Post-2015 Consensus: Health Perspective, Luca et al.

Perspective Paper

Summary

There is robust evidence that improved population health helps boost incomes. We argue that female-specific health interventions are a sound investment and, in particular, that vaccinating against human papilloma virus (HPV) in developing countries would reduce the substantial burden of cervical cancer. Further, we propose that diminishing the lifetime risk of cervical cancer and HPV-related disease by 40% (representing nearly 3 million deaths) through increased HPV vaccination coverage in developing countries is a worthy goal for inclusion in the post-2015 global development agenda.

Cervical cancer is the fourth most common cancer among women globally, with more than half a million cases diagnosed each year and an annual death toll of more than 200,000. About 85% of cases occur in developing countries, where it is the second deadliest cancer among women. In developed countries, adequate health system infrastructure, resources, and personnel have reduced the cervical cancer burden substantially, primarily through widespread screening and HPV vaccination programs, but there are fundamental challenges to replicatingthis in poorer countries.

Immunizing girls before they begin to initiate sexual activity is a key strategy for preventing cervical cancer. However, three doses are needed over six months, and the market price of HPV vaccine is considerably higher than prices for traditional vaccines such as those for polio or measles. In the US and other high-income countries, the market price for the series of vaccinations is $300 or more, but as of 2013, Gavi, the Vaccine Alliance, has successfully negotiated a price of $4.50 per dose for a substantial portion of low- to middle-income- countries, which would imply an approximate cost of $25 per girl vaccinated. Most studies suggest that vaccination would be very cost-effective at this cost. The difficulties and high cost of a conventional program of screening and treatment would also argue in favor of wide-scale vaccination.

In addition to the health care cost savings from reduced morbidity and mortality, there could be other benefits including productivity gains as women can continue in employment and positive spillovers on their families as women can better care for them and improved community health once a sufficiently high percentage of the population has been vaccinated. To set against this are the costs of the vaccine itself plus the system costs for delivery - mainly human resources, the cold chain infrastructure and transport. Based on the experience of several countries, we suggest that a potential way to achieve wide-scale implementation of HPV vaccination is through school-based programs.

Assuming a DALY of $1,000, the benefit-cost ratios of vaccination range from 2.7 to 4.9 depending on the region. The benefit-cost ratios are considerably higher than those for tri-annual smear tests and penta-annual VIA (visual inspection with acetic acid) screening, at 0.83 and 1.73 respectively. For a DALY of $5,000, the BCRs for vaccination rise to a range of 13.4 to 24.4. Although the benefit-cost ratios are lower than for family planning programs, vaccination is potentially more scalable and replicable, especially if school-based programs can be implemented and sustained. Further, these estimates are conservative as they only capture health cost savings. If we take into account the broader economic and health externality benefits of HPV vaccination, the benefit-cost ratio should increase substantially. To conclude, we believe that scaling up HPV vaccination to 70% coverage among girls – in conjunction with judicious screening during the years of greatest risk – may be the key to reducing the burden of cervical cancer in developing countries.