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BMJ. 2009 Oct 8;339:b3884. doi: 10.1136/bmj.b3884.

Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States.

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  • 1Harvard School of Public Health, Department of Health Policy and Management, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115, USA.



To assess the cost effectiveness of including preadolescent boys in a routine human papillomavirus (HPV) vaccination programme for preadolescent girls.


Cost effectiveness analysis from the societal perspective.


United States.


Girls and boys aged 12 years.


HPV vaccination of girls alone and of girls and boys in the context of screening for cervical cancer. Main outcome measure Incremental cost effectiveness ratios, expressed as cost per quality adjusted life year (QALY) gained.


With 75% vaccination coverage and an assumption of complete, lifelong vaccine efficacy, routine HPV vaccination of 12 year old girls was consistently less than $50,000 per QALY gained compared with screening alone. Including preadolescent boys in a routine vaccination programme for preadolescent girls resulted in higher costs and benefits and generally had cost effectiveness ratios that exceeded $100,000 per QALY across a range of HPV related outcomes, scenarios for cervical cancer screening, and assumptions of vaccine efficacy and duration. Vaccinating both girls and boys fell below a willingness to pay threshold of $100,000 per QALY only under scenarios of high, lifelong vaccine efficacy against all HPV related diseases (including other non-cervical cancers and genital warts), or scenarios of lower efficacy with lower coverage or lower vaccine costs.


Given currently available information, including boys in an HPV vaccination programme generally exceeds conventional thresholds of good value for money, even under favourable conditions of vaccine protection and health benefits. Uncertainty still exists in many areas that can either strengthen or attenuate our findings. As new information emerges, assumptions and analyses will need to be iteratively revised to continue to inform policies for HPV vaccination.

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