The Cost-effectiveness of Screening for Chronic Hepatitis B Infection in the United States

Division of General Internal Medicine and the Center for Clinical Effectiveness, Ohio, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 06/2011; 52(11):1294-306. DOI: 10.1093/cid/cir199
Source: PubMed


Hepatitis B virus (HBV) continues to cause significant morbidity and mortality in the United States. Current guidelines suggest screening populations with a prevalence of ≥2%. Our objective was to determine whether this screening threshold is cost-effective and whether screening lower-prevalence populations might also be cost-effective.
We developed a Markov state transition model to examine screening of asymptomatic outpatients in the United States. The base case was a 35-year-old man living in a region with an HBV infection prevalence of 2%. Interventions (versus no screening) included screening for Hepatitis B surface antigen followed by treatment of appropriate patients with (1) pegylated interferon-α2a for 48 weeks, (2) a low-cost nucleoside or nucleotide agent with a high rate of developing viral resistance for 48 weeks, (3) prolonged treatment with low-cost, high-resistance nucleoside or nucleotide, or (4) prolonged treatment with a high-cost nucleoside or nucleotide with a low rate of developing viral resistance. Effectiveness was measured in quality-adjusted life years (QALYs) and costs in 2008 US dollars.
Screening followed by treatment with a low-cost, high-resistance nucleoside or nucleotide was cost-effective ($29,230 per QALY). Sensitivity analyses revealed that screening costs <$50,000 per QALY in extremely low-risk populations unless the prevalence of chronic HBV infection is <.3%.
The 2% threshold for prevalence of chronic HBV infection in current Centers for Disease Control and Prevention/US Public Health Service screening guidelines is cost-effective. Furthermore, screening of adults in the United States in lower-prevalence populations (eg, as low as .3%) also is likely to be cost-effective, suggesting that current health policy should be reconsidered.

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Available from: Mark H Eckman,
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    • "Guidelines recommend diagnosing chronic HBV infection by testing a subject for hepatitis B surface antigen (HBsAg) positivity [1] [5]. Recently Eckman et al. demonstrate in United States that screening for chronic HBV infection in foreign born subjects from endemic area is cost effective to implement treatment and prevention policies [5] [6]. However testing for HBsAg to establish chronic HBV infection in subjects may be hampered in low-income sub-Saharan African countries as in Côte d'Ivoire where HBV is hyper endemic [1] [7]. "
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    ABSTRACT: Background: The high burden of viral hepatitis B (HBV) remains a challenge in Côte d’Ivoire where patients are mostly seen in hospital at the end stage of the disease. Aim: This cross sectional study is aimed at assessing the usefulness of anamnestic findings, clinical and biological factors in predicting chronic hepatitis B surface antigen (HBsAg) carriers in clinical practice. Patients and methods: The study was conducted in 230 workers (median age: 39 years, female: 20%) of government press enterprise (GPE) in 2010. Socio-demographic, clinical and biological parameters were collected. Chronic HBsAg carrier was defined as serum HBsAg positivity after 2 assessments within 6 months interval. Diagnostic accuracy of predictive factors was determined by multivariate logistic regression. Results: The prevalence of chronic HBsAg was 12.6% [95%CI: 8.61-17.60]. Chronic HBsAg carriers frequently expressed a history of hepatitis (13.8 vs 2.5%, p=0.003), or jaundice (37.9 vs 14.3, p=0.003), had slightly high level of AST (33 vs 25.5 IU/L, p=.004) and ALT (31.5 vs 22, p=<0.0001) compared to non-carriers. In multivariate analysis, age (OR: 0.93, p=0.03), history of hepatitis (OR=8.18, p=0.005), unsafe injection with boiled syringe (OR: 3.41, p=0.03), and ALT (OR=1.03, p=0.002) were predictive factors of chronic HBsAg carriers. The model yielded an AUROC of 0.793±0.06. With a cut-off <0.125, the model allowed predicting chronic HBsAg carrier with a sensitivity and negative predictive value of 78.6 and 96.1% respectively. Among 28 chronic HBsAg carriers 22(78.6%) were correctly predicted and 6(21.4%) were false negative. With a cut-off >0.5, the model showed a specificity, positive and negative predictive values of 99, 66.7 and 88.9% respectively. The model correctly classified 192(99%) workers as non-chronic HBsAg carriers and 2(1%) were misclassified. Conclusion: This study suggests that age, history of hepatitis, unsafe injection with boiled syringe combined with ALT could be used to predict chronic HBsAg carrier in Côte d’Ivoire and other endemic areas in Africa
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    • "The only study found that considered general population screening for HBsAg [47], suggested this would be cost-effective in populations with a prevalence above 0.3%. This includes nearly all European countries. "
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    ABSTRACT: Background Treatment for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is improving but not benefiting individuals unaware to be infected. To inform screening policies we assessed (1) the hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV-Ab) prevalence for 34 European countries; and (2) the cost-effectiveness of screening for chronic HBV and HCV infection. Methods We searched peer-reviewed literature for data on HBsAg and anti-HCV-Ab prevalence and cost-effectiveness of screening of the general population and five subgroups, and used data for people who inject drugs (PWID) and blood donors from two European organizations. Of 1759 and 468 papers found in the prevalence and cost-effectiveness searches respectively, we included 124 and 29 papers after assessing their quality. We used decision rules to calculate weighted prevalence estimates by country. Results The HBsAg and anti-HCV-Ab prevalence in the general population ranged from 0.1%-5.6% and 0.4%-5.2% respectively, by country. For PWID, men who have sex with men and migrants, the prevalence of HBsAg and anti-HCV-Ab was higher than the prevalence in the general population in all but 3 countries. There is evidence that HCV screening of PWID and HBsAg screening of pregnant women and migrants is cost-effective. Conclusion The prevalence of chronic HBV and HCV infection varies widely between European countries. Anti-HCV-Ab screening of PWID and HBsAg screening of pregnant women and migrants have European public health priority. Cost-effectiveness analyses may need to take effect of antiviral treatment on preventing HBV and HCV transmission into account.
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