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A Reappraisal of Hepatitis B Virus Vaccination Strategies Using Cost-Effectiveness Analysis

Bernard S. Bloom, PhD; Alan L. Hillman, MD, MBA; A. Mark Fendrick, MD; and J. Sanford Schwartz, MD
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From the School of Dental Medicine, the School of Medicine, The Wharton School, and the Leonard Davis Institute of Health Economics, of the University of Pennsylvania, Philadelphia, Pennsylvania. Requests for Reprints: Bernard S. Bloom, PhD, University of Pennsylvania, 2L Nursing Education Building, Philadelphia, PA 19104-6020. Acknowledgments: The authors thank Drs. Martin Black (Chief, Liver Unit, Temple University School of Medicine); Gene Gibson (Associate Director, Pharmacy of the Hospital of the University of Pennsylvania), Mark Kane (E.I.S. Officer, Centers for Disease Control); Ray Koff (Chief of Medicine, Framingham Union Hospital); and Michael Scheld (Professor of Medicine, University of Virginia Health Sciences Center) for their participation in the expert panel. Grant Support: By a grant from SmithKline Beecham.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1993;118(4):298-306. doi:10.7326/0003-4819-118-4-199302150-00009
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Objective: To determine clinical and economic consequences of alternative vaccination strategies for preventing hepatitis B virus infection (HBV).

Methods: Decision analysis was used to evaluate costs, outcomes, and cost-effectiveness of three HBV management strategies (“no vaccination,” “universal vaccination,” and “screen and vaccinate”) in four populations (newborns, 10-year-old adolescents, a high-risk adult population, and the general adult U.S. population). Information on HBV incidence and prevalence, clinical course, and management of acute illness and chronic sequelae was obtained from the literature and a panel of experts. Actual payments (costs) were obtained from Blue Cross/Blue Shield and local pharmacies. Incremental cost-effectiveness was calculated from the perspective of the payer of medical care and subjected to sensitivity analysis.

Results: Vaccination (with or without screening) prevents more disease at somewhat increased cost than no vaccination for the neonatal, adolescent, and adult populations. Vaccination (with or without screening) is a dominant strategy in adult high-risk populations (lower cost and greater benefit than no vaccination). Optimal cost-effectiveness, with nonmonetary benefits not discounted, results if all pregnant women are screened for active HBV infection, and HBV vaccine and hepatitis B immune globulin are administered to babies born to mothers with positive screening tests. Then HBV vaccine is administered to all children at age 10 and again 10 years later (incremental cost-per-year-of-life-saved relative to the “no vaccination” strategy is $375). A strategy of universal newborn vaccination alone leads to an incremental cost-per-year-of-life saved of $3332. If adolescents are vaccinated at age 10, incremental cost-per-year-of-life saved is $13 938; for the general adult population, the incremental cost-per-year-of-life saved of universal vaccination is $54 524. Discounting benefits will increase cost-per-year-of-life saved 7 to 12 times for all strategies.

Conclusions: HBV vaccine is most cost-effective when a strategy of screening newborns is combined with routine administration to 10-year-old children. The means to achieve substantial improvements in the health of the public in a cost-effective fashion are now available and should be pursued aggressively.


Grahic Jump Location
Figure 1.
Structure of basic adult decision tree for first 10-year period.

Terminal branches ending in closed circles represent persons who lived through the period without contracting hepatitis B (HB). These persons re-enter the model for two subsequent 10-year time periods. Terminal branches ending in open circles reflect persons who contract active hepatitis B infection and are subject to various acute presentations and long-term sequelae of infection. Persons with a true-positive (TP) test result are eligible only for the chronic sequelae following subclinical infection. Persons with a false-positive (FP) test result enter the “no intervention” arm of the tree (that is, they are incorrectly reassured that they are protected from future hepatitis B infection). Persons with a true negative (TN) test result enter the “vaccinate all” arm of the tree. Persons with a false-negative (FN) test result are rare (approximately 1/1000) and are not included in the model. All strategies shown (screen, vaccinate all, no intervention) account for the fact that previously infected members of the cohort are protected from recurrent hepatitis B infection.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Structure of the decision tree for persons who contract hepatitis B virus.

CAH = chronic active hepatitis; CPH = chronic persistent hepatitis.

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Grahic Jump Location
Figure 3.
Cost-per-year-of-life saved for each age category of “vaccinate all” hepatitis B virus vaccination strategy.
Grahic Jump Location




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