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

David W. Hutton, MS; Daniel Tan, MS; Samuel K. So, MD; and Margaret L. Brandeau, PhD
[+] Article and Author 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@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@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.


Ann Intern Med. 2007;147(7):460-469. doi:10.7326/0003-4819-147-7-200710020-00004
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We used a Markov model of acute HBV infection and disease progression to assess the clinical and economic consequences of alternative HBV screening and vaccination strategies in a hypothetical cohort of 10 000 Asian and Pacific Islander adults 20 to 60 years of age (Appendix).

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Figure 1.
Total costs incurred and quality-adjusted life-years (QALYs) experienced by a cohort of 10 000 persons for each intervention and the status quo.
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Figure 2.
Results of sensitivity analysis: cost-effectiveness acceptability curves.Table 1

The incremental cost-effectiveness of the screen-and-treat strategy was calculated compared with the status quo, and the incremental cost-effectiveness ratio of the screen, treat, and ring vaccinate strategy was calculated compared with the screen-and-treat strategy. Results are based on 10 000 Monte Carlo simulations. All variables were varied simultaneously. We assumed that each variable was uniformly distributed between the high and low estimates shown in , and that variable values were independent. QALY = quality-adjusted life-year.

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Appendix Figure 1. Circles represent health states, and lines represent transitions. At the start of the time horizon, individuals in the cohort can be in 1 of 4 states: susceptible, immune, normal ALT [alanine aminotransferase] level, or elevated ALT level. For clarity, the state “death” is not shown, although all states can transition to it. Transition rates between chronic HBV states may differ depending on whether the patient is aware of his or her status (and under medical management and treatment). The model was implemented with annual transition probabilities. *The model assumes that individuals in the decompensated cirrhosis state also have ascites, variceal hemorrhage, or encephalopathy.
Markov model of hepatitis B virus (HBV) infection and progression.
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Appendix Figure 2. A person who acquires acute HBV infection is assumed to traverse this tree in the span of 1 year. A patient who starts in the susceptible state (see ) and acquires an acute HBV infection will end in the immune state (if the infection resolves), the normal ALT [alanine aminotransferase] level state (if the infection is chronic), or the death state.
Process of acute hepatitis B virus (HBV) infection.Appendix Figure 1
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