Public health impact and cost-effectiveness of catch-up 9-valent HPV vaccination of individuals through age 45 years in the United States

Figures & data

Figure 1. Vaccination coverage for 9–45-year-old females and males over historical and analytic time horizon. The dashed segment is the historical coverage for this age group from 2007 to 2019 where it reaches 29.2% coverage. The lower curve is the status quo coverage from 2019 to 2119 with a final coverage of 73.8%. The upper curve is the expanded catch-up program coverage from 2019 to 2119 with a final coverage of 77.1%

Table 1. Cumulative HPV 6/11/16/18/31/33/45/52/58-related total diseases cases and deaths and cases averted over a 100-year time horizon, base case analysis

	Status-quo^b Number of cases^a			Expanded catch-up^c Number of cases^a			Cases averted compared with status quo
HPV-related disease	Female	Male	Total	Female	Male	Total	Female	Male	Total
Cervical cancer	335,909	-	335,909	320,187	-	320,187	15,721	-	15,721
Vulvar cancer	128,215	-	128,215	126,161	-	126,161	2,054	-	2,054
Vaginal cancer	33,097	-	33,097	32,545	-	32,545	552	-	552
Anal Cancer	136,448	87,458	223,905	132,620	84,416	217,036	3,827	3,042	6,869
Oropharyngeal cancer	128,132	509,557	637,689	125,707	500,852	626,558	2,425	8,705	11,131
Penile cancer	-	54,501	54,501	-	52,972	52,972	-	1,529	1,529
All cancers	761,800	651,516	1,413,316	737,220	638,239	1,375,459	24,580	13,276	37,856
CIN 1	5,357,575	-	5,357,575	5,426,836	-	5,426,836	171,472	-	171,472
CIN 2/3	2,723,260	-	2,723,260	2,408,792	-	2,408,792	314,468	-	314,468
VaIN 1	101,028	-	101,028	97,615	-	97,615	3,413	-	3,413
VaIN 2/3	151,076	-	151,076	147,221	-	147,221	3,855	-	3,855
Genital warts	2,506,613	2,973,091	5,479,704	1,721,140	2,015,104	3,736,243	785,473	957,987	1,743,461
RRP	11,357	18,348	29,704	8,116	12,901	21,016	3,241	5,447	8,688
HPV-related diseases deaths	232,050	236,798	468,848	225,786	232,364	447,581	6,264	4,434	10,698
Cervical cancer deaths	107,657	-	107,657	103,835	-	174,690	3,821	-	3,821
Vaginal cancer deaths	13,311	-	13,311	13,100	-	10,955	211	-	211
Vulvar cancer deaths	30,605	-	30,605	30,135	-	22,132	471	-	471
Anal cancer deaths	19,359	12,885	32,243	18,842	232,364	34,264	516	424	940
Oropharyngeal cancer deaths	60,416	208,193	268,608	59,318	204,822	188,282	1,097	3,371	4,469
Penile cancer deaths	-	14,644	14,644	-	14,251	7,749	-	394	394
RRP deaths	702	1,076	1,779	555	831	9,510	147	245	392

^a Case counts are based on a static population size of 322.899 million.

^bStatus quo includes vaccination of 11–26 year females, and 11–21 year males

^cExpanded catch-up is defined as additional catch-up vaccination for females 27–45 and males 22–45.

Abbreviations: CIN, cervical intraepithelial neoplasia; HPV, human papillomavirus; RRP, recurrent respiratory papillomatosis; VaIN, vaginal intraepithileal neoplasia

Figure 2. Pre-vaccine era cumulative proportion of the age at acquisition of HPV infection. The cumulative proportion of HPV infection was calculated for all female high-risk HPV infection acquired by age. The proportion was calculated by summing all new incident HPV 16/18/31/33/45/52/58 infections within each age group, dividing by the total infections over all age groups and accumulating through each age group

Table 2. Cost-effectiveness results for base case analysis^ab.

Strategy	Treatment costs ($)	Screening costs ($)	Vaccine costs ($)	Total costs ($)	Total QALYs	Incremental cost-effectiveness ratio (ICER)^c ($/QALY)^b
Status quo	287.83	1,003.43	140.57	1,431.83	27.6097625	-
Expanded catch-up	280.15	1,003.34	187.00	1,470.49	27.6100365	141,000^d

^aCosts and QALYs are per capita accumulated over a 100-year time horizon with 3% annual discount rate. ^b Base case analysis compared two strategies: the status quo and expanded catch up. Status quo includes vaccination of 11–26 year females and 11–21 year males. Expanded catch-up is defined as additional catch-up vaccination for females 27–45 and males 22–45.

^bResults include impact of cervical, vaginal, vulvar, penile, anal, oropharyngeal cancers and precancers, genital warts, and RRP. ICER is rounded to nearest 1000.

