The economic burden of HPVrelated diseases: Austria
Key highlights
• Human Papillomavirus (HPV) infection remains one of the most prevalent sexually transmitted infections worldwide, affecting millions of individuals annually.
• In Austria, where the median age at first sexual intercourse is 16.6 years, all individuals aged 15 years and older, totalling 85.62% of the population, are potentially susceptible to HPV infection, depending on their sexual activity
• Cervical cancer is the most prevalent HPV-related cancer in Austria, and the fourth most common female cancer in the country. Healthcare costs per incidence were estimated to range on average between €27,390 and €32,785. Considering that on an annual basis, there are 385 cases of cervical cancer, the economic burden remains considerable. Moreover, routine screening remains essential, and the diagnosis and treatment of cervical cancer continue to be costly.
• Other HPV-related diseases are, likewise, associated with increased mortality and impose significant costs on individuals and society. For instance, the average cost per HPV-related cancer case ranges between €21,025 for penile cancer and €41,709 for head and neck cancer. In total, the annual economic healthcare burden of HPV-related cancers amounts to, approximately, €25.8 million.
• The economic impact of HPV-related diseases highlights the crucial role of effective prevention strategies, including vaccination and screening programs, in mitigating both health and financial consequences.
• Literature on Austria does not report indirect costs, such as productivity losses, indicating that the country's socioeconomic impact of HPV-related diseases is underestimated
• Preventive measures aimed at reducing the occurrence of HPV-related diseases and, consequently, their socioeconomic burden include cervical cancer screening and HPV vaccine.
• Austria stands out as the first European country to initiate an HPV vaccination program for both sexes in 2014. The program targets people aged 9 to 21 years
3.2.
3.2.1.
3.2.1.1.
3.2.1.2.
3.2.2.
3.2.3.
3.3.
3.3.1.
3.3.2.
Abbreviations
Abbreviation Definition
CC Cervical cancer
CIN Cervical intraepithelial neoplasia
HPV Human Papillomavirus
Economic
1. Introduction
Human Papillomavirus (HPV) infection remains one of the most prevalent sexually transmitted infections worldwide, affecting millions of individuals annually. In Austria, as in many other countries, HPV poses a significant public health challenge due to its association with various cancers, including cervical, anal, and oropharyngeal cancers, among others. These diseases not only impact individual health but also impose substantial socioeconomic burdens on healthcare systems and society at large.
Understanding the socioeconomic impact of HPV-related diseases is crucial for several reasons. Firstly, the direct medical costs associated with treating HPV-induced cancers are substantial, encompassing diagnosis, treatment, and long-term care. Moreover, indirect costs such as productivity losses due to morbidity and premature mortality further exacerbate the economic burden. The economic impact of HPV-related diseases underscores the importance of effective prevention strategies, including vaccination and screening programs, in mitigating both health and financial consequences.
Investigating the socioeconomic aspects of preventive measures against HPV is imperative for accurately allocating resources to mitigate the health burden caused by HPV-related diseases. Vaccination against high-risk HPV types has demonstrated significant effectiveness in reducing infections and subsequently, preventing cancers. Early detection through screening programs allows for timely intervention, potentially preventing the progression of precancerous lesions to invasive cancer. By assessing the cost-effectiveness of these interventions, policymakers and healthcare providers can make informed decisions about resource allocation and public health policies.
In Austria, as elsewhere, the socioeconomic impact of HPV-related diseases and the effectiveness of preventive measures warrant comprehensive analysis. This report aims to explore these facets, providing insights into the current landscape, identifying gaps in knowledge, and recommending strategies to enhance public health outcomes and economic efficiency in managing HPV infections and associated diseases.
2. Methodology
To this aim, we performed a literature search in PubMed to identify indexed literature as well as grey literature sources to identify additional and complementary sources of information. For the PubMed search, articles were screened and identified using key terms such as
"economic," "costs," "cost-effectiveness," and "cost of illness," along with HPV-related terms. Studies focusing on the economic impact of HPV-related diseases and studies reporting the economic effects of preventive measures were included in our review Furthermore, a targeted Google search was conducted to identify any additional relevant information. Only credible sources, such as governmental websites (e.g., Bundesministerium Soziales, Gesundheit, Pflege, und Konsumentenschutz), were considered. The identified articles and documents were then reviewed to extract relevant data on the costs associated with HPVrelated diseases, including direct medical costs, indirect costs, and broader economic impacts. This methodology ensures a comprehensive overview of the economic burden, incorporating both peer-reviewed studies and authoritative grey literature sources.
