{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T13:37:13Z","timestamp":1793367433507,"version":"4.5.0"},"reference-count":40,"publisher":"BMJ","issue":"12","license":[{"start":{"date-parts":[[2024,12,5]],"date-time":"2024-12-05T00:00:00Z","timestamp":1733356800000},"content-version":"unspecified","delay-in-days":4,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2024,10,16]]},"published-print":{"date-parts":[[2024,12]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>The objective of this study is to assess the cost utility of the implementation of the human papillomavirus (HPV) vaccination programme in Tunisia in addition to the current cytology screening strategy. This study is very important to guide health policy decision-makers and to help them allocate their scarce healthcare resources.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>We used a previously described Markov model on the Online Cost Effectiveness Analysis tool programmed with R Software. The Markov cohort model was used to simulate the natural history of HPV infection and cervical cancer for a cohort of 100\u2009000 females aged from 10 to 84 years. The model was calibrated with Tunisian parameters to calculate the long-term health benefits and costs of different cervical cancer preventive strategies in Tunisia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures<\/jats:title>\n                    <jats:p>The primary outcome was the incremental cost-effectiveness ratio (ICER) of the implementation of HPV vaccination to the current cytology screening strategy to fight against cervical cancer. The ICER was calculated per life-years saved and per quality-adjusted life-year (QALY) gained, expressed in 2020 US$. Thresholds were fixed at one to three times the gross domestic product (GDP). One-way sensitivity analyses were carried out concerning the coverage rate of the cytology screening and vaccination as well as for the vaccination cost and doses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Compared with screening alone, the combined strategy predicted an ICER of US$1920.8 year of life saved and US$2239.3\/QALY which is still lower than the GDP per capita of Tunisia in 2020 (US$3319). Sensitivity analysis showed that the cost-effectiveness of adding vaccination to the existing screening programme did not exceed the GDP per capita by varying the cost per dose upwards to US$45 (ICER would be US$2910\/QALY) and vaccination coverage up to 100% (ICER of US$3245\/QALY). However, the combined strategy exceeds the GDP per capita threshold when the cytological screening coverage rises to 70%, causing the ICER to rise to US$4787\/QALY.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study showed that compared with screening alone, the implementation of HPV vaccination in addition to the current cytology screening programme in Tunisia would be considered cost-effective on the basis of the threshold GDP per capita. Improvement of the current screening programme itself also remains important and provides further potential to achieve optimal cervical cancer prevention strategies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2024-085462","type":"journal-article","created":{"date-parts":[[2024,12,5]],"date-time":"2024-12-05T21:47:12Z","timestamp":1733435232000},"page":"e085462","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":7,"title":["Cost-effectiveness of human papillomavirus (HPV) vaccination in Tunisia: a modelling study"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5145-5457","authenticated-orcid":false,"given":"Hyem","family":"Khiari","sequence":"first","affiliation":[{"name":"Institut Salah-Azaiz, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karima","family":"Makni","sequence":"additional","affiliation":[{"name":"University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khedija","family":"Meddeb","sequence":"additional","affiliation":[{"name":"Institut Salah-Azaiz, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olfa","family":"Jaidane","sequence":"additional","affiliation":[{"name":"Institut Salah-Azaiz, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed","family":"Hsairi","sequence":"additional","affiliation":[{"name":"Institut Salah-Azaiz, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2024,12,5]]},"reference":[{"key":"2025121509530306000_14.12.e085462.1","doi-asserted-by":"publisher","DOI":"10.3322\/caac.21660"},{"key":"2025121509530306000_14.12.e085462.2","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1097\/CEJ.0000000000000202","article-title":"Present and future of cervical cancer prevention in Spain: a cost-effectiveness analysis","volume":"25","author":"Georgalis","year":"2016","journal-title":"Eur J Cancer Prev"},{"key":"2025121509530306000_14.12.e085462.3","doi-asserted-by":"crossref","DOI":"10.1186\/s12911-020-01232-9","article-title":"Online Cost-Effectiveness ANalysis (OCEAN): a user-friendly interface to conduct cost-effectiveness analyses for cervical cancer","volume":"20","author":"Mori\u00f1a","year":"2020","journal-title":"BMC Med Inform Decis Mak"},{"key":"2025121509530306000_14.12.e085462.4","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1002\/ijgo.13879","article-title":"Worldwide initiatives to eliminate cervical cancer","volume":"155","author":"Wilailak","year":"2021","journal-title":"Intl J Gynecology & Obste"},{"key":"2025121509530306000_14.12.e085462.5","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1002\/ijgo.12186","article-title":"Progress in HPV vaccination in low\u2010 and lower\u2010middle\u2010income countries","volume":"138","author":"LaMontagne","year":"2017","journal-title":"Intl J Gynecology & Obste"},{"key":"2025121509530306000_14.12.e085462.6","first-page":"148","article-title":"Strategies of the Maghreb countries in the fight against cancer","volume":"99","author":"Khiari","year":"2021","journal-title":"Tunis Med"},{"key":"2025121509530306000_14.12.e085462.7","unstructured":"Hsairi M , Khiari H , Mallekh R , et al . 