^cICER is Incremental costs/Incremental QALYs

^dIncludes survival QALYs due to undiagnosed cancer deaths, when these QALYs are excluded the ICER is $142,000/QALY (see Appendix 4 for additional information)

Abbreviations: ICER, incremental cost-effectiveness ratio; QALYs, quality-adjusted life years

Table 3. Cost-effectiveness for expanded HPV Vaccination: incremental increase of upper age limit of expanded catch-up^a.

Strategy	Treatment costs ($)	Screening costs ($)	Vaccine costs ($)	Total costs ($)	Total QALYs (QALY)	ICER ($/QALY)
Status quo^b	287.83	1,003.43	140.57	1,431.83	27.6097625	–
Expanded catch-up for 13–26 year-olds	286.60	1,003.42	146.68	1,436.70	27.6098038	Weakly Dominated ($117,000^c)
Expanded catch-up for 13–29 year-olds	285.37	1,003.41	152.07	1,440.85	27.6098501	103,000^d
Expanded catch-up for 13–34 year-olds	283.21	1,003.38	162.70	1,449.29	27.6099291	107,000^e
Expanded catch-up for 13–39 year-olds	281.42	1,003.35	174.47	1,459.24	27.6099926	157,000^f
Expanded catch-up for 13–45 year-olds	280.15	1,003.34	187.00	1,470.49	27.6100365	256,000^g

^aCosts and QALYs are per capita accumulated over a 100-year time horizon with 3% annual discount rate.

^bStatus quo includes vaccination of 9–26 year females, and 9–21 year males

^cThe ICER of current ACIP recommendations (harmonization) compared with status quo is $117,000/QALY

^dICER for expanded catch-up for 13–29 years, compared with status quo

^eICER for expanded catch-up for 13–34 years, compared with vaccinating 13–29 years

^fICER for expanded catch-up for 13–39 years, compared with vaccinating 13–34 years

^gICER for expanded catch-up for 13–45 years, compared with vaccinating 13–39 years

Abbreviations: ICER, incremental cost-effectiveness ratio; QALYs, quality-adjusted life years

Table 4. Cost-effectiveness results for sensitivity analysis^a.

Strategy		Total costs ($)	Total QALYs (QALY)	ICER ($/QALY)
Discount rate
0%	Status quo	4,137.56	86.1119756	-
	Expanded catch-up	4,202.94	86.1132341	52,000
1.5%	Status quo	2,243.69	44.7814782	-
	Expanded catch-up	2,291.35	44.7820234	87,000
3% (base case)	Status quo	1,431.83	27.6097625	-
	Expanded catch-up	1,470.49	27.6100365	141,000
5%	Status quo	936.83	17.5092661	-
	Expanded catch-up	968.57	17.5094005	236,000
Costs
Lower limit values	Status quo	1,069.87	27.6097625	–
	Expanded catch-up	1,110.48	27.6100365	148,000
Upper limit values	Status quo	1,737.76	27.6097625	–
	Expanded catch-up	1,773.58	27.6100365	131,000
Health utilities
Lower limit values	Status quo	1,432.87	27.6035336	–
	Expanded catch-up	1,471.52	27.6040961	69,000
Upper limit values	Status quo	1,432.87	27.6151270	–
	Expanded catch-up	1,471.52	27.6152287	380,000
Varying mid-adult uptake rates by gender
Status quo		1,431.83	27.6097625	–
Both Low (female = 1.76%; male = 1.42%)		1,453.74	27.6099179	141,000^b,c
Both High (female = 5.27%; male = 4.27%)		1,483.96	27.6101325	141,000^b,c
Female only (female = 3.5%; male = 0.0%)		1,445.27	27.6099200	85,000^b
Male only (female = 0.0%; male = 2.8%)		1,456.67	27.6098911	193,000^b
NIS-Teen Historical Coverage
Lower 95% CI NIS-Teen Coverage	Status quo	1,434.02	27.6095228	-
	Expanded catch-up	1,472.56	27.6098096	134,000
Upper 95% CI NIS-Teen Coverage	Status quo	1,429.67	27.6099702	-
	Expanded catch-up	1,468.19	27.6102279	149,000
NHANES as historical vaccination coverage
Status quo		1,416.32	27.6079577	-
Expanded catch-up		1,469.51	27.6085115	96,000

^aCosts and QALYs are per capita accumulated over a 100-year time horizon with 3% annual discount rate. ICERS are rounded to the nearest $1000/QALY

^bICER relative to status quo,

^cDifferences between ICERs are <$50/QALY

Abbreviations: CI, confidence interval; HPV, human papillomavirus; ICER, incremental cost-effectiveness ratio; QALYs, quality adjusted life-years.