American and Caribbean region:
Vaccine Impact and Disease Prevention
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- Andrus, J.K., Lewis, M.J., Goldie, S.J., García, P.J., Winkler, J.L., Ruiz-Matus, C. & de Quadros, C.A. 2008, “Human papillomavirus vaccine policy and delivery in Latin America and the Caribbean,” vol. 26 (Suppl. 11), pp. L80-L87.
Abstract
Cervical cancer caused by human papillomavirus (HPV) is a major preventable public health problem. Two vaccines are now available for primary prevention of HPV infection and their introduction offers new opportunities to enhance comprehensive cervical cancer prevention and control. Currently, HPV vaccine price is a significant barrier to rapid vaccine introduction and access. Therefore, making evidence based decisions about whether and how to introduce HPV vaccine into the immunization schedule in the countries of Latin America and the Caribbean (LAC) requires a rigorous analysis of several factors. These include: estimates of disease burden, cost-effectiveness, operational feasibility of reaching a population of adolescent females and other key analyses that have been used in recent years to support the introduction of other vaccines, such as rotavirus and pneumococcal conjugate vaccines. Given the large number of public health priorities that are competing for limited public resources, developing and using a sound evidence base is of particular importance for vaccines, like HPV, which are currently available only at prices higher than other vaccines now in use. HPV vaccination provides the opportunity to dramatically improve women’s health and partnerships must also be broad-based and effectively coordinated. This can be achieved by developing programs based on the lessons learned from vaccination strategies used to eliminate rubella and neonatal tetanus and for scaling up influenza vaccination in countries of LAC.
© 2008 Published by Elsevier Ltd.
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Abstract: Cervical cancer is a major cause of suffering and premature death among women in the developing world, yet it is largely prevented in most higher-income countries. From an equity perspective, cervical cancer is unequally distributed globally in ways that are unnecessary, avoidable and unjust. Although cost-effectiveness analyses demonstrate that prevention measures are justified in low-resource countries, affordability and lack of prioritisation have contributed to a lack of progress. This paper describes the inequities in cervical cancer disease burden, barriers in access to and utilisation of services, and the underlying conditions of poverty and low socio-economic status that put women in a disadvantaged position. These social disadvantages are aggravated by the disease itself, with serious consequences for women, their families and communities. Remedies are available in the form of new prevention and treatment approaches, including vaccines against human papillomavirus (HPV), rapid HPV testing, visual inspection of the cervix with acetic acid (VIA) and cryotherapy. These technologies could help to overcome the social, economic, and political disadvantages that contribute to disparities in cervical cancer incidence and mortality through an optimal combination of vaccination, screening and treatment. In the long run, however, increasing women's access to care will also require societies to address structural barriers related to health systems and poverty.
©2008 Reproductive Health Matters. All rights reserved.
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- Goldie, S.J., Diaz, M., Constenla, D., Alvis, N., Andrus, J.K. & Kim, S.-Y. 2008, “Mathematical models of cervical cancer prevention in Latin America and the Caribbean,” Vaccine, vol. 26 (Suppl. 11), pp. L59-L72. .
Abstract
Using population and epidemiologic data for 33 countries in Latin America and the Caribbean (LAC), a model-based approach estimated averted cervical cancer cases and deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (I$/DALY averted) for human papillomavirus (HPV) vaccination of young adolescent girls. Absolute reduction in lifetime cancer risk varied between countries, depending on incidence, proportion attributable to HPV-16 and 18, and population age-structure; for example, with 70% coverage, cancer reduction ranged from 40% in Mexico to more than 50% in Argentina. Screening of women over age 30 three times per lifetime, after vaccinating them as pre-adolescents, is expected to provide a relative increase of 25% to 30% in mortality reduction. Countries with the highest risk of cancer (age-standardized rate > 33.6) accounted for only 34% of deaths averted with vaccination, highlighting why a regional universal vaccination approach will be most effective in reducing the overall global burden. At I$25 per vaccinated girl ($5 per dose), for all 33 countries, the cost per DALY averted is less than I$400; at I$10 ($2 per dose) the vaccine is cost saving in 26 out of 33 countries. For all countries, ratios become less attractive (i.e., increase) as the cost of the vaccine increases. For example, at current vaccine prices ($120 per dose), the cost per DALY averted is I$7,300 in Mexico, I$3,700 in Nicaragua, and I$6,300 in Costa Rica. Vaccine price has an even greater effect on predicted affordability. For the 33 countries, vaccinating 5 consecutive birth cohorts at 70% coverage would cost $360 million at $5.00 per dose, $811 million at $12.25 per dose, and $1.26 billion at $19.50 per dose. In the LAC region, if effective delivery mechanisms can achieve high coverage rates in young adolescent girls, vaccination against HPV-16 and 18 will provide similar health value for resources invested as other new vaccines such as rotavirus. If the cost per vaccinated girl is less than I$25 HPV-16/18 vaccination would be very cost-effective in all 33 countries; for it to be affordable, costs may need to be lower.