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Age-period-cohort analysis: a summary of analytical approaches and results. 2018."},{"key":"2025121509530306000_14.12.e085462.13","doi-asserted-by":"crossref","DOI":"10.3390\/v14102175","article-title":"The Prevalence, Genotype Distribution and Risk Factors of Human Papillomavirus in Tunisia: A National-Based Study","volume":"14","author":"Ardhaoui","year":"2022","journal-title":"Viruses"},{"key":"2025121509530306000_14.12.e085462.14","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1016\/j.vhri.2015.10.010","article-title":"Cost-Utility Analysis of Human Papillomavirus Vaccination and Cervical Screening on Cervical Cancer Patient in Indonesia","volume":"9","author":"Setiawan","year":"2016","journal-title":"Val Health Reg Issues"},{"key":"2025121509530306000_14.12.e085462.15","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199603283341306"},{"key":"2025121509530306000_14.12.e085462.16","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1080\/15598608.2012.695571","article-title":"Median-Based Incremental Cost-Effectiveness Ratio (ICER)","volume":"6","author":"Bang","year":"2012","journal-title":"J Stat Theory Pract"},{"key":"2025121509530306000_14.12.e085462.17","unstructured":"Plan de lutte contre le cancer en tunisie 2015-2019. disponible sur. n.d. 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Committee to study priorities for vaccine development, division of health promotion and disease prevention institute of medicine. Vaccines for the 21st Century: Atool for Decision Making; 2000."},{"key":"2025121509530306000_14.12.e085462.22","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1080\/13696998.2019.1624556","article-title":"Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis","volume":"22","author":"Messoudi","year":"2019","journal-title":"J Med Econ"},{"key":"2025121509530306000_14.12.e085462.23","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-015-2046-1","article-title":"A cost-utility analysis of cervical cancer screening and human papillomavirus vaccination in the Philippines","volume":"15","author":"Guerrero","year":"2015","journal-title":"BMC Public Health"},{"key":"2025121509530306000_14.12.e085462.24","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.15.164418"},{"key":"2025121509530306000_14.12.e085462.25","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-023-15842-1","article-title":"Barriers and facilitators of HPV vaccination in sub-saharan Africa: a systematic review","volume":"23","author":"Kutz","year":"2023","journal-title":"BMC Public Health"},{"key":"2025121509530306000_14.12.e085462.26","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(19)30531-5"},{"key":"2025121509530306000_14.12.e085462.27","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1177\/0141076819899308","article-title":"Will HPV vaccination prevent cervical cancer?","volume":"113","author":"Rees","year":"2020","journal-title":"J R Soc Med"},{"key":"2025121509530306000_14.12.e085462.28","doi-asserted-by":"crossref","first-page":"e1115","DOI":"10.1016\/S2214-109X(22)00241-8","article-title":"Cervical cancer screening programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis","volume":"10","author":"Bruni","year":"2022","journal-title":"Lancet Glob Health"},{"key":"2025121509530306000_14.12.e085462.29","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1080\/14789450.2021.1980387","article-title":"Molecular markers for cervical cancer screening","volume":"18","author":"G\u00fczel","year":"2021","journal-title":"Expert Rev Proteomics"},{"key":"2025121509530306000_14.12.e085462.30","doi-asserted-by":"crossref","DOI":"10.1016\/j.clinsp.2022.100080","article-title":"Cervical cancer screening in low- and middle-income countries: A systematic review of economic evaluation studies","volume":"77","author":"Casas","year":"2022","journal-title":"Clinics (Sao Paulo)"},{"key":"2025121509530306000_14.12.e085462.31","doi-asserted-by":"publisher","DOI":"10.4161\/hv.7.2.13690"},{"key":"2025121509530306000_14.12.e085462.32","doi-asserted-by":"crossref","DOI":"10.1080\/21645515.2022.2150454","article-title":"Key decision-making factors for human papillomavirus (HPV) vaccine program introduction in low-and-middle-income-countries: Global and national stakeholder perspectives","volume":"18","author":"Guillaume","year":"2022","journal-title":"Hum Vaccin Immunother"},{"key":"2025121509530306000_14.12.e085462.33","doi-asserted-by":"crossref","first-page":"2723","DOI":"10.1002\/cam4.1155","article-title":"Ten-year immune persistence and safety of the HPV-16\/18 AS04-adjuvanted vaccine in females vaccinated at 15-55 years of age","volume":"6","author":"Schwarz","year":"2017","journal-title":"Cancer Med"},{"key":"2025121509530306000_14.12.e085462.34","doi-asserted-by":"crossref","unstructured":"Deler\u00e9 Y , Wichmann O , Klug SJ , et al . 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