Cost-effectiveness of screening and vaccinating Asian and Pacific Islander adults for hepatitis B

Stanford University, Asian Liver Center, and Stanford University School of Medicine, Stanford, California 94305-4026, USA.
Annals of internal medicine (Impact Factor: 17.81). 11/2007; 147(7):460-9.
Source: PubMed


As many as 10% of Asian and Pacific Islander adults in the United States are chronically infected with hepatitis B virus (HBV), and up to two thirds are unaware that they are infected. Without proper medical management and antiviral therapy, up to 25% of Asian and Pacific Islander persons with chronic HBV infection will die of liver disease.
To assess the cost-effectiveness of 4 HBV screening and vaccination programs for Asian and Pacific Islander adults in the United States.
Markov model with costs and benefits discounted at 3%.
Published literature and expert opinion.
Asian and Pacific Islander adults (base-case age, 40 years; sensitivity analysis conducted on ages 20 to 60 years).
U.S. societal.
A universal vaccination strategy in which all individuals are given a 3-dose vaccination series; a screen-and-treat strategy, in which individuals are given blood tests to determine whether they are chronically infected, and infected persons are monitored and treated; a screen, treat, and ring vaccinate strategy, in which all individuals are tested for chronic HBV infection and close contacts of infected persons are screened and vaccinated if needed; and a screen, treat, and vaccinate strategy, in which all individuals are tested and then vaccinated with a 3-dose series if needed. In all cases, persons found to be chronically infected are monitored and treated if indicated.
Costs (2006 U.S. dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness.
Compared with the status quo, the screen-and-treat strategy has an incremental cost-effectiveness ratio of $36,088 per QALY gained. The screen, treat, and ring vaccinate strategy gains more QALYs than the screen and treat strategy and incurs modest incremental costs, leading to incremental cost-effectiveness of $39,903 per QALY gained compared with the screen and treat strategy. The universal vaccination and screen, treat, and vaccinate strategies were weakly dominated by the other 2 strategies.
Over a wide range of variables, the incremental cost-effectiveness ratios of the screen and treat and screen, treat, and ring vaccinate strategies were less than $50,000 per QALY gained.
Results depend on the accuracy of the underlying data and assumptions. The long-term effectiveness of new and future HBV treatments is uncertain.
Screening programs for HBV among Asian and Pacific Islander adults are likely to be cost effective. Clinically significant benefits accrue from identifying chronically infected persons for medical management and vaccinating their close contacts. Such efforts can greatly reduce the burden of HBV-associated liver cancer and chronic liver disease in the Asian and Pacific Islander population.

