Defining elimination of genital warts—a modified delphi study

Laila Khawar*, Dorothy A. Machalek, David G. Regan, Basil Donovan, Skye McGregor, Rebecca J. Guy

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


Background: Substantial declines in genital warts (GW) have been observed in countries with quadrivalent HPV vaccination programmes, with Australia showing the highest reductions due to early commencement and high vaccination coverage. There is a real potential to achieve GW elimination; however, no GW elimination definition exists. Taking Australia as a case study, we aimed to reach expert consensus on a proposed GW elimination definition using a modified Delphi process. Method: We used modelling and epidemiological data to estimate the expected number of new GW cases, from pre-vaccination (baseline) in 2006 to the year 2060 in Australian heterosexuals, men who have sex with men (MSM), and newly arrived international travellers and migrants. We used these data and the literature, to develop a questionnaire containing ten elimination-related items, each with 9-point Likert scales (1—strongly disagree; 9—strongly agree). The survey was completed by 18 experts who participated in a full day face-to-face modified Delphi study, in which individuals and then small groups discussed and scored each item. The process was repeated online for items where consensus (≥70% agreement) was not initially achieved. Median and coefficient of variation (COV) were used to describe the central tendency and variability of responses, respectively. Findings: There was a 95% participation rate in the face-to-face session, and 84% response rate in the final online round. The median item score ranged between 7.0 and 9.0 and the COV was ≤0.30 on all items. Consensus was reached that at ≥80% HPV vaccination coverage, GW will be eliminated as a public health problem in Australia by 2060. During this time period there will be a 95% reduction in population-level incidence compared with baseline, equivalent to <1 GW case per 10,000 population. The reductions will occur most rapidly in Australian heterosexuals, with 73%, 90% and 97% relative reductions by years 2021, 2030 and 2060, respectively. The proportion of new GW cases attributable to importation will increase from 3.6% in 2006 to ~49% in 2060. Interpretation: Our results indicate that the vaccination programme will minimise new GW cases in the Australian population, but importation of cases will continue. This is the first study to define GW elimination at a national level. The framework developed could be used to define GW elimination in other countries, with thresholds particularly valuable for vaccination programme impact evaluation. Funding: LK supported through an Australian Government Research Training Programme Scholarship; unconditional funding from Seqirus to support the Delphi Workshop.

Original languageEnglish
Article number316
Pages (from-to)1-17
Number of pages17
Issue number2
Publication statusPublished - Jun 2020
Externally publishedYes

Bibliographical note

Funding Information:
Funding: The lead author was supported through an Australian Government Research Training Program Scholarship. In addition, Seqirus provided unconditional funds to support the Delphi Workshop. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Publisher Copyright:
© 2020 by the authors.


  • 9-valent vaccine
  • Delphi study
  • Elimination
  • Elimination as a public health problem
  • Elimination target
  • Elimination threshold
  • Epidemiology
  • Expert workshop
  • Genital warts
  • Group Delphi study
  • HPV 6 and 11,elimination definition, Australia
  • HPV vaccination programme
  • HPV vaccine
  • Human papillomavirus HPV
  • Modified Delphi study
  • Nonavalent HPV vaccine
  • Quadrivalent HPV
  • Vaccine


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