Economic analyses to support decisions about HPV vaccination in low- and middle-income countries: a consensus report and guide for analysts

Jit et al. BMC Medicine 2013, 11:23 http://www.biomedcentral.com/1741-7015/11/23 CORRESPONDENCE Open Access Economic analyses to support decisions about HPV vaccination in low- and middle-income countries: a consensus report and guide for analysts Mark Jit1,2, Carol Levin3, Marc Brisson4,5, Ann Levin6, Stephen Resch7, Johannes Berkhof8, Jane Kim7 and Raymond Hutubessy9* Abstract Low- and middle-income countries need to consider economic issues such as cost-effectiveness, affordability and sustainability before introducing a program for human papillomavirus (HPV) vaccination. However, many such countries lack the technical capacity and data to conduct their own analyses. Analysts informing policy decisions should address the following questions: 1) Is an economic analysis needed? 2) Should analyses address costs, epidemiological outcomes, or both? 3) If costs are considered, what sort of analysis is needed? 4) If outcomes are considered, what sort of model should be used? 5) How complex should the analysis be? 6) How should uncertainty be captured? 7) How should model results be communicated? Selecting the appropriate analysis is essential to ensure that all the important features of the decision problem are correctly represented, but that the analyses are not more complex than necessary. This report describes the consensus of an expert group convened by the World Health Organization, prioritizing key issues to be addressed when considering economic analyses to support HPV vaccine introduction in these countries. Keywords: Human papillomavirus, vaccination, lowand middle-income countries, economic evaluation. * Correspondence: 9 Initiative for Vaccine Research, World Health Organization, 20 Avenue Appia, CH-1211 Geneva, Switzerland Full list of author information is available at the end of the article Background The World Health Organization (WHO) recommends that cost-effectiveness be considered before human papillomavirus (HPV) vaccination is introduced in national programs [1]. However, many low- and middle-income countries (LMICs) lack the technical capacity and accurate empirical data to develop and parameterize de novo models of complex interventions such as HPV vaccination [2-5]. Given these constraints, LMIC decision-makers may want to apply or adapt a previous economic evaluation conducted in a different country. The practice of adapting existing models is common: one systematic review of economic evaluations of HPV vaccination found that 35 of 58 relevant articles were adaptations of previous models [6]. However, most existing analyses (44/58) were set exclusively in high-income countries (HICs). Hence, analysts in LMICs who want to understand whether they should adapt a previous model, develop a new one, or not conduct an economic evaluation at all have fewer examples and guidance on which to rely. Furthermore, analysts often face a dilemma in choosing which models to develop or adapt. On the one hand, simpler models are easier to parameterize, adapt, and interpret; however, such models are designed to answer a limited range of questions, and can be misleading if used to address more complex issues [7,8]. On the other hand, models that are equipped to address more complex issues may require expertise or data that may not be available in that country. In addition to cost-effectiveness results, decision-makers may need to know the financing requirements and affordability of vaccine introduction to support financial planning and forecasting. Such considerations are informed by models that comprehensively capture the programmatic costs and logistic considerations involved in national © 2013 Jit et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Jit et al. BMC Medicine 2013, 11:23 http://www.biomedcentral.com/1741-7015/11/23 scale-up of vaccine introduction [9], but are less focused on reproducing the natural history and epidemiology of HPV-related diseases. A further challenge is translating economic results into conclusions that are useful to decision-makers. In particular, decision-makers need to understand the type of policy questions that economic models can address, and the appropriate caveats around model conclusions (such as data shortcomings and model uncertainty). To address these questions, the WHO convened a panel of modelers and economists to develop guidance for analysts based in LMICs who advise policy-makers on HPV vaccination (but based on principles applicable to all countries). Panel members held several meetings to outline issues, then agreed on a summary. Each member then drafted sections of the guidelines, then received comments from all other participants. Comments were collated, harmonized and further reviewed by all participants until complete consensus was reached. Full details of guideline development are available in the Appendix. Question 1: Is an economic analysis needed? Three ways to use economic analyses to inform decisions around HPV vaccination are: 1) conducting no structured analysis, 2) borrowing insights from analyses in other settings, and 3) conducting a de novo country-specific analysis using an economic model. The option of not conducting any analysis is particularly attractive in LMICs with limited analytical capacity. However, such countries may also have the greatest need for evidence, because poor allocation of funding at the margin has greater health consequences when funds are limited. Policy-makers may also consider using existing analyses and insights from other settings. When analytical results are stable across settings, conducting new setting-specific studies may add little value. For example, model conclusions about vaccinating girls before onset of sexual activity have been similar across HICs [7,8]. There have been fewer results from LMICs, but existing analyses suggest that HPV vaccines need to be priced much more competitively in LMICs than in HICs for vaccination to be costeffective [6,10]. Vaccine price, HPV prevalence, and uptake of cancer screening and treatment are key drivers of the costeffectiveness of HPV vaccination in LMICs [6,10]. Hence, studies investigating similar policy questions in settings where such parameters are similar can be adapted to a new setting. Many parameters that vary across settings (such as unit costs) are usually easy to adjust for in economic models. Hence, before deciding whether to conduct a de novo analysis, decision-makers should consider existing analyses, investigate the main drivers of results in similar countries, and appraise the Page 2 of 9 extent to which these analyses are suited for their own country. Ideally, such a process should be transparent and unbiased, using best-practice methodology f (...truncated)