Potential health impact and cost-effectiveness of human papillomavirus vaccination in Tunisia: A comparative modeling study

Background: Cervical cancer is one of the most prevalent cancers affecting women especially in low- and middle income countries and is caused by persistent infection with human papillomavirus (HPV). HPV vaccination can significantly reduce the cervical cancer burden. However, HPV vaccination is not yet included in the Tunisian immunization program. To inform decision-making on HPV vaccine introduction in Tunisia, we conducted a comparative modeling study to project the health impact and cost-effectiveness of four HPV vaccines (Cecolin, Cervarix, Gardasil, 4, and Gardasil-9) targeted to 12-year-old girls in 2025. Methods: We used two static cohort models (UNIVAC and Papillomavirus Rapid Interface for Modeling and Economics (PRIME)) to estimate the health and economic impact of HPV vaccination from the health system and societal perspectives. Our data inputs to the model include demography and cervical cancer burden as well as unit costs for treatment, vaccines, and vaccine delivery. We estimated health impact in terms of cases, deaths, and disability-adjusted life years (DALYs) averted by HPV vaccination, and economic impact in terms of vaccination costs, treatment costs saved, net cost, and incremental cost-effectiveness ratios (ICERs). Results: We estimated that Cecolin is the most cost-effective HPV vaccine in Tunisia, particularly when cross-protection is considered. Despite Cervarix offering greater health benefits of 70% versus 62% reductions in cervical cancer cases and deaths at 87% coverage, Cecolin has lower net costs and is more favorable across different willingness-to-pay (WTP) thresholds. At a WTP of USD 1169 per DALY averted (30% of Tunisia’s GDP per capita), Cecolin and Cervarix demonstrate similar probabilities of being cost-effective. Conclusion: Based on the vaccine impact estimates generated by the UNIVAC and PRIME models, we inferred that the four HPV vaccines (Cecolin, Cervarix Gardasil,4, and Gardasil-9) were cost-effective in the Tunisian context. This evidence is useful to inform HPV vaccine introduction in Tunisia.