HPV vaccine introduction in the Americas: a decade of progress and lessons learned

Figures & data

Table 1. Characteristics and technical aspects of the available^‡ HPV vaccines.

	Bivalent	Quadrivalent	Nonavalent
Manufacturer	GSK	Merck	Merck
Composition	20 µg HPV16 L1 protein20 µg HPV18 L1 proteinAdjuvant: AS04	20 µg HPV6 L1 protein40 µg HPV11 L1 protein40 µg HPV16 L1 protein20 µg HPV18 L1 proteinAdjuvant: AAHS	30 µg HPV6 L1 protein40 µg HPV11 L1 protein60 µg HPV16 L1 protein40 µg HPV18 L1 protein20 µg HPV31 L1 protein20 µg HPV33 L1 protein20 µg HPV45 L1 protein20 µg HPV52 L1 protein20 µg HPV58 L1 proteinAdjuvant: AAHS
Indication	Use in females and males from the age of 9 years for the prevention of premalignant anogenital lesions affecting the cervix, vulva, vagina and anus, and cervical and anal cancers causally related to specific HPV types.	Use in females and males from the age of 9 years for the prevention of premalignant lesions and cancers affecting the cervix, vulva, vagina, and anus caused by high-risk HPV types, and anogenital warts causally related to specific HPV types.
Recommended schedule	9–14 years old: two doses six month apart≥15 years old or known immunodeficiency: three doses, 0-2-6 months intervalNote: there is no upper limit on the duration of interval between doses; however, every effort should be made to initiate the recommended series before sexual debut.
Recommended age for vaccination	For the prevention of cervical cancer: girls ages 9–14, prior to sexual debut. Selection of specific age cohort or range should align with delivery strategy.For prevention of secondary outcomes: boys and older girls only once after achieving coverage >80% in girls and if considered feasible, affordable, and complementary to the existing cervical cancer control objectives.
Route of administration	Intramuscular injection
Presentation	Single or two dose vial	Single dose vialPre-filled single dose syringe	Single dose vialPre-filled single dose syringe
Efficacy	Hildesheim et al., 2014Lehitenen et al., 2012Against CIN2+ regardless of genotype: 64.9%Against CIN3+ regardless of genotype: 93.2%	Kjaer et al., 2009Munoz et al. 201098.2% (95 CI: 93.3–99.8) against HPV16/18 related CIN2+ in women naïve to HPV16/1851.5% (95 CI: 40.6–60.6) against HPV16/18 related CIN2+ in women who had prevalent HPV16/18 infection at vaccination100% (95 CI:) against anogenital warts HPV6/1190.4% (95 CI: 69.2–98.1) against external genital lesions related to HPV16/18/11/6 in men (Giuliano et al. 2011) and 77.5% (95 CI: 39.6–93.3) against anal intraepithelial neoplasia related to vaccine targeted genotypes in men (Palefsky et al., 2011).	97.4% (95 CI: 85–99.9) against high-grade cervical, vulvar, and vaginal lesions related to HPV genotypes 31, 33, 45, 52, and 58; and immune responses non-inferior to HPV4 against HPV6, 11, 16, and 18.Huh et al., 2017
Safety	HPV vaccine has an excellent safety profile, with a lower number of Adverse Events Following Immunization (AEFIs) than many other vaccines
Cost-effectiveness	Most published cost-effectiveness analyses (n = 24) regarding the introduction of HPV vaccine (any product) compared to no vaccination or screening alone have yielded economically favorable incremental cost-effectiveness ratios (cost per incremental unit of health) in Latin America and the Caribbean. ICERs (standardized to International Dollars) ranged from <0 to 214,000 I$, with more than 60% of studies reporting a ICER below a willingness-to-pay threshold equal to 1 GDP per capita, concluding that HPV vaccination, specifically in young girls, is cost-effective or cost-savings in most country contexts in the region (Tejada, Malgon, Franco 2022).
Price/affordability	Not currently offered via PAHO Revolving Fund; country negotiated prices vary and not publicly available	US$9.98 per dose(PAHO Revovling Fund, 2020)	Not currently offered via PAHO Revolving Fund; country negotiated prices vary and not publicly available

^‡Only these 3 HPV vaccine products were used or are currently used in the region. Another bivalent vaccine product (Cecolin) is available, but not currently in use.

Table 2. HPV vaccine introduction and program characteristics in Latin America and the Caribbean, 2020, by country^‡,†.

