Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries
Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries
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DOI：
10.1016/s0140-6736(20)30068-4
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发表时间：
2020-02-22
期刊：
影响因子：
168.9
通讯作者：
Hutubessy, Raymond
中科院分区：
文献类型：
--
作者：
Brisson, Marc;Kim, Jane J.;Hutubessy, Raymond
背景世界卫生组织总干事呼吁采取行动消除宫颈癌这一公共卫生问题。为了帮助为全球努力提供信息，我们在低收入和中低收入国家(LMIC)模拟了潜在的人乳头瘤病毒(HPV)疫苗接种和宫颈筛查情景，以检查在不同阈值下消除的可行性和时机，并估计在消除的道路上避免宫颈癌病例的数量。方法世界卫生组织宫颈癌消除模型联盟(CCEMC)由世卫组织根据预先定义的标准确定的三个独立的传播动力学模型组成，在三个标准化的基本情景下，预测78个低收入中等收入国家(LMIC)的宫颈癌发病率随着时间的推移而减少：仅女孩接种疫苗；仅女孩接种疫苗和一次性筛查；以及仅限女孩接种疫苗和终身两次筛查。女孩在9岁时接种疫苗(直到14岁)，假定对16、18、31、33、45、52和58型HPV具有90%的覆盖率和100%的终身保护。宫颈筛查包括在35岁和45岁时每一生进行一次或两次HPV检测，吸收率从45%(2023年)增加到90%(2045年以后)。检查的消除阈值是平均年龄标准化宫颈癌发病率每10万妇女年四例或更少病例，每10万妇女年十例或更少病例，发病率降低85%或更多。进行了不同的疫苗接种和筛查策略和假设的敏感性分析。我们使用模型预测的中位数(范围)来总结结果。发现仅针对女孩接种HPV疫苗将在下个世纪将LMIC中年龄标准化宫颈癌发病率的中位数从每10万妇女年19.8(19.4-19.8)例降低到2.1(2.0-2.6)例(减少89.4%[86.2-90.1])，并在此期间避免6100万(60.5-63.0)例。增加两次终身筛查将发病率降低到每10万妇女年0.7(0.6-1.6)例(减少96.7%[91.3-96.7]例)，并避免额外的1210万(9.5-13.7)例。根据每100000妇女年4例或更少病例的阈值，预计只接种女孩疫苗的LMICs将消除60%(58-65例)，以每100000妇女年10例或更少病例为阈值，预测99%(89-100例)LMICs消除，根据85%或更高的减少阈值，87%(37-99例)LMICs消除。当增加两次寿命筛查时，100%(71-100)的LMIC达到了所有三个阈值的消除。在所有国家都可以通过仅对女孩接种疫苗实现宫颈癌消除的地区，根据门槛和地区的不同，可能在2059年至2102年之间消除宫颈癌。引入两次终生筛查可使消除速度加快11-31年。根除需要长期的疫苗保护。在我们的三个模型中，解释预测是一致的，并表明女孩的高HPV疫苗接种率可以导致在本世纪末消除大多数LMIC中的宫颈癌。高吸收率的筛查将加速减少，对于在负担最重的国家消除宫颈癌是必要的。
Background The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination.Methods The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions.Findings Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19.8 (range 19.4-19.8) to 2.1 (2.0-2.6) cases per 100 000 women-years over the next century (89.4% [86.2-90.1] reduction), and to avert 61.0 million (60.5-63.0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0.7 (0.6-1.6) cases per 100 000 women-years (96.7% [91.3-96.7] reduction) and averted an extra 12.1 million (9.5-13.7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination.Interpretation Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden.