Cost-effectiveness analysis of hepatitis A vaccination strategies for adults.

Our objective in this study was to determine the cost-effectiveness of hepatitis A vaccination strategies in healthy adults in the United States. We constructed a decision model simulating costs and health consequences for otherwise healthy adults with respect to hepatitis A prevention. Three strategies were compared: (1) no intervention, (2) vaccination against hepatitis A, and (3) testing for antibodies to hepatitis A and vaccinating those without antibodies. Costs and probabilities were obtained from the published literature. One- and two- way sensitivity analyses were performed. Under baseline conditions, the "test" strategy cost $230,100 per life-year saved compared with the "no intervention" strategy. The incremental cost-effectiveness of the "vaccination" strategy compared with the "test" strategy was $20.1 million per life-year saved. The "test" strategy was cost-effective when the hepatitis A case fatality rate exceeded 17% (baseline 2.7%). The "vaccination" strategy was cost-effective when 1 dose of vaccine cost $7 or less (baseline $57). Under baseline conditions, neither the "test" nor the "vaccination" strategies are considered cost-effective according to current standards. Large changes in hepatitis A incidence, mortality rates, or vaccine cost are required for either of the intervention strategies to approach potentially cost-effectiveness. Such conditions may occur in areas in which hepatitis A is endemic, and/or under mass-vaccination scenarios.     

Update on the management and treatment of viral hepatitis

This review aims to summarize the current evidence on the treatment of viral hepatitis, focusing on its clinical management. Also, future treatment options and areas of potential research interest are detailed. PubMed and Scopus databases were searched for primary studies published within the last ten years. Keywords included hepatitis A virus, hepatitis B virus (HBV), hepatitis C virus, hepatitis D virus (HDV), hepatitis E virus, and treatment. Outcomes reported in the studies were summarized, tabulated, and synthesized. Significant advances in viral hepatitis treatment were accomplished, such as the advent of curative therapies for hepatitis C and the development and improvement of hepatitis A, hepatitis B, and hepatitis E vaccination. Drugs that cure hepatitis B, going beyond viral suppression, are so far unavailable; however, targeted antiviral drugs against HBV (immunomodulatory therapies and gene silencing technologies) are promising approaches to eradicating the virus. Ultimately, high vaccination coverage and large-scale test-and-treat programmes with high screening rates may eliminate viral hepatitis and mitigate their burden on health systems. The development of curative hepatitis C treatment renewed the enthusiasm for curing hepatitis B, albeit further investigation is required. Novel therapeutic options targeting HDV life cycle are currently under clinical investigation.     

Hepatitis B vaccination. Three decision strategies for the individual

Three strategies regarding hepatitis B virus vaccination were compared by decision analysis: no vaccination, immediate vaccination, and vaccination after two years. The potential advantage of waiting two years is to learn whether serious side effects of the vaccine will become evident. For example, it was found that immediate hepatitis B vaccination of 100,000 surgical house officers with a 