Country	Vaccine, year(s) introduced	Primary target population	Secondary target populations	Primary vaccination schedule	Delivery approach	Complete series primary target group coverage in females, 2020	Dropout^§ among females in target group, 2020
Anguilla	Bivalent, 2016 Quadrivalent, ...	Girls 9–11 years	…	…	…	…	…
Antigua and Barbuda	Quadrivalent, 2018	Girls and boys 9–13 years	Males and females 14–26 years	2-doses at 0 and 6 months 14–26: 3-doses	Facility-based	…	…
Argentina	Quadrivalent, 2011	Girls and boys 11 years	Males and females age 11–26 living with HIV and/or organ transplants	2-doses at 0 and 6 months	School-based and facility-based, varies by province	46%	26%
Aruba	Quadrivalent, 2014	Girls 11–12 years	…	…	…	…	…
Bahamas	Quadrivalent, 2015	Girls and boys 9–10 years	…	3-doses at 0, 1–2, and 6+ months	School-based	4%	8%
Barbados	Quadrivalent, 2014	Girls and boys 11 years	…	2-doses at 0 and 6 months	School-based	7%	57%
Belize	Quadrivalent, 2016	Girls 9–14 years	Boys on request and availability of vaccine	2-doses at 0 and 6 months	School-based	11%	40%
Bermuda	Quadrivalent, 2017	Girls 9–13 years	…	…	…	…	…
Bolivia	Quadrivalent, 2017	Girls 10 years	…	2 doses at 0 and 6 months	School-based	24%	36%
Bonaire	Quadrivalent, 2015	Girls 11–12 years	…	…	…	…	…
Brazil	Quadrivalent, 2013	Girls 9–14 years; Boys 11–14 years	Males and females 9–26 years of special risk groups	2 doses at 0 and 6 months	…	72%	16%
British Virgen Island	Bivalent, 2019 Quadrivalent, current	Girls 10 − 11 years	…	…	…	…	…
Canada	Quadrivalent, 2007–2009 Nonavalent, current	Girls and boys 12–13 years	Catch-up for girls and boys grades 8–12	2-doses at 0 and 6 months		87%	…
Cayman Islands	Quadrivalent, 2019	Girls 10–11 years	…	…	…	…	…
Chile	Quadrivalent, 2014	Girls and boys 9 years	Catch-up >14 years	2-doses at 0 and 12 months	School-based	74%	4%
Colombia	Quadrivalent, 2012	Girls 9–17 years	…	2-doses at 0 and 6 months	School-based	34%	23%
Costa Rica	Quadrivalent, 2019	Girls 10 years	…	2-doses at 0 and 6 months	School-based	…	…
Dominica	Quadrivalent, 2019	Girls and boys 11–12 years	…	2-doses at 0 and 6 months	School = based	69%	11%
Dominican Republic	Bivalent, 2017 Quadrivalent, ,,,	Girls 9–14 years	…	2-doses at 0 and 6 months	School-based	7%	11%
Ecuador	Bivalent, 2014 Quadrivalent, current	Girls 9 years	…	2-doses at 0 and 6 months	School-based	36%	39%
Guadeloupe	Quadrivalent, 2008	Girls 11–14 years	…	…	…	…	…
Guatemala	Quadrivalent, 2018	Girls 10–14 years	…	2-doses at 0 and 6 months	School-based	20%	18%
Guyana	Quadrivalent, 2012–2017 (phased)	Girls and boys 9–16 years	…	9–14 years: 2-doses at 0 and 6 months 15–16 years: 3 doses doses at 0, 1–2, and 6 months	School-based	25%	7%
Grenada	Quadrivalent, 2019	Girls 10–11 years	…	…	…	32%	25%
Honduras	Quadrivalent, 2016	Girls 11 years	…	2-doses at 0 and 6 months	School-based	47%	20%
Jamaica	Bivalent, 2017 Quadrivalent, ...	Girls 11–12 years	…	2-doses at 0 and 6 months	School-based	3%	5%
Mexico	Quadrivalent, 2012	Girls 9–11 years	HIV+ females 11–49 years	2-doses at 0 and 6 months	School-based	5%	12%
Monserrat	Bivalent, 2017 Quadrivalent, current	Girls and boys 10–11 years	…	…	…	…	…
Panama	Quadrivalent, 2008	Girls and boys 10 years	Sexual abuse victims and HIV+ individuals	2-doses at 0 and 6 months	School-based and facility-based	44%	23%
Paraguay	Quadrivalent, 2013	Girls 10 years	…	2-doses at 0 and 6 months	School-based and facility-based	37%	19%
Peru	Quadrivalent, 2015	Girls 10 years	…	2-doses at 0 and 6 months	School-based	16%	63%
Puerto Rico	Quadrivalent, 2006	Girls and boys 11–12 years	…	…	…	…	…
Saba	Bivalent, 2013 Quadrivalent, current	Girls 11–12 years	…	…	…	…	…
Saint Lucia	Quadrivalent, 2019	Girls and boys 10–11 years	…	2-doses at 0 and 6 months	School-based	74%	…
Saint Maarten	Quadrivalent, 2013	Girls 11–12 years	…	…	…	…	…
Saint Eustatius	Bivalent, 2013 Quadrivalent, current	Girls 11–12 years	…	…	…	…	…
Saint Kitts and Nevis	Quadrivalent, 2019	Girls and boys 10–11 years	…	2-doses at 0 and 6 months	School-based	12%	…
Saint Vincent and Grenadines	Bivalent, 2017 Quadrivalent, current	Girls 11 years	…	2-doses at 0 and 6 months	School-based	12%	…
Suriname	Bivalent, 2013 Quadrivalent, current	Girls 9–13 years	…	2-doses at 0 and 6 months	School-based	4%	13%
Trinidad and Tobago	Quadrivalent, 2012	Girls and boys 11–14 years	Females 15–45 years; Males 15–26 years	2-doses at 0 and 6 months	School-based and facility-based	…	…
Turks and Caicos	Bivalent, 2019 Quadrivalent, ...	Girls 11–12 years	…	…	…	…	…
USA	Quadrivalent, 2006 Nonavalent, 2015	Girls and boys 11–12 years	Catch-up through age 26; Shared clinical decisionmaking ages 27–45	2-doses at 0 and 6–12 months	Facility-based	49%	19%
Uruguay	Quadrivalent, 2013	Girls and boys 11 years	…	2-doses at 0 and 6 months	Facility-based	25%	13%

^‡… refers to no data is available

^†The table summarizes data reported to PAHO/WHO via the PAHO/WHO/UNICEF Joint Reporting Form on Immunization: https://ais.paho.org/imm/IM_JRF_COVERAGE.asp

^§Dropout refers to the proportion of the target population who do not complete the second dose of the schedule, where recommended. The coverage of a single dose of HPV vaccine is the sum of last two columns. Single dose coverage is much higher than two-dose coverage of the HPV vaccine in the region.