Cost-effectiveness of nonavalent HPV vaccination in the Netherlands

Figures & data

Figure 1. Flow diagram of the model for cancers associated with human papillomavirus infection.

HPV, human papillomavirus.

Figure 2. Forecasted incidence of nonavalent human papillomavirus vaccine-strain-attributable (a) cervical cancer and (b) all other anogenital plus head & neck cancers in the Netherlands with strategies using a bivalent or nonavalent human papillomavirus vaccine for individuals ≥9 years of age before sexual debut, with or without catch-up vaccination programs for individuals ≤26 years of age.

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine.

The 2vHPV (status quo) strategy includes an immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 2vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The 9vHPV and 9vHPV plus catch-up strategies are as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine.

Figure 3. Forecasted incidence of nonavalent human papillomavirus vaccine-strain-attributable anogenital warts in the Netherlands with strategies using a bivalent or nonavalent human papillomavirus vaccine for individuals ≥9 years of age before sexual debut, with or without catch-up vaccination programs for individuals ≤26 years of age.

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine.

The 2vHPV (status quo) strategy includes an immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 9vHPV strategy is as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine. The 9vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The data for the 2vHPV and 2vHPV plus catch-up strategies were identical, and therefore only the former is included in the graph.

Figure 4. Forecasted incidence of nonavalent human papillomavirus vaccine-strain-attributable (a) juvenile-onset and (b) adult-onset recurrent respiratory papillomatosis in the Netherlands with strategies using a bivalent or nonavalent human papillomavirus vaccine for individuals ≥9 years of age before sexual debut, with or without catch-up vaccination programs for individuals.

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine.

The 2vHPV (status quo) strategy includes an immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 9vHPV strategy is as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine. The 9vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The data for the 2vHPV and 2vHPV plus catch-up strategies were identical, and therefore only the former is included in the graphs.

Table 1. Nonavalent human papillomavirus vaccine-strain-attributable disease cases and deaths in the Netherlands over 100 years with use of 9vHPV versus 2vHPV, with and without catch-up vaccination.

	2vHPV		9vHPV		2vHPV + catch-up		9vHPV + catch-up
Estimated outcomes per vaccination scenario	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths
CIN
CIN1	999		658		940		599
CIN2–3	6,897		4,816		6,532		4,451
Cancer
Total	36,541	7,903	33,296	7,078	35,180	7,658	31,935	6,833
Female	24,289	6,082	21,269	5,292	23,556	5,911	20,536	5,121
Anal	3,504	348	3,311	319	3,336	334	3,143	305
Cervical	12,123	4,110	9,987	3,468	11,697	3,975	9,561	3,333
Oropharyngeal	1,851	280	1,840	279	1,765	267	1,754	266
Vaginal	773	283	727	268	769	282	723	267
Vulvar	6,038	1,060	5,404	959	5,989	1,052	5,355	951
Male	12,251	1,821	12,027	1,785	11,623	1,747	11,399	1,711
Anal	4,664	473	4,648	471	4,282	436	4,266	434
Oropharyngeal	2,717	320	2,657	314	2,559	302	2,499	296
Penile	4,871	1,028	4,722	1,000	4,783	1,009	4,634	981
Anogenital warts
Total	1,226,998		217,361		1,226,998		217,361
Female	804,341		141,242		804,341		141,242
Male	422,657		76,119		422,657		76,119
RRP
Total	5,167	246	919	55	5,167	246	919	55
Female	2,701	129	475	29	2,701	129	475	29
Male	2,466	117	444	26	2,466	117	444	26

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine; CIN, cervical intraepithelial neoplasia; RRP, recurrent respiratory papillomatosis. The 2vHPV (status quo) strategy includes immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 2vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The 9vHPV and 9vHPV plus catch-up strategies are as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine.

^aDue to rounding, total values may not equal the sum of all subgroup values.

Table 2. Cost-effectiveness outcomes of four base-case human papillomavirus vaccination strategies in the Netherlands over 100 years.

Strategy	Cost per capita (€)	QALYs per capita	ICER (€/QALY)
2vHPV (status quo)	69.11	47.37613035	NA
2vHPV + catch-up	82.23	47.37633838	Dominated^a
9vHPV	73.72	47.37705608	4,975^b
9vHPV + catch-up	88.36	47.37741902	40,331^c

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine; ICER, incremental cost-effectiveness ratio; NA, not applicable; QALY, quality-adjusted life year. The 2vHPV (status quo) strategy includes immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 2vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The 9vHPV and 9vHPV plus catch-up strategies are as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine.

^aThe 2vHPV plus catch-up vaccination strategy was dominated by the 9vHPV strategy, which cost less and resulted in more QALYs per capita. The ICER for the 2vHPV plus catch-up strategy was therefore negative.

^bCompared to the 2vHPV strategy.

^cCompared to the 9vHPV strategy.

Figure 5. Deterministic sensitivity analysis of the incremental cost-effectiveness ratios of 9vHPV versus 2vHPV human papillomavirus vaccination strategies for the Netherlands over 100 years.

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year. The 2vHPV (status quo) strategy includes an immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 9vHPV strategy is as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine.

Table 3. Cost-effectiveness outcomes of four human papillomavirus vaccination strategies in the Netherlands over 100 years in scenarios of increased vaccination coverage or cross-protection against additional viral strains.

Strategy	Improved vaccination coverage scenario^a			Cross-protection scenario^b
	Cost per capita (€)	QALYs per capita	ICER (€/QALY)	Cost per capita (€)	QALYs per capita	ICER (€/QALY)
2vHPV (status quo)	82.72	47.37628462	NA	69.14	47.37613782	NA
2vHPV + catch-up	103.76	47.37657740	Dominated^c	82.29	47.37638618	Dominated^c
9vHPV	89.63	47.37726251	7,067^d	73.72	47.37705608	4,991^d
9vHPV + catch-up	113.39	47.37775911	47,837^e	88.36	47.37741902	40,331^e

2vHPV, bivalent human papillomavirus vaccine; 9vHPV, nonavalent human papillomavirus vaccine; ICER, incremental cost-effectiveness ratio; NA, not applicable; QALY, quality-adjusted life year. In the base case, the 2vHPV (status quo) strategy includes immediate transition to vaccination of individuals ≥9 years of age (change from ≥12 years of age), with a year of catch-up vaccination for individuals 11 years of age in the year of transition. Vaccination coverage is assumed to continue at 70% for girls and 50% for boys. The 2vHPV plus catch-up strategy adds vaccination of individuals ≤26 years of age for 3 years such that coverage among this age group increases to 70% for girls/women and 50% for boys/men. The 9vHPV and 9vHPV plus catch-up strategies are as for the 2vHPV versions, but with an immediate switch from a bivalent to a nonavalent HPV vaccine.

^aVaccination coverage was immediately increased to 90% among females and 70% among males in both the primary group (adolescents) and the catch-up group (individuals ≤26 years of age).

^bModel incorporated impact of cross-protection provided by the bivalent vaccine against persistent infection with HPV strains 31, 33, and 45.

^cThe 2vHPV + catch-up vaccination strategy was dominated by the 9vHPV strategy, which cost less and resulted in more QALYs per capita. The ICER for the 2vHPV + catch-up strategy was therefore negative.

^dCompared to the 2vHPV strategy.

^eCompared to the 9vHPV strategy.