3. The Austrian Landscape
Statistics for Austria
• Population (2023)(1)
9.13 million
• GDP per capita (2023)(2)
US$56,506.0
• Currency Euro (€)
• National HPV prevention programs Vaccination (2014) –Cervical cancer screening (1970)
• Vaccine coverage 53% (3)
3.1. HPV transmission and HPV-related diseases in Austria
Since sexual intercourse is the primary route of transmission, all sexually active individuals are at risk of genital HPV infection. In Austria, the median age at first sexual intercourse is 16.6 years (based on 2017 data) (4). Given that 85.62% of the population is aged 15 and older, a substantial portion of the Austrian population is at risk of HPV infection and, consequently, HPV-related diseases.
Cervical cancer (CC) is the most prevalent HPV-related cancer in Austria and the fourth most common female cancer in women aged 15 to 44 years in the country. It has an incidence
Figure 1. Map of Austria and key statistical information for the country
rate of approximately 8.3 cases per 100,000 women per year, leading to about 385 new CC cases being diagnosed annually in Austria (estimations for 2020). Moreover, CC ranks as the fourteenth leading cause of female cancer in Austria, with a crude mortality rate of 3.72 deaths per 100,000 women per year, leading to about 170 death cases annually (estimations for 2020).
Other HPV-related cancers in Austria include cancers of the oral cavity, vulva, vagina, anus, penis, and oropharynx, which are also often consequences of HPV infection After CC, the second most frequent HPV-related cancer is oral cavity cancer, with a crude incidence rate of 8.31 per 100,000 individuals for males and 4.29 for females. However, it is important to note that, unlike CC, not all cases of oral cavity cancer are directly associated with HPV. A summary of the annual number of cases and deaths for cervical and other HPV-related diseases is presented in Table 1
Abbreviations: M: men; W: women
3.2. Socioeconomic burden of HPV-related diseases in Austria
HPV-related diseases are not only associated with increased mortality but also impose significant costs on individuals and society. The socioeconomic burden of these diseases was estimated using available data that we obtained from the literature. This involved extracting reported healthcare costs incurred by both the healthcare system and patients for each HPVrelated disease. Whenever possible, we also extracted societal costs, which include, for instance, productivity losses due to absenteeism or mortality, informal care costs, and productivity losses related to caregiving.
3.2.1. Healthcare costs
3.2.1.1. Cervical intraepithelial neoplasia and cervical cancer
Table 1. Estimated annual number of new cases and annual number of new deaths per cancer type in Austria in
Data on the economic burden of HPV-related diseases in Austria is, in general, limited Nonetheless, a study conducted in 2007 by an Austrian health technology assessment body, Ludwig Boltzmann, provided detailed information on costs associated with CC (6) Table 2 presents the costs for the individual service packages (excluding vaccination) associated with CC in the Austrian context In 2003, the total costs for all women screened and treated for CC, including follow-up costs, were estimated at €66.9 million (€105.2 million inflated to 2024) The largest share of the total costs, over 60%, came from routine screening with Pap tests Further 20% of the costs are attributed to the service package “Management/treatment of precancerous cervical lesions”, the costs of which highly depend on the number and price of conization procedures, i.e., cone biopsies of the cervix performed for both diagnostic and therapeutic purposes Furthermore, 15% of the total costs are caused by the treatment of invasive CC. In 2024, these numbers are expected to be lower, considering that a vaccination program has been in place since 2014. However, as vaccination coverage is still not at its target to eliminate cervical cancer, routine screening is still necessary and diagnosis and treatment of cervical cancer remains costly.
Table 2. Estimated total costs of the service packages based on 2003 (6)
Total costs for the “screening only” strategy (for all those screened + treated in 2003, including follow-up costs)
Table 3 shows the breakdown of costs for treatment of invasive CC. Based on the available cost data of this study performed in 2003, the average cost per case for the treatment of CC in Austria was around €27,390, adjusted for 2024 inflation. Based on the individual stages of CC, the average treatment costs were estimated to range from approximately €20,939 to €35,532 Considering the total number of existing CC cases, the healthcare-related burden of CC in Austria is substantial.
Table 3. Costs of treating invasive cervical cancer in
Conization
Hysterectomy
Teletherapy
Brachytherapy
Chemotherapy
Radiotherapy
Chemotherapy
Specialist
Tumor markers
Vaginal ultrasound
Cytology
Breast diagnostics
CT Thorax/Abdomen
Total treatment costs for patients in 2003
Average treatment costs per case
€3,445
€9,387
€13,220
€8,446
€7,203
€21,667
€7,203
€19
€22
€31
€10
€63
€12
€10,209,349 (not inflated)
€12,955,974 (inflated)
€27,390
In 2014, another study estimated the cost of care for each stage of CC per incidence case (7) To estimate the average cost of care per incidence case by cancer type, we calculated the weighted average of stage-specific costs (Table 4) For CC, this amounted to €32,785
Table 4. Cost of care per incidence of cervical cancer (2024 euros) (7)
Cancer type (1) Cost of care per incidence case (2024€)
Note: (1) Disease stages can be related to the traditional Tumour-Node-Metastasis (TNM) classification system as follows: “Local disease” corresponds to stages I and II TNM classification, i.e., localized primary tumour; “Regional disease” corresponds to stage III TNM classification system, i.e., metastasis to regional lymph nodes; “Distant disease” corresponds to stage IV TNM classification system, i.e., distant metastatic disease (2) As the costs for unstaged cancer are unknown, the percentage of unstaged cancer cases were added to the portion of the local disease stage to maintain a conservative estimation of the costs. (3) United States-based database
3.2.1.2.
Other HPV-related cancers
The economic burden becomes even more significant when considering the additional costs of other HPV-related diseases. Evidence on the costs for HPV-related diseases other than CC and cervical intraepithelial neoplasia (CIN) is often lacking; however, in 2014, a study estimated the costs of care per incidence case for several HPV-related cancers. These costs, adjusted for 2024 inflation, are presented in Table 5. Costs were reported only for local, regional, and distant diseases. To estimate the average cost of care per incidence case per cancer type, we calculated the weighted average of the costs for these stages
Table 5. Cost of care per incidence of HPV-related cancer (inflated to 2024) (7) Cancer type (1)
Note: (1) Disease stages can be related to the traditional Tumour-Node-Metastasis (TNM) classification system as follows: “Local disease” corresponds to stages I and II TNM classification, i.e., localized primary tumour; “Regional disease” corresponds to stage III TNM classification system, i.e., metastasis to regional lymph nodes; “Distant disease” corresponds to stage IV TNM classification system, i.e., distant metastatic disease (2) As the costs for unstage cancer are unknown, the percentage of unstaged cancer cases were added to the portion of local disease stage to maintain a conservative estimation of the costs. (3) United States-based database
Table 5 shows that the average cost per HPV-related cancer case ranges from €21,025 for penile cancer to €41,709 for head and neck cancer.
3.2.2. Indirect costs
Indirect costs associated with HPV-related diseases were not identified in the literature on Austria. However, these costs can be substantial, particularly in the case of cancer, and consist primarily of productivity losses. These productivity losses arise from absenteeism due to cancer treatment, premature death, and the caregiving responsibilities shouldered by family members or other caregivers. Additionally, the emotional and psychological impact on patients and their families may lead to further mental health care costs.
A rough estimation of the productivity losses arising from absenteeism due to cancer treatment can be calculated by considering the average hourly rate for men and women, the length of the absence, and the assumption that a working day consists of eight hours per day (Table 6) To do so, we extracted the data from a study that estimated productivity losses from short-term work absences due to neoplasms in Poland, as equivalent data were not available for Austria.
6. Estimated average productivity losses due to short-term work absence due to cervical cancer
(2018)
This results in an estimated annual productivity loss of €1.0 million from short-term work absences due to CC cases alone. The total productivity losses are even greater when considering long-term work absence, premature death and caregiver absenteeism. Moreover, similar estimates can also be applied to other HPV-related cancers. Additionally, while less impactful than cancer, genital warts can incur indirect costs such as travel expenses to general practitioners or clinics and absenteeism due to receiving treatment
The lack of reported indirect costs means that the true socioeconomic burden of HPVrelated diseases in Austria is likely underestimated. This can lead to insufficient resource allocation for prevention and treatment programs. Recognizing and addressing these hidden costs is crucial for a comprehensive understanding of the impact of HPV-related diseases on individuals and society, ultimately guiding more effective public health policies and interventions.
3.2.3. Total costs
A rough estimation, due to limited data availability, of the total annual costs of various HPVrelated cancers is provided in Table 7. This estimation was derived by taking into account the annual incidences of cases in 2020, as well as the percentage attribution to HPV and multiplying these figures by the respective costs which were reported in the previous section.
Table
Table 7. Estimated
Note: (1) The calculation used costs from head & neck cancer due to the unavailability of cost data for these cancers
The total lifetime economic burden of HPV-related cancers is approximately €25.8 million for all cancer cases. These costs exclude indirect societal costs such as productivity losses due to absenteeism, disability, and premature mortality, as well as intangible costs, such as psychological distress and reduced quality of life, which further compound the economic impact.
Even though genital warts are less invasive than cancer and require less expensive treatments, they still contribute significantly to the overall economic burden. No studies specifically reported the total socioeconomic burden of genital warts in Austria. However, Boiron et al. reported that the cost per episode of care for genital warts was €661 in 2014 (€839 inflated to 2024) (7). This figure can be used to estimate the total costs for genital warts when multiplied by the incidence rate.
Since updated incidence data for genital warts in Austria is not available, we used the most conservative value from a study by Desai et al., which estimated the incidence of genital warts in Europe. The lowest estimate was for England, at 289 per 100,000 population (9). Given Austria's total population of 9,158,750, we estimated the annual economic burden of genital warts by multiplying this incidence rate by the total Austrian population, the percentage of genital warts related to HPV infection, and the cost per episode of care (10) This results in an estimated total annual healthcare economic burden of €19,986,580 (2024 euros). It is important to note that these are direct medical costs, and indirect societal costs (e.g., productivity losses) are not included.
Including these indirect costs would provide a more accurate and higher estimate of the financial impact. This highlights the necessity for further research to capture the full economic burden of HPV-related diseases, enabling more informed decision-making and resource allocation for prevention and treatment programs.
3.3.
Economic benefits of HPV-related preventive measures
To fight the occurrence of HPV-related diseases and reduce the socioeconomic burden associated with the virus, several preventive measures have been put in place. First of all,
there is a cancer screening program to prevent cervical cancer by identifying risks and removing precancerous lesions. In Austria, individuals aged over 18 years can participate in this program, which has been running since 1970 However, individuals do not receive an active invitation to screening, meaning that they need to seek the information and services themselves, which potentially results in a lower number of individuals using the available program. The coverage of cervical cancer screening in Austria is shown in Figure 2
Since 2014, the HPV vaccine has been part of the Austrian National Vaccination Program. The program targets people aged 9 to 21 years (4). According to the WHO, the current vaccination rate of the last dose for both sexes is 53% (3). Austria stands out as the first European country to initiate an HPV vaccination program in 2014 that includes both girls and boys. The decision to vaccinate boys alongside girls was based on three main factors: (i) the significant burden of HPV-related diseases in males, (ii) the need for equity since men who have sex with men do not benefit from herd immunity provided by vaccinating only girls, and (iii) the goal of achieving sufficient coverage to ensure herd protection. By vaccinating both genders, Austria aims to enhance overall vaccination coverage and halt the transmission of HPV-related diseases more effectively. In addition, starting from 1 July and with a limited offer until the end of 2025, people up to their 30th birthday will now also be able to catch up on the HPV vaccination free of charge (11). (12).
Numerous studies have evaluated the preventive measures related to HPV to analyse the cost-effectiveness and socioeconomic benefits. These studies are crucial for helping
Figure 2 Estimated coverage of cervical cancer screening in Austria (1)
policymakers and healthcare providers allocate resources efficiently, ensuring that funds are directed toward the most beneficial and cost-effective measures. Moreover, highlighting the economic and health benefits of HPV prevention can increase public support and uptake of vaccination and screening programs
3.3.1. Cervical cancer screening
Cervical screening was shown to be an effective measure to prevent CC. In 2009, Zechmeister et al. assessed the socioeconomic impact of vaccination compared to screening only. The findings show that vaccination results, over a lifetime horizon, in a total savings of 1,988 life years. On the other hand, total direct and indirect costs were lower with the screening-only strategy, with a difference of €127 million for direct costs and €98 million for indirect costs related to productivity losses. This means that from a healthcare perspective, preventing measures in the form of vaccination cost €64,000 for each life year gained. While vaccination leads to a significant number of life years saved, the higher costs associated with it highlight the need for careful consideration of budget allocations within healthcare systems. Policymakers must weigh the long-term benefits of increased life expectancy against the immediate financial burden (13).
3.3.2. Vaccination
The first economic evaluation in the Austrian setting to assess the impact of universal vaccination was conducted in 2009 (13). To evaluate the cost-effectiveness of vaccination programs, the authors considered the effects of vaccination on the spread of HPV and the burden of CC, disregarding the effects on other HPV-related diseases, especially for males. This omission was likely due to the perceived small burden of disease associated with HPV 16/18 in males and the unknown efficacy of vaccines for the prevention of these relatively rare cancers (14). When considering only the effects of vaccination for CC prevention, vaccinating boys was found to be inefficient from an economic perspective.