© 2008 Elsevier Ltd. All rights reserved.
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Disease Burden and Economic Impact
- Colantonio, L., G?mez, J.A., Demarteau, N., Standaert, B., Pich?n-Riviére, A. & Augustovski, F., “Cost-effectiveness analysis of cervical cancer vaccine in five Latin American countries,” GlaxoSmithKline Biologicals. .
Abstract
Implementation of cervical cancer (CC) vaccination in Latin America is expected to reduce the high CC burden in those countries. But the efficiency of such vaccination programs in the region still remains unknown. This study assesses the cost-effectiveness and cost-utility of introducing vaccination into the current CC disease management of five Latin American countries (Argentina, Brazil, Chile, Mexico, and Peru). The modelling results indicate that universal mass vaccination is cost-effective in the current health care setting of each country (< 3 x gross domestic product per capita, per country) with a substantial number of CC cases and deaths avoided in addition to an increase of quality adjusted life years. This study will help guide the design of future clinical programmes and health-related policies. It will assist early and effective decision-making processes related to vaccine implementation in Latin America.
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- Andrés-Gamboa, O., Chicaíza, L., García-Molina, M., Diaz, J., González, M., Murillo, R., Ballesteros, M. & Sánchez, R. 2008, “Cost-effectiveness of conventional cytology and HPV DNA testing for cervical cancer screening in Colombia,” Salud Pública de México, vol. 50, no. 4, pp. 276-285.
Abstract
Objective: To assess cost-effectiveness of conventional cytology and HPV DNA testing for cervical-cancer screening in Colombia.
Material and Methods: The National Cancer Institute of Colombia (NCIC) in 2007 developed a Markov model on the natural history of cervical cancer; no screening, conventional cytology, and HPV DNA testing were compared. Only direct costs were used. Outcomes comprise cervical cancer mortality, years of life saved, and lifetime costs. Discounted incremental cost-effectiveness ratios were estimated and sensitivity analyses were conducted for key parameters.
Results: Depending on the screening strategy a 69-81% mortality reduction might be expected. The HPV DNA testing every five years is a cost-effective strategy (Incremental Cost-Effectiveness Ratio (ICER): USD$44/YLS) if the cost per test is under USD$31. The effectiveness was sensitive to coverage and primarily to follow-up.
Conclusions: HPV DNA testing is a cost-effective alternative for screening in Colombia. Not only high coverage but high follow-up rates are critical for successful screening programs.
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- Goldie, S.J., Kim, J.J., Kobus, K., Goldhaber-Fiebert, J.D., Salomon, J., O’Shea, M.K.H., Xavier Bosch, F., de Sanjosé, S. & Franco, E.L. 2007, “Cost-effectiveness of HPV 16, 18 vaccination in Brazil,” Vaccine, vol. 25, no. 33, pp. 6257-6270.
