Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study.
Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study.
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DOI：
10.1016/s2468-2667(17)30238-4
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发表时间：
2018-01
期刊：
影响因子：
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通讯作者：
Edmunds WJ
中科院分区：
文献类型：
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作者：
Johnson HC;Lafferty EI;Eggo RM;Louie K;Soldan K;Waller J;Edmunds WJ
在评估公共卫生干预措施时，越来越多地将健康平等与总体健康收益一并考虑。然而，疫苗接种的直接效果和群体免疫之间的权衡可能导致人群中疾病负担分布的非直观后果。我们使用人乳头瘤病毒（HPV）的传播动态模型来研究英格兰疫苗接种和宫颈筛查的种族差异对疾病发病率不平等的影响。我们开发了一个基于个体的HPV传播和疾病模型，用最新的性行为数据（来自国家性态度和生活方式调查[Natsal-3]）、疫苗和按种族筛查的数据（来自英国公共卫生部[PHE]）将其参数化，并将其与HPV患病率（来自art、PHE、Natsal-3）和HPV相关疾病发病率（来自国家癌症登记处[ONS]）的数据进行拟合。考虑到英格兰各种族在疫苗接种和筛查方面的差异和变化，研究的结果是英格兰所有女性hpv相关癌症（宫颈和非宫颈）的年龄调整发病率。我们还研究了三种潜在的公共卫生干预措施，旨在减少hpv相关疾病发病率的不平等：增加黑人和亚洲女性的疫苗接种率，以与白人相匹配；2018年或之后年满25岁的女性进行子宫颈筛查；以及所有年龄段的子宫颈检查。在疫苗接种前的时代，2008年之前，英国少数民族妇女报告的子宫颈疾病比例不成比例。我们的模型显示，亚洲女性被诊断为宫颈癌的可能性是白人女性的1.7倍（95%可信区间[CI] 1·1 - 2·7）（每10万名女性中有22.8例对13.4例）。由于少数民族的HPV疫苗接种率较低，我们预测这一差距最初会扩大，在接种疫苗20年后，亚洲妇女的宫颈癌发病率比白人妇女高2.5倍（95% CI 1.34 - 1.8）（相当于每年增加10.8例[95% CI 10.1 - 11.5]）。随着时间的推移，我们预测群体免疫的好处将从较大的白人亚群中扩散开来，差距将缩小。在接种了HPV疫苗的少数民族妇女中增加子宫颈筛查将导致20年后发病率平等的迅速改善。我们的研究表明，在英格兰引入HPV疫苗接种最初将扩大HPV相关癌症发病率的种族差异，部分原因是群体免疫不成比例地受益于高疫苗接种率的亚组。虽然随着时间的推移，这种差距会缩小，但应鼓励增加少数民族女孩的子宫颈检查，以在中期消除宫颈癌发病率的不平等。我们建议在估计公共卫生规划对平等的影响时考虑动态效应。英国癌症研究中心。
Health equality is increasingly being considered alongside overall health gain when assessing public health interventions. However, the trade-off between the direct effects of vaccination and herd immunity could lead to unintuitive consequences for the distribution of disease burden within a population. We used a transmission dynamic model of human papillomavirus (HPV) to investigate the effect of ethnic disparities in vaccine and cervical screening uptake on inequality in disease incidence in England. We developed an individual-based model of HPV transmission and disease, parameterising it with the latest data for sexual behaviour (from National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) and vaccine and screening uptake by ethnicity (from Public Health England [PHE]) and fitting it to data for HPV prevalence (from ARTISTIC, PHE, Natsal-3) and HPV-related disease incidence (from National Cancer Registry [ONS]). The outcome of interest was the age-adjusted incidence of HPV-related cancer (both cervical and non-cervical) in all women in England in view of differences and changes in vaccination and screening uptake by ethnicity in England, over time. We also studied three potential public health interventions aimed at reducing inequality in HPV-related disease incidence: increasing uptake in black and Asian females to match that in whites for vaccination; cervical screening in women who turn 25 in 2018 or later; and cervical screening in all ages. In the pre-vaccination era, before 2008, women from ethnic minorities in England reported a disproportionate share of cervical disease. Our model suggests that Asian women were 1·7 times (95% credibility interval [CI] 1·1–2·7) more likely to be diagnosed with cervical cancer than white women (22·8 vs 13·4 cases per 100 000 women). Because HPV vaccination uptake is lower in ethnic minorities, we predict an initial widening of this gap, with cervical cancer incidence in Asian women up to 2·5 times higher (95% CI 1·3–4·8) than in white women 20 years after vaccine introduction (corresponding to an additional 10·8 [95% CI 10·1–11·5] cases every year). In time, we predict that herd immunity benefits will diffuse from the larger white sub-population and the disparity will narrow. Increased cervical screening uptake in vaccinated women from ethnic minorities would lead to rapid improvement in equality with parity in incidence after 20 years of HPV vaccination. Our study suggests that the introduction of HPV vaccination in England will initially widen a pre-existing disparity in the incidence of HPV-related cancer by ethnicity, partly due to herd immunity disproportionately benefiting subgroups with high vaccination rates. Although in time this induced disparity will narrow, increasing cervical screening uptake in girls from ethnic minorities should be encouraged to eliminate the inequality in cervical cancer incidence in the medium term. We recommend that dynamic effects should be considered when estimating the effect of public health programmes on equality. Cancer Research UK.