In 2014, when the universal HPV vaccination program was implemented, a study by Bresse et al. assessed the cost-effectiveness of universal HPV vaccination in Austria, considering the effects of vaccination on other cancer types as well (15). The findings showed that the HPVrelated cancer burden could be reduced annually by 71% in men with universal vaccination using a quadrivalent HPV vaccine, avoiding 121 cancer cases, while for women it could be reduced by 75%, avoiding 310 cancer cases. Anogenital warts would be reduced by 71% in both men and women.
Figure 3. Annual number of HPV 16/18-related carcinoma cases among males and females when considering a vaccination strategy of boys and girls aged 9 years of age versus no vaccination. (A) Annual number of HPV 16/18-related carcinoma cases among females according to vaccination strategy. (B) Annual number of HPV 16/18-related carcinoma cases among males according to vaccination strategy. (15)
Universal vaccination proved to be highly cost-effective, with virus circulation being controlled already at a coverage rate of 65%. Although higher coverage rates made vaccination less cost-effective, they ensured more certain control of the virus. Similarly, Boiron et al. (2014) estimated the health and cost effects of vaccinating both girls and boys with nonavalent or quadrivalent HPV vaccines (7). Their analysis included reductions in cervical, vaginal, vulvar, penile, anal, and head and neck cancers, as well as genital warts and recurrent respiratory papillomatosis based on the vaccine efficacy reported during the clinical trials. The outcomes showed a drastic reduction in the incidence of all HPV-related diseases over 100 years, resulting in 23,652 cancer cases and 8,399 cancer deaths averted with the 9valent vaccine compared to no vaccination. Figure 3 illustrates the reduction in incidence over 100 years using the 4-valent and 9-valent vaccines.
Figure 4 Incidence reduction with quadrivalent and nonavalent vaccination at a steady-state (7)
The analysis also showed that with a vaccine price of up to €153 for the quadrivalent vaccine and €113 for the 9-valent, vaccinating both boys and girls for HPV is cost-effective. At €113 and €116 for the quadrivalent and nonovalent vaccines, respectively, this strategy is even cost-saving for the healthcare system (7).
Both studies highlighted the significant impact of such a vaccination program even with relatively low coverage rates, especially for boys. This high impact was assessed without considering other factors such as productivity losses averted from preventing HPV-related diseases, as well as broader societal impacts like reduced emotional suffering linked to screening outcomes and preserved fertility. Beyond being more cost-effective and preventing a high number of HPV-related diseases, the universal HPV vaccination program in Austria has guaranteed equal access, and gender equality as well as distributing the responsibility for prevention more equitably between genders. This approach aids in de-sexualizing the vaccination, thereby reducing any stigma associated with a girl-only vaccination program. Such stigma reduction can alleviate the burden on women and address socio-cultural barriers, making the HPV vaccination more acceptable to a wider audience. Increased acceptability is likely to boost vaccination uptake rates, which enhances the overall effectiveness of the program.
Moreover, expanding the assessment to include other HPV-related diseases, not just CC, significantly enhances the benefits of the vaccination program. By considering the impact on a broader range of cancers such as vaginal, vulvar, penile, anal, and head and neck cancers
as well as conditions like genital warts and recurrent respiratory papillomatosis, the comprehensive health benefits become clear. This broader assessment demonstrates how HPV vaccination can lead to substantial reductions in the incidence of these diseases, providing a more holistic view of its effectiveness and reinforcing its economic viability. However, it is important to point out that this analysis was performed using clinical trial data, and the applicability of the results may vary across different regions. For instance, in Austria, the HPV vaccines are not currently indicated for the prevention of certain conditions, namely head and neck cancers, penile cancer, and respiratory papillomatosis. As a result, the benefits of the vaccine in preventing these specific diseases cannot be firmly established in this context.
Overall, the CC screening program and the universal HPV vaccination program in Austria have the potential to be a successful public health strategy, providing equal access and promoting gender equality By preventing a wide range of HPV-related diseases and reducing the burden on healthcare systems, the program underscores the significant health and economic benefits of comprehensive HPV vaccination policies. Regarding the WHO CC elimination target, Austria has already achieved the goal of screening 70% of women by the age of 35 using a high-performance test. However, with only 53% coverage, Austria has yet to meet the target of vaccinating 90% of the population with an HPV vaccine by the age of 15. Achieving full vaccination coverage remains critical to maximizing the public health impact and ensuring Austria's continued progress towards eliminating CC
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