Abstract
We use an empirically calibrated model to estimate the cost-effectiveness of cervical cancer prevention in Brazil, a country with a high cervical cancer burden. Assuming 70% coverage, HPV 16, 18 vaccination of adolescent girls is expected to reduce the lifetime risk of cancer by approximately 42.7% (range, 33.2–53.5%); screening three times per lifetime is expected to reduce risk by 21.9–30.7% depending on the screening test, and a combined approach of vaccination and screening is expected to reduce cancer risk by a mean of 60.8% (range, 52.8–70.1%). In Brazil; provided the cost per vaccinated woman is less than I$ 25, implying a per dose cost of approximately I$ 5, vaccination before age 12, followed by screening three times per lifetime between ages 35 and 45, would be considered very cost-effective using the country’s per capita gross domestic product as a cost-effectiveness threshold. Assuming a coverage rate of 70%, this strategy would be expected to prevent approximately 100,000 cases of invasive cervical cancer over a 5-year period. Vaccination strategies identified as cost-effective may be unaffordable in countries with similar socioeconomic profiles as Brazil without assistance; these results can provide guidance to the global community by identifying health investments of highest priority and with the greatest promise.
© 2007 Elsevier Ltd. All rights reserved.
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- Insinga, R.P., Dasbach, E.J., Elbasha, E.H., Puig, A. & Reynales-Shigematsu, L.M. 2007, “Cost-effectiveness of quadrivalent human papillomavirus (HPV) vaccination in Mexico: A transmission dynamic model-based evaluation,” Vaccine, vol. 26, no. 1, pp. 128-139.
Summary We examined the potential health outcomes and cost-effectiveness of quadrivalent human papillomavirus (HPV) 6/11/16/18 vaccination strategies in the Mexican population using a multi-HPV type dynamic transmission model. Assuming similar cervical screening practices, with or without vaccination, we examined the incremental cost-effectiveness of vaccination strategies for 12 year-old females, with or without male vaccination, and temporary age 12—24 catch-up vaccination for females or both sexes. The most effective strategy therein was vaccination of 12-year-olds, plus a temporary 12—24-year-old catch-up program covering both sexes; whereby HPV 6/11/16/18-related cervical cancer, high-grade cervical precancer, and genital wart incidence was reduced by 84—98% during year 50 following vaccine introduction. Incremental cost-effectiveness ratios in the primary analyses ranged from $3000 (U.S.) per quality-adjusted life year (QALY) gained for female vaccination strategies to $16000/QALY for adding male vaccination with catch-up.
© 2007 Elsevier Ltd. All rights reserved.
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- Gutiérrez-Delgado, C., Báez-Mendoza, C., González-Pier, E., Prieto de la Rosa, A. & Witlen, R. 2008, “Generalized cost-effectiveness of preventative interventions against cervical cancer in Mexican women,” Salud Pública de México, vol. 50, no. 2, pp. 107-118. (Spanish and English).
Abstract
Objective. To develop a generalized cost-effectiveness analysis (GCEA) of the HPV vaccine, hybrid capture screening (HC) and Papanicolaou screening (Pap) in the Mexican context.
Materials and Methods. From April to August 2007, in Mexico, a GCEA of the interventions was developed for 10 possible scenarios using a Markov model from the public sector perspective as payer. Results. Scenarios considering 80% coverage show an ACER per DALY averted of $16 678 pesos for Pap of women between ages 25 and 64, $17 277 pesos for HC of women between ages 30 and 64, and $84 008 pesos for vaccination of 12-year-old girls. Annual financing of $621, $741 and $2 255 million pesos, respectively, is needed for these scenarios.
Conclusions. A selective, combined introduction of Pap-HC screening that considers the comparative advantages of application in different populations and geographical areas is suggested. Additionally, it is suggested to introduce the vaccine once a threshold price of $181 pesos per dose –when the vaccine becomes equal in terms of cost- effectiveness to HC– has been achieved.
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- Goldie, S.J., O’Shea, M., Campos, N.G., Diaz, M., Sweet, S. & Kim, S.-Y. 2008, “Health and economic outcomes of HPV 16-18 vaccination in 72 GAVI-eligible countries,” Vaccine, vol. 26, no. 32, pp. 4080-4093.
