Schedules and strategies for HPV immunization Conclusions and proposed recommendations for SAGE

Transcription

1 1 Schedules and strategies for HPV immunization Conclusions and proposed recommendations for SAGE Andrew Pollard, SAGE Member SAGE meeting, October 2016

2 Questions for SAGE 2 1. What is the incremental effectiveness and cost-effectiveness for cervical cancer prevention of different HPV vaccines based on girls-only immunization? 2. What is the incremental effectiveness and cost-effectiveness for prevention of HPV-related diseases of adolescent genderneutral HPV immunization compared to girls-only HPV immunization? 3. What is the incremental effectiveness and cost-effectiveness for cervical cancer prevention of immunization of multiple female cohorts (multiple age cohorts within a defined age range) compared to single age cohort immunization of only girls aged 9 13 years or of both girls and boys aged 9 13 years?

3 3 (1) What is the incremental effectiveness and costeffectiveness for cervical cancer prevention of different HPV vaccines based on girls-only immunization?

4 Age-standardized incidence rates (per 100,000 women) Comparison of cervical cancer incidence in countries that have and have not introduced HPV vaccine Size = 1,000 incident CC cases HPV vaccine introduced HPV vaccine NOT introduced India 0 Low Lower middle China Higher middle High WB country income classification Sources: IARC, GLOBOCAN 2012 (estimated annual number of new cervical cancer cases); World Bank, List of economies, July 2016; WHO/IVB Database, national HPV vaccine introductions as of 27 June 2016, based on country reports.

5 % of HPV-related cancers 5 Relative contribution of different viral types to cervical cancer World, % 10.2% Types for which all vaccines afford direct protection % 3.8% 5.9% Types for which 2/4-valent vaccines may afford crossprotection % 2.3% Types for which 9- valent vaccine affords direct protection 0% 20% 40% 60% 80% 100% Serrano et al, 2015 % cancers

6 Vaccine choice 6 Similar effectiveness of registered vaccines have to prevent cervical cancer due to HPV 16/18 Clinical trials and post-introduction observational studies point to cross-protection for non-vaccine HPV types by 2/4-valent vaccines Additional long-term data, including for CIN3, from post-introduction studies in near future

7 Question 1: Key modelling results 7 Effectiveness High population-level impact and strong herd effects Cost-effectiveness Immunization with any vaccine vs. no vaccination: Highly cost-effective, irrespective of vaccine and even w/o herd immunity or cross-protection Immunization with 9-valent vs. 2/4-valent vaccines: Dependent on cross-protection by 2/4-valent vaccine and vaccine cost

8 Question 1: Main considerations 8 Priority remains cervical cancer prevention through the immunization of girls, prior to sexual initiation Opportunity to harmonized age range to 9 14 years Introduction in national programmes should be strongly recommended, with current qualifiers At national level, country-wide introductions Phased only when immediate country-wide vaccination not affordable or operational

9 9 (2) What is the incremental effectiveness and costeffectiveness for prevention of HPV-related diseases of adolescent gender-neutral immunization compared to girlsonly HPV immunization?

10 Estimated cancer cases attributable to HPV, by regions World, Ferlay et al, 2013; Plummer et al, 2016

11 Burden of anogenital warts 11 Incidence/prevalence varies by study setting Impact on quality of life is difficult to relate to cancer burden Overall, very low quality of evidence

12 Question 2: Key modelling results Effectiveness HIC: strong herd effects from girls-only vaccination (even at low coverage) greater impact from increasing coverage in girls than including boys LMIC: same, but vaccinating boys can be beneficial under specific conditions Cost-effectiveness HIC: unlikely cost-effective if coverage in girls is >70 80% LMIC: lacking evidence, expected to vary by level of herd effects 12

13 Question 2: Main considerations 13 High coverage among adolescent girls is priority, then adding boys immunization generally not costeffective Nonetheless, tangible benefits of gender-neutral immunization Gender-neutral immunization could be considered based on national context

14 14 (3) What is the incremental effectiveness and cost-effectiveness for cervical cancer prevention of immunization of multiple female cohorts (multiple age cohorts within a defined age range) compared to single age cohort immunization of only girls aged 9 13 years or of both girls and boys aged 9 13 years?

15 % Reduction in HPV-16/18 prevalence Multiple age cohort immunization: HPV-16/18 & Girls-only vaccination, Coverage=80%, Vaccine duration=lifelong, Vaccine Efficacy=95% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CANADA INDIA 10 yr-old routine yr-olds yr-olds yr-olds &: HPV-ADVISE, Median (line) of model predictions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Years since start of Vaccination VIETNAM UGANDA

16 Question 3: Key modelling results 16 Effectiveness Rapid impact with stronger herd effects Greater impact by including additional cohorts Cost-effectiveness Cost-effective in ages 9 14 years, specially with 2- dose schedule Incremental cost-effectiveness in female ages 15 years dependent on country context

17 17 Question 3: Main considerations Due to direct and herd effects, targeting multiple age cohorts results in faster population impact. Also, economies of scale in delivery and programme resiliency Immunization of multiple cohorts of girls aged 9 14 years should be recommended As with single age cohort immunization, it will require adequate operational and financial planning

18 Thank you 18