BACKGROUND:The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. METHODS:The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. FINDINGS:Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4-19·8) to 2·1 (2·0-2·6) cases per 100 000 women-years over the next century (89·4% [86·2-90·1] reduction), and to avert 61·0 million (60·5-63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6-1·6) cases per 100 000 women-years (96·7% [91·3-96·7] reduction) and averted an extra 12·1 million (9·5-13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination. INTERPRETATION:Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden. FUNDING:WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec-Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.

译文

背景:世界卫生组织总干事已发出呼吁采取行动消除宫颈癌这一公共卫生问题。为帮助全球做出努力,我们对低收入和中低收入国家(LMIC)中潜在的人乳头瘤病毒(HPV)疫苗接种和宫颈筛查方案进行了建模,以研究在不同阈值处进行消除的可行性和时机,并估计数量子宫颈癌病例避免在消除的道路上。
方法:WHO子宫颈癌消除建模协会(CCEMC)由WHO根据预先定义的标准确定的三个独立的传播动力学模型组成,预计在三种标准化的基本情况下,随着时间的推移,78个LMIC的子宫颈癌发病率将降低。 -仅接种疫苗;仅限女孩的疫苗接种和终生筛查;以及仅限女孩的疫苗接种和终生两次筛查。假定90%的覆盖率和100%的人乳头瘤病毒类型16、18、31、33、45、52和58的终生防护能力,女孩在9岁时接种疫苗(到14岁为止)。宫颈癌筛查涉及HPV在35岁和45岁的年龄段中,一生进行一次或两次测试,摄取率从45%(2023)增加到90%(2045起)。检查的消除阈值是按年龄标准化的子宫颈癌的平均发病率,每10万名女性-年不超过4例,每10万名女性-年不超过10例,且发病率降低85%或以上。进行了敏感性分析,改变了疫苗接种,筛查策略和假设。我们使用模型预测的中位数(范围)来汇总结果。
结果:仅女孩HPV疫苗接种预计将使中低收入国家的年龄标准化宫颈癌发病率中位数从19·8(19·4-19·8)降低到每人2·1(2·0-2·6)例到下个世纪,将有10万妇女年(减少89·4%[86·2-90·1]),并在此期间避免6100万(60·5-63·0)例。进行两次终生筛查可将发病率降至每100 000妇女年0·7(0·6-1·6)例(减少96·7%[91·3-96·7]),避免额外的12· 1百万(9·5-13·7)例。根据每100 000妇女年中有四个或更少病例的阈值,预计仅女孩的疫苗接种将导致60%(58-65)的LMIC消除,基于阈值的99%(89-100)个LMIC的消除每100 000名妇女年中有10例或更少的病例,以及基于85%或更高的降低阈值的87%(37-99)的中低收入国家。当添加两次寿命筛查时,所有三个阈值的LMIC均达到100%(71-100)。在所有国家都可以通过仅通过女孩接种疫苗消除子宫颈癌的地区中,根除阈值和地区的不同,消除可能发生在2059年至2102年之间。引入两次终生筛选可将淘汰时间提高11-31年。需要长期的疫苗保护才能消除。
解释:在我们的三个模型中,预测是一致的,这表明到本世纪末,大多数女孩的HPV疫苗接种覆盖率较高,可以消除子宫颈癌。高摄入量的筛查将加快减少筛查的速度,这对于消除负担最重的国家的子宫颈癌必不可少。
资金:卫生组织,开发计划署,联合国人口基金,儿童基金会-卫生组织-世界银行关于人类生殖的研究,发展和研究培训特别方案,加拿大卫生研究所,魁北克省桑德基金会,加拿大计算,国家卫生和医疗研究委员会澳大利亚宫颈癌控制研究卓越中心。

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