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    • "Currently available antiviral therapies have the potential to change the natural history of CHB, [11–14] given that screening and treating high-risk populations appear cost effective in studies from the USA [15], Canada [16], Australia [17], and The Netherlands [18]. This is predicated upon people being aware of their status and willing and able to access regular monitoring and treatment [19], not readily provided through opportunistic CHB screening. "
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    ABSTRACT: Introduction Chronic hepatitis B (CHB) affects over 350 million people worldwide and can lead to life-threatening complications, including liver failure and hepatocellular cancer (HCC). Modern antiviral therapies could stem the rising tide of hepatitis B-related HCC, provided that individuals and populations at risk can be reliably identified through hepatitis B screening and appropriately linked to care. Opportunistic disease screening cannot deliver population-level outcomes, given the large number of undiagnosed people, but they may be achievable through well-organized and targeted community-based screening interventions. Material and methods This review summarizes the experience with community-based CHB screening programs published in the English-language literature over the last 30 years. Results They include experiences from Taiwan, the USA, The Netherlands, New Zealand, and Australia. Despite great variability in program setting and design, successful programs shared common features, including effective community engagement incorporating the target population’s cultural values and the ability to provide low-cost or free access to care, including antiviral treatment. Conclusion While many questions still remain about the best funding mechanisms to ensure program sustainability and what the most effective strategies are to ensure program reach, linkage to care, and access to treatment, the evidence suggests scope for cautious optimism. A number of successful, large-scale initiatives in the USA, Asia–Pacific, and Europe demonstrated the feasibility of community-based interventions in effectively screening large numbers of people with CHB. By providing an effective mechanism for community outreach, scaling up these interventions could deliver population-level outcomes in liver cancer prevention relevant for many countries with a large burden of disease.
    Hepatology International 10/2014; 8(4):478-492. DOI:10.1007/s12072-014-9562-4 · 1.78 Impact Factor
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    • "These results highlight the importance of complete serological screening among immigrants before recommending immunization, as well as serological follow up to confirm successful immunization. A recently issued IOM action plan for Hepatitis B prevention and management [34] is consistent with cost-effectiveness studies favoring the ‘Screen and Treat’ model [35-37] and the incorrect report of immunization status findings in this cross sectional prevalence study. Furthermore, our results illustrate providers and policy makers should consider the new prevalence estimates when providing services for foreign-born patients. "
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    ABSTRACT: Background Hepatitis B virus (HBV) infection is prevalent in Asian immigrants in the USA. California’s Inland Empire region has a population of approximately four million, including an estimated 19,000 first generation Koreans. Our aim was to screen these adult individuals to establish HBV serological diagnoses, educate, and establish linkage to care. Methods A community-based program was conducted in Korean churches from 11/2009 to 2/2010. Subjects were asked to complete a HBV background related questionnaire, provided with HBV education, and tested for serum HBsAg, HBsAb and HBcAb. HBsAg positive subjects were tested for HBV quantitative DNA, HBeAg and HBeAb, counseled and directed to healthcare providers. Subjects unexposed to HBV were invited to attend a HBV vaccination clinic. Results A total of 973 first generation Koreans were screened, aged 52.3y (18-93y), M/F: 384/589. Most (75%) had a higher than high school education and were from Seoul (62.2%). By questionnaire, 24.7% stated they had been vaccinated against HBV. The serological diagnoses were: HBV infected (3.0%), immune due to natural infection (35.7%), susceptible (20.1%), immune due to vaccination (40.3%), and other (0.9%). Men had a higher infection prevalence (4.9% vs. 1.7%, p = 0.004) and a lower vaccination rate (34.6% vs. 44.0%, p = 0.004) compared to women. Self-reports of immunization status were incorrect for 35.1% of subjects. Conclusions This large screening study in first generation Koreans in Southern California demonstrates: 1) a lower than expected HBV prevalence (3%), 2) a continued need for vaccination, and 3) a need for screening despite a reported history of vaccination.
    BMC Infectious Diseases 05/2014; 14(1):269. DOI:10.1186/1471-2334-14-269 · 2.61 Impact Factor
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    • "In the United States, CHB disproportionately affects the Asian and Pacific Islander communities and Asian Americans are 2 to 3 times more likely to develop and die from HCC than Caucasian Americans.5 HBV screening and vaccination was shown to be cost effective in Asian and Pacific islander Americans.6 In September 2008, the Centers for Disease Control and Prevention updated recommendations for HBV screening to include persons born in countries with HBV infection prevalence ≥2%.7 However, fewer than 25% of Asian American CHB patients have been diagnosed, and 40% to 65% go unscreened.8 "
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    ABSTRACT: Screening for hepatitis B virus (HBV) is recommended in populations with anticipated prevalence ≥2%. This study surveyed HBV screening and vaccination practices of Asian American primary care providers (PCPs). Approximately 15,000 PCPs with Asian surnames in the New York, Los Angeles, San Francisco, Houston, and Chicago areas were invited to participate in a web-based survey. Asian American PCPs with ≥25% Asian patients in their practice were eligible. Of 430 (2.9%) survey respondents, 217 completed the survey. Greater than 50% followed ≥200 Asian patients. Although 95% of PCPs claimed to have screened patients for HBV, 41% estimated that ≤25% of their adult Asian patients had ever been screened, and 50% did not routinely screen all Asian patients. In a multivariable analysis, the proportion of Asian patients in the practice, provider geographic origin and the number of liver cancers diagnosed in the preceding 12 months were significantly associated with a higher likelihood of screening for HBV. Over 80% of respondents reported that ≤50% of their adult Asian patients had received the HBV vaccine. Screening and vaccination for HBV in Asian American patients is inadequate. Measures to improve HBV knowledge and care by primary-care physicians are critically needed.
    Gut and liver 07/2013; 7(4):450-7. DOI:10.5009/gnl.2013.7.4.450 · 1.81 Impact Factor
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