Goldie Sue J, O'Shea Meredith, Campos Nicole Gastineau, Diaz Mireia, Sweet Steven, Kim Sun-Young
Program in Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115, USA.
Vaccine. 2008 Jul 29;26(32):4080-93. doi: 10.1016/j.vaccine.2008.04.053. Epub 2008 May 15.
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 (approximately $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 approximately 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.
发展中国家的女性承担着不成比例的宫颈癌死亡风险。两种新疫苗对预防人乳头瘤病毒16、18型感染非常有效，而这两种病毒导致了约70%的宫颈癌，对未曾感染的女孩效果显著。全球疫苗免疫联盟（GAVI）为世界上最贫困国家的免疫接种提供技术援助和资金支持。利用72个符合GAVI条件国家的基于人群的流行病学数据，我们估算了与年轻少女接种人乳头瘤病毒16、18型疫苗相关的宫颈癌病例和死亡避免数、避免的伤残调整生命年（DALY）以及增量成本效益比（每避免一个DALY的成本，单位为国际美元）。除了疫苗覆盖率和效力外，相对和绝对的癌症减少量还取决于潜在发病率、人乳头瘤病毒16和18型所致比例、人口年龄结构以及竞争性死亡率。在覆盖率为70%的情况下，一些国家（如尼日利亚、加纳）终身患癌风险的平均降低幅度低于40%，而其他国家（如印度、乌干达、肯尼亚）则高于50%。按照每个接种女孩10国际美元的成本（假设接种三剂，每剂约2.00美元，加上浪费、接种管理、项目支持费用），以人均国内生产总值为阈值，在所有国家接种疫苗都是具有成本效益的；在72个国家中的49个国家，每避免一个DALY的成本低于100国际美元，59个国家低于200国际美元。考虑到引入年份的国家特定假设（人均国民总收入、白百破三联疫苗覆盖率、五年级女生入学率）、第一年实现的覆盖率以及达到最大覆盖率所需的年份，一个为期10年的模拟情景可预防约200万青春期接种疫苗女性未来的死亡。尽管成本效益良好，但对财务成本的评估引发了对可负担性的担忧；随着每个接种女孩的成本从10国际美元增加到25国际美元（每剂约2至5美元），10年情景的财务成本从超过9亿美元增加到22.5亿美元。如果对年轻少女实现高覆盖率是可行的，并且疫苗成本降低，那么人乳头瘤病毒16、18型疫苗接种即使在最贫困国家也可能具有很高的成本效益，并能为资源提供与轮状病毒等其他新疫苗相当的价值。
