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Logo of eidEmerging Infectious Diseases
Emerg Infect Dis. 2007 December; 13(12): 1958–1959.
PMCID: PMC2876765

Human Papillomavirus Vaccination Strategies

To the Editor: An article by Elbasha et al. in the January 2007 issue of Emerging Infectious Diseases showed an economic evaluation of human papillomavirus (HPV) vaccination strategies (1). In this model, incremental cost-effectiveness ratio (ICER) calculations were based on costs measured as US dollars for 2005 and effectiveness measured as quality-adjusted life years (QALYs). Authors presented these data transparently and showed costs and QALYs of each strategy in 2 tables, where they did not show ICER of dominated options; i.e., “Strategy A is dominated if there is another strategy, B, that is more effective and less costly than strategy A” (1). Unfortunately, splitting data into 2 tables can be misleading.

First, ICERs of strategies for vaccination at the age of 12 (70% coverage) compared with a strategy of no vaccination showed that the strategy of vaccinating 12-year-old girls and boys is dominated by other strategies. Furthermore, vaccination of 12-year-old girls only and vaccination of 12-year-old girls only with catch-up (vaccination of girls and women 12–24 years of age) have lower ICERs, which could be interpreted as the most cost-effective approaches.

Finally, ICERs of strategies of vaccinating at 15 and 18 years of age (50% coverage) are presented without comparison strategies. Thus, one might assume that these strategies are compared with the baseline strategy (vaccination of 12-year-old girls only); however, they are compared with the no-vaccination strategy.

The transparency of the Elbasha et al. article enabled us to build a new table based on their data (Table). In our table, ICERs of the whole set of strategies showed that vaccination of 12-year-old girls only is dominated by the vaccination of 18-year-old women plus a catch-up strategy (women 18–24 years of age), although older groups have lower coverages.

Cost-effectiveness analysis of alternative human papillomavirus vaccination strategies*

In addition, I point out 2 particulars. First, epidemiology of HPV varies between countries (2), probably because of differences in culture and sexual habits. Thus, vaccination at older ages should be considered in countries in which prevalence of adolescent sexual activity or HPV is low. Second, higher vaccine coverage in older groups would decrease ICERs of these strategies (1). Both facts could reflect the real situation in some countries, e.g., Spain (2,3).

In conclusion, economic evaluations of HPV vaccination strategies should have broader sensitivity analysis to include as many country-specific realities as possible. To avoid misunderstandings that could lead policymakers to misallocate funds, these results should be evident to readers.


Suggested citation for this article: Cachafeiro SP. Human papillomavirus vaccination strategies [letter]. Emerg Infect Dis [serial on the Internet]. 2007 Dec [date cited]. Available from


1. Elbasha EH, Dasbach EJ, Insinga RP Model for assessing human papillomavirus vaccination strategies. Emerg Infect Dis 2007;13:28–41 10.3201/eid1301.060438 [PMC free article] [PubMed] [Cross Ref]
2. Clifford GM, Gallus S, Herrero R, Munoz N, Snijders PJF, Vaccarella S, et al. Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis. Lancet 2005;366:991–8 10.1016/S0140-6736(05)67069-9 [PubMed] [Cross Ref]
3. HBV vaccination programmes in adolescent population 1996–1997 period [in Spanish] Boletín Epidemiológico Semanal Instituto de Salud Carlos III. 1998;6:209–10

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