The Clinical and Economic Impact of a Nonavalent Versus Bivalent Human Papillomavirus National Vaccination Program in Taiwan

Published:September 15, 2022DOI:


      • To prevent cervical cancer, 2 strategies are used in combination: cervical screening and human papillomavirus (HPV) vaccination. HPV vaccination offers primary prevention of HPV-related precancers and cancers; it also protects against genital warts. Since December 2018, the Taiwanese government has provided the bivalent HPV vaccine free of charge to girls in the first year of junior high school (aged 13 years) as part of the National Immunization Program. A new nonavalent vaccine has become available.
      • The cost-effectiveness of nonavalent HPV vaccination in Taiwan has been evaluated once to date, but the static cohort model used could not account for herd immunity and likely underestimated the effectiveness of the vaccines. The objectives of this study were to assess the public health impact and to estimate the cost-effectiveness of introduction of the nonavalent vaccine into the National Immunization Program in Taiwan, taking herd immunity into account via a dynamic transmission model.
      • Introducing a 2-dose nonavalent vaccination program for girls aged 13 to 14 years in Taiwan would reduce the incidence and costs associated with cervical cancer, precancerous lesions, and genital warts caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 compared with bivalent vaccination. The analysis also showed that the nonavalent HPV vaccination strategy was highly cost-effective in Taiwan compared with the bivalent vaccination strategy.



      This study aimed to estimate the epidemiologic and economic impact of a nonavalent human papillomavirus (HPV) vaccination program for 13- to 14-year-old females compared with that of the bivalent vaccine in Taiwan.


      A previously developed dynamic transmission model for the nonavalent HPV vaccine was adapted to the Taiwan setting. The natural history of cervical cancer and genital warts was simulated by the HPV model assuming an 80% vaccination coverage rate in girls aged 13 to 14 years of age with a 2-dose schedule for the nonavalent and bivalent HPV vaccines. A lifetime duration of vaccine protection was assumed for the HPV vaccine types.


      The model estimated that the nonavalent HPV vaccine would prevent an additional 15 951 cervical cancer cases, 6600 cervical cancer-related deaths, 176 702 grade 2 or grade 3 cervical intraepithelial neoplasia cases, 103 959 grade 1 cervical intraepithelial neoplasia cases, and 1 115 317 genital warts cases compared with the bivalent HPV vaccine. The nonavalent HPV vaccination program was projected to cost an additional New Taiwan dollars (NTD) 675.21 per person and to produce an additional 0.00271 quality-adjusted life-year per person over 100 years compared with the bivalent HPV vaccine. Thus, the incremental cost-effectiveness ratio of the nonavalent HPV vaccine versus the bivalent HPV vaccine was NTD 249 462/quality-adjusted life-year.


      A nonavalent HPV vaccination program for 13- to 14-year-old girls would have additional public health and economic impacts and would be highly cost-effective compared with the bivalent HPV vaccine, relative to per capita gross domestic product, which is estimated at NTD 746 526 for Taiwan.


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