Abstract
The risk of dying from cervical cancer is disproportionately borne by women in developing countries. Two new vaccines are highly effective in preventing HPV 16, 18 infection, responsible for approximately 70% of cervical cancer, in girls not previously infected. The GAVI Alliance (GAVI) provides technical assistance and financial support for immunization in the world’s poorest countries. Using population-based and epidemiologic data for 72 GAVI-eligible countries we estimate averted cervical cancer cases and deaths, disability-adjusted years of life (DALYs) averted and incremental cost effectiveness ratios (I$/DALY averted) associated with HPV 16,18 vaccination of young adolescent girls. In addition to vaccine coverage and efficacy, relative and absolute cancer reduction depended on underlying incidence, proportion attributable to HPV types 16 and 18, population age-structure and competing mortality. With 70% coverage, mean reduction in the lifetime risk of cancer is below 40% in some countries (e.g., Nigeria, Ghana) and above 50% in others (e.g., India, Uganda, Kenya). At I$10 per vaccinated girl (?$2.00 per dose assuming three doses, plus wastage, administration, program support) vaccination was cost-effective in all countries using a per capita GDP threshold; for 49 of 72 countries, the cost per DALY averted was less than I$100 and for 59 countries, it was less than I$200. Taking into account country-specific assumptions (per capita GNI, DPT3 coverage, percentage of girls who are enrolled in fifth grade) for the year of introduction, percent coverage achieved in the first year, and years to maximum coverage, a 10-year modeled scenario prevented the future deaths of ?2 million women vaccinated as adolescents. Despite favorable cost-effectiveness, assessment of financial costs raised concerns about affordability; as the cost per vaccinated girl was increased from I$10 to I$25 (approximately $2 to $5 per dose), the financial costs for the 10-year scenario increased from>US$ 900 million to US$ 2.25 billion. Provided high coverage of young adolescent girls is feasible, and vaccine costs are lowered, HPV 16, 18 vaccination could be very cost-effective even in the poorest countries, and provide comparable value for resources to other new vaccines such as rotavirus.
© 2008 Published by Elsevier Ltd
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- Saxenian, H. 2007, “HPV vaccine adoption in developing countries: cost and financing issues,” International AIDS Vaccine Initiative/Program for Appropriate Technology in Health, retrieved May 4, 2010, Available from: http://www.rho.org/files/IAVI_PATH_HPV_financing.pdf.
Summary
This paper looks at a subset of challenges related to cost and financing requirements for HPV vaccine adoption in developing countries. It examines the cervical cancer burden in developing countries, characteristics of HPV vaccines, delivery challenges, likely cost and cost effectiveness of HPV vaccination in low- and middle-income countries, financial needs at the national level and across low-income countries as a group, and possible mechanisms for meeting these needs.
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Summary
Infection with human papillomavirus (HPV) is the primary cause of cervical cancer, other anogenital cancers, genital warts, and recurrent respiratory papillomatosis. Clinical studies have demonstrated that a prophylactic HPV vaccine can prevent infection, genital warts, and the precancerous lesions that lead to cervical cancer. Given the absence of data on the long-term effectiveness of HPV vaccination, a number of mathematical models have been developed to provide insight to policy makers by projecting the long-term epidemiologic and economic consequences of vaccination and evaluate alternative vaccination policies. This paper reviews the state of these models. Three types of HPV mathematical models have been reported in the literature: cohort, population dynamic, and hybrid. All have demonstrated that vaccination can significantly reduce the incidence of cervical cancer in the long term. However, only the cohort and hybrid models have evaluated the cost-effectiveness of vaccination strategies for preventing cervical cancer. These models have generally shown that vaccinating females can be cost-effective. None has accounted for the potential benefits of vaccinating the population to reduce the burden of recurrent respiratory papillomatosis and cancers of the vagina, vulva, anus, penis, and head/ neck. Given that only the population dynamic model can account for both the direct and indirect (i.e., herd immunity effects) benefits of vaccination in the population, future research should focus on further development of dynamic models by expanding the range of epidemiologic outcomes tracked and including the ability to assess the cost-effectiveness of alternative vaccination policies.
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