Case Study: HPV Vaccination and Public Health in Nicaragua

This case study focuses on the potential introduction of HPV vaccination in Nicaragua, examining the context of cervical cancer control within a middle-income country. The case highlights the role of a philanthropic organization, the Foundation, and its Fund for Cervical Cancer Control (F3C) in supporting the initiative. The scenario involves the Foundation's CEO meeting with the President of Nicaragua to discuss the proposed HPV vaccination campaign, considering the country's high cervical cancer incidence and limited resources. The case presents the learning objectives to understand the economic evaluation of vaccines, including cost-effectiveness analysis, types of costs and health effects, and how to address uncertainty. The case underscores the importance of government commitment, disease burden, and programmatic feasibility in selecting investment sites. The document references WHO recommendations and provides links to additional resources on HPV vaccines and public health policy.

Pushing a priority or setting an agenda? HPV vaccination in Nicaragua
Introduction
The following case is one option of two cases that will inform live session discussions and course
homework assignments due in live sessions 5, 6, 7 and 9. You should review the following learning
objectives, case narrative and additional resources before live session 2. Additional guidance for each of
the homework assignments will be provided and reviewed during the upcoming live sessions.
Learning objectives of case and related course assignments
 Understand the relevance of economic evaluation and other decision analysis approaches in the
broader context of public health policy making
 Understand the types of costs and health effects considered in an economic evaluation of
vaccines
 Understand how to apply the basic principles of an economic evaluation to a real-world decision
problem: cost the intervention, measure the health effects, generate an incremental cost-
effectiveness ratio
 Understand how to reflect or deal with uncertainty in an analysis plan
 Develop an understanding of different simple modeling approaches for economic evaluations
(Markov and decision tree)
Case note
A large philanthropic organization has joined the global health community in a pledge to significantly
reduce death and suffering due to cervical cancer among women by 2050. The philanthropic
organization plans to create a special fund from its multibillion dollar endowment to accelerate uptake
of innovative technology to prevent, detect and treat cancers of the cervix in low- and middle-income
countries (LMIC), where 81% of cervical cancer cases occur. The new Fund for Cervical Cancer Control
(F3C) has not been announced publically yet. However, the organization (called Foundation from here
forward) has initiated talks with governments selected as pilot sites.
Cervical cancer is the consequence of long-term, persistent infection from human papillomavirus (HPV),
the most common viral infection of the reproductive tract. There are 13 known high-risk HPV cancer-
causing types of the more than 100 genotypes. Two of these types, 16 and 18, are responsible for 70%
of cervical cancers and precancerous cervical lesions. Additional risk types have links to cancers of the
anus, vulva, vagina and penis as well as genital warts. For the Foundation’s CEO, the global prevalence of
high-risk HPV is more than a concerning statistic. She lost her eldest daughter to a persistent HPV
infection that went undetected and progressed to late-stage cervical cancer in her early 30s.
According to the World Health Organization (WHO), more than one million women globally are currently
living with cervical cancer. High-income countries have successfully reduced the cervical cancer burden
among women with large-scale routine screening to ensure early detection and treatment of pre-
cancerous lesions of the cervix. Weak health systems plagued by scarce investment in much of the rest
of the world have limited the reach and effectiveness of screening programs. In addition, the prohibitive

costs among other barriers to access of curative and palliative care of disease that is detected late
results in higher rates of death from cervical cancer in these countries.
Other multilateral and philanthropic arrangements have supported the least developed countries in the
world to improve quality and access to healthcare services, with particular focus on disease-specific
interventions for malaria control, tuberculosis treatment and HIV prevention. More recently public-
private partnerships have emerged to accelerate the introduction of new vaccines, for example Gavi the
Vaccine Alliance, in the lowest income countries. Regions where the majority of countries fall into the
middle-income category can struggle to keep pace with global goals since they generally self-finance
programs that represent public goods, i.e. vaccines, yet have limited slack in their budgets and
insufficient economic growth to consider early adoption of high cost technology or biologics. For this
reason, the Foundation has decided that the F3C will primarily focus support on Middle-Income
Countries (MIC).
Latin America is home to many MICs. Despite efforts to expand and scale screening services for women
in the region, 83,000 of women are diagnosed with cervical cancer and 36,000 of them die from the
disease in a typical year. Should these trends continue, the number of deaths in the Americas is
projected to increase up to 45% by 2030. Highlighting the inequities between Upper Income (UIC) and
MIC in the region, mortality due to cervical cancer is three times higher in Latin America than in North
America. While cervical cancer deaths have declined in some countries, the leading cause of cancer
deaths among women in three countries – Honduras, Nicaragua and Bolivia – remains to be cervical
cancer.
WHO recommends that countries adopt an integrated strategy for comprehensive control of cervical
cancer, including vaccination among adolescent girls at age of sexual debut to prevent HPV infection and
early detection of pre-cancerous lesions through screening of adult women. In countries like Nicaragua
only 10% of women routinely have access to screening. Basic treatment of pre-cancerous lesions is
available, however, often these lesions go undetected and develop into late-stage cancers. Incidence of
cervical cancer in Nicaragua is the highest among countries in Central America and is among the top 25
highest rates in the world at 36 cases per 100,000 women (ASR).
The Foundation’s F3C selected country sites for initial investments based on three main criteria: (1)
strong demonstrated government commitment to cervical cancer control, represented by willingness to
co-finance proposed control strategies; (2) high rates of disease and death due to cervical cancer; (3)
programmatic feasibility to achieve high coverage of the selected control approach. Nicaragua, among
other countries, was selected as an initial investment site for an HPV vaccination campaign by an
external review committee to the Foundation. The government of Nicaragua was recently notified of the
external financing opportunity. In the Government’s response, much to the Foundation’s surprise, the
President of Nicaragua and his wife extended a personal invitation to the Foundation CEO to discuss the
terms and plans for the proposed agreement in person.
The Foundation CEO is eager to meet with the President of Nicaragua and his wife and has accepted the
invitation to visit Managua. While she plans to openly share her personal story behind her ambition to
end needless death and suffering due to cervical cancer, she is well aware of the existing budget
constraints and competing priorities of the Ministry of Health. She will want to inform her talking points
with data on the costs, health benefits and potential treatment cost savings due to the introduction of a
HPV vaccine.

Additional resources
Human papillomavirus vaccines: WHO position paper. 2014. Weekly epidemiologic record, no. 43, vol.
89: 465-492. Available at: http://www.who.int/wer/2014/wer8943.pdf?ua=1
Goldie, Sue. 2013. Chapter 15: Public Health Policy and Cost-effectiveness Analysis, J Natl Cancer Inst,
102-110. Available at: http://jncimono.oxfordjournals.org/content/2003/31/102.full.pdf+html