Sir,

Cervical cancer is the most common type worldwide. Human papillomavirus (HPV) is an important etiology of this cancer.[1] At present, the prevention of this cancer is possible since cervical cancer vaccine is available.[2] For vaccination, there is still an argument on the effective regimen. The topic that is widely discussed is the selection for two-dose or three-dose regimens for vaccinating the young women who should receive the cervical cancer vaccine.[2] Indeed, the two-dose and three-dose cervical cancer vaccination regimens are mentioned in several reports from different settings.[3] [4] [5] [6] [7] [8] [9] Many reports usually use the immunogenicity for judgment of proper regimen. For example, the study from India noted that the two-doe regimen could induce sufficient immunogenicity.[6] Sankaranarayanan et al. studied difference regimens and recommended the two-dose regimen for the Indian situation.[7] [8] [9] Similar observations are also reported in the study from UK and France.[4] [5] In another report from the Netherlands, the immunogenicity of vaccine in the two-dose and three-dose regimen is not different.[3] Nevertheless, the economical concern is also important in regimen selection.

In this short report, the author compares the two regimens. The cost–utility comparison based on the present epidemiology of HPV in Thailand is done. In analysis, the cost refers to the unit for each regimen reported by referencing tertiary hospitals in Thailand (Vibhavadi hospital, Bangkok) and presented in USD. The utility is referred to the expected adjusted immunogenicity determined in geometric mean titer at 36 months after vaccination as shown in previous validation study and presented in mMU/mL.[10] The path probability assignment is according to the recent data from epidemiological study on HPV in cervical smear samples in Thailand.[11] The primary data of utility quoted from the referenced study [10] and derived expected utility after assignment of path probability are shown in [Table 1]. Then, cost per utility values for two-dose and three-dose regimens are calculated. The final cost–utility analysis result is presented in [Table 2]. Based on this study, the three-dose regimen has less cost per utility than the two-dose regimen; hence, the three-dose regimen of cervical cancer vaccination should be used in the study setting. In conclusion, the three-dose regimen of cervical cancer vaccination is hereby recommended based on cost–utility analysis. The finding is an important topic and relevant to other settings [12] [13] including India. For each setting, the comparative cost–utility analysis is recommended.

1. McCance DJ. Human papillomavirus (HPV) infections in the aetiology of cervical cancer. Cancer Surv 1988; 7: 499-506
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3. Donken R, Schurink-Van’t Klooster TM, Schepp RM, van der Klis FR, Knol MJ, Meijer CJ. et al. Immune responses after 2 versus 3 doses of HPV vaccination up to 4½ years after vaccination: An observational study among Dutch routinely vaccinated girls. J Infect Dis 2017; 215: 359-67
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5. Lazcano-Ponce E, Stanley M, Muñoz N, Torres L, Cruz-Valdez A, Salmerón J. et al. Overcoming barriers to HPV vaccination: Non-inferiority of antibody response to human papillomavirus 16/18 vaccine in adolescents vaccinated with a two-dose vs. a three-dose schedule at 21 months. Vaccine 2014; 32: 725-32
6. Bhatla N, Nene BM, Joshi S, Esmy PO, Poli UR, Joshi G. et al. Are two doses of human papillomavirus vaccine sufficient for girls aged 15-18 years? Results from a cohort study in India. Papillomavirus Res 2018; 5: 163-71
7. Sankaranarayanan R, Joshi S, Muwonge R, Esmy PO, Basu P, Prabhu P. et al. Can a single dose of human papillomavirus (HPV) vaccine prevent cervical cancer? Early findings from an Indian study. Vaccine 2018; 36: 4783-91
8. Sankaranarayanan R, Bhatla N, Basu P. Current global status and impact of human papillomavirus vaccination: Implications for India. Indian J Med Res 2016; 144: 169-80
9. Sankaranarayanan R, Prabhu PR, Pawlita M, Gheit T, Bhatla N, Muwonge R. et al. Immunogenicity and HPV infection after one, two, and three doses of quadrivalent HPV vaccine in girls in India: A multicentre prospective cohort study. Lancet Oncol 2016; 17: 67-77
10. Dobson SR, McNeil S, Dionne M, Dawar M, Ogilvie G, Krajden M. et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs. 3 doses in young women: A randomized clinical trial. JAMA 2013; 309: 1793-802
11. Phoolcharoen N, Kantathavorn N, Sricharunrat T, Saeloo S, Krongthong W. A population-based study of cervical cytology findings and human papillomavirus infection in a suburban area of Thailand. Gynecol Oncol Rep 2017; 21: 73-7
12. Widdice LE, Unger ER, Panicker G, Hoagland R, Callahan ST, Jackson LA. et al. Antibody responses among adolescent females receiving two or three quadrivalent human papillomavirus vaccine doses at standard and prolonged intervals. Vaccine 2018; 36: 881-9
13. Lamb F, Herweijer E, Ploner A, Uhnoo I, Sundström K, Sparén P. et al. Timing of two versus three doses of quadrivalent HPV vaccine and associated effectiveness against condyloma in Sweden: A nationwide cohort study. BMJ Open 2017; 7: e015021

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Article published online:
24 May 2021

© 2019. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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