Cost-Effectiveness of Screening and Vaccinating Asian and Pacific Islander Adults for Hepatitis B

2 October 2007 | Volume 147 Issue 7 | Pages 460-469

Background: 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.

Objective: To assess the cost-effectiveness of 4 HBV screening and vaccination programs for Asian and Pacific Islander adults in the United States.

Design: Markov model with costs and benefits discounted at 3%.

Data Sources: Published literature and expert opinion.

Target Population: Asian and Pacific Islander adults (base-case age, 40 years; sensitivity analysis conducted on ages 20 to 60 years).

Time Horizon: Lifetime.

Perspective: U.S. societal.

Interventions: 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.

Outcome Measures: Costs (2006 U.S. dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness.

Results of Base-Case Analysis: 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.

Results of Sensitivity Analysis: 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.

Limitations: Results depend on the accuracy of the underlying data and assumptions. The long-term effectiveness of new and future HBV treatments is uncertain.

Conclusions: 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.

Editors' Notes Context About 10% of Asian and Pacific Islander adults in the United States are chronically infected with hepatitis B virus (HBV). Many are unaware of their infection and do not receive antiviral treatment. Contribution This analysis assesses the incremental cost-effectiveness of alternative strategies for voluntary screening for HBV in Asian and Pacific Islander adults. Compared with voluntary screening only, a strategy of screening and then treating infected persons and a strategy of screening and treating infected persons and ring vaccinating close contacts were cost-effective (about $36 000 to $40 000 per quality-adjusted life-year gained). Implication Programs to screen and treat Asian and Pacific Islander adults for HBV infection are probably cost-effective. —The Editors

 

Author and Article Information

From Stanford University, Asian Liver Center, and Stanford University School of Medicine, Stanford, California.

Acknowledgments: The authors thank Dr. Ellen T. Chang of the Asian Liver Center at Stanford University for helpful comments on the manuscript.

Grant Support: Mr. Hutton was supported by a Stanford Graduate Fellowship. Dr. So is the recipient of a U50 award from the National Center for Infectious Disease.

Reproducible Research Statement: The model and statistical code are available to interested readers by contacting Mr. Hutton (e-mail, billdave{at}stanford.edu).

Potential Financial Conflicts of Interest: None disclosed.

Request for Single Reprints: Margaret L. Brandeau, PhD, Department of Management Science and Engineering, Terman Building, Stanford University, Stanford, CA 94305-4026; e-mail, brandeau{at}stanford.edu.

Current Author Addresses: Mr. Hutton and Dr. Brandeau: Department of Management Science and Engineering, Terman Building, Stanford University, Stanford, CA 94305.

Mr. Tan: Block 297A, Compassvale Street 10-24, Singapore 541297.

Dr. So: Asian Liver Center, Stanford University, 300 Pasteur Drive, H3680, Stanford, CA 94305.

Author Contributions: Conception and design: D.W. Hutton, D. Tan, S.K. So, M.L. Brandeau.

Analysis and interpretation of the data: D.W. Hutton, D. Tan, S.K. So, M.L. Brandeau.

Drafting of the article: D.W. Hutton, D. Tan, S.K. So, M.L. Brandeau.

Critical revision of the article for important intellectual content: D.W. Hutton, S.K. So, M.L. Brandeau.

Final approval of the article: D.W. Hutton, S.K. So, M.L. Brandeau.

Collection and assembly of data: D. Tan.