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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    • "The intensity of the infection, which was assumed to be constant, and the annual probability of acquiring HBV infection, which was also assumed to be constant, were both identified as important parameters in another study [16]. With both, the assumption of a constant rate was found to limit the study's ability to infer precise cost-effectiveness results [16].In addition, compliance rates together with the length of efficacy of the vaccine (e.g. 10 years) and efficacy of the treatment were found to impact on the disease part of the economic model [20]. It was further assumed that vaccines do not incur any side effects that required medical care, thus impacting in particular on the treatment costs. "
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    ABSTRACT: Studies evaluating the cost-effectiveness of screening for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are generally heterogeneous in terms of risk groups, settings, screening intervention, outcomes and the economic modelling framework. It is therefore difficult to compare cost-effectiveness results between studies. This systematic review aims to summarise and critically assess existing economic models for HBV and HCV in order to identify the main methodological differences in modelling approaches.
    Full-text · Article · Dec 2015 · PLoS ONE
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    • "Recent estimates suggest that 44 % of people living with CHB in Australia are undiagnosed [3]. Only 5 % of people living with CHB are currently receiving antiviral therapy [7], representing a minority of the estimated 10–25 % who would benefit from treatment891011. Undiagnosed CHB can lead to ongoing transmission, while late diagnosis limits opportunities to prevent progression to HCC or cir- rhosis [4]. "
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    ABSTRACT: Background It is estimated that over 40 % of the 218,000 people with chronic hepatitis B (CHB) in Australia in 2011 are undiagnosed. A disproportionate number of those with undiagnosed infection were born in the Asia-Pacific region. Undiagnosed CHB can lead to ongoing transmission and late diagnosis limits opportunities to prevent progression to hepatocellular carcinoma (HCC) and cirrhosis. Strategies are needed to increase testing for hepatitis B virus (HBV) (including culturally and linguistically diverse communities, Aboriginal and/or Torres Strait Islander (Indigenous) people and people who inject drugs). General practitioners (GPs) have a vital role in increasing HBV testing and the timely diagnosis CHB. This paper describes the impact of a GP-based screening intervention to improve CHB diagnosis among priority populations in Melbourne, Australia. Methods A non-randomised, pre-post intervention study was conducted between 2012 and 2013 with three general practices in Melbourne, Australia. Using clinic electronic health records three priority populations known to be at increased CHB risk in Australia (1: Asian-born patients or patients of Asian ethnicity living in Australia; 2: Indigenous people; or 3): people with a history of injecting drugs were identified and their HBV status recorded. A random sample were then invited to attend their GP for HBV testing and/or vaccination. Baseline and follow-up electronic data collection identified patients that subsequently had a consultation and HBV screening test and/or vaccination. Results From a total of 33,297 active patients, 2674 (8 %) were identified as a priority population at baseline; 2275 (85.1 %) of these patients had unknown HBV status from which 338 (14.0 %) were randomly sampled. One-fifth (n = 73, 21.6 %) of sampled patients subsequently had a GP consultation during the study period; only four people (5.5 %) were subsequently tested for HBV (CHB detected in n = 1) and none were vaccinated against HBV. Conclusion CHB infection is an important long-term health issue in Australia and strategies to increase appropriate and timely testing are required. The study was effective at identifying whether Asian-born patients and patients of Asian had been tested or vaccinated for HBV; however the intervention was not effective at increasing HBV testing.
    Preview · Article · Dec 2015 · BMC Public Health
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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.
    Full-text · Article · Oct 2014 · Hepatology International
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