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Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States

BMJ 2009; 339 doi: (Published 08 October 2009) Cite this as: BMJ 2009;339:b3884
  1. Jane J Kim, assistant professor,
  2. Sue J Goldie, professor
  1. 1Harvard School of Public Health, Department of Health Policy and Management, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115, USA
  1. Correspondence to: J J Kim jkim{at}
  • Accepted 9 September 2009


Objective To assess the cost effectiveness of including preadolescent boys in a routine human papillomavirus (HPV) vaccination programme for preadolescent girls.

Design Cost effectiveness analysis from the societal perspective.

Setting United States.

Population Girls and boys aged 12 years.

Interventions HPV vaccination of girls alone and of girls and boys in the context of screening for cervical cancer.

Main outcome measure Incremental cost effectiveness ratios, expressed as cost per quality adjusted life year (QALY) gained.

Results With 75% vaccination coverage and an assumption of complete, lifelong vaccine efficacy, routine HPV vaccination of 12 year old girls was consistently less than $50 000 per QALY gained compared with screening alone. Including preadolescent boys in a routine vaccination programme for preadolescent girls resulted in higher costs and benefits and generally had cost effectiveness ratios that exceeded $100 000 per QALY across a range of HPV related outcomes, scenarios for cervical cancer screening, and assumptions of vaccine efficacy and duration. Vaccinating both girls and boys fell below a willingness to pay threshold of $100 000 per QALY only under scenarios of high, lifelong vaccine efficacy against all HPV related diseases (including other non-cervical cancers and genital warts), or scenarios of lower efficacy with lower coverage or lower vaccine costs.

Conclusions Given currently available information, including boys in an HPV vaccination programme generally exceeds conventional thresholds of good value for money, even under favourable conditions of vaccine protection and health benefits. Uncertainty still exists in many areas that can either strengthen or attenuate our findings. As new information emerges, assumptions and analyses will need to be iteratively revised to continue to inform policies for HPV vaccination.


  • Contributors: JJK and SJG conceived and designed the study; analysed and interpreted the data; drafted and critically revised the manuscript for important intellectual content; and approved the version to be published. Both authors had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. JJK is the guarantor.

  • Funding: The authors are supported by grants from the National Cancer Institute (R01 CA93435), the Centers for Disease Control and Prevention, and the American Cancer Society, and by the Bill and Melinda Gates Foundation (30505) for related work in developing countries. The authors’ work was independent of the funders, and the funding sources had no involvement in the study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the paper for publication.

  • Competing interests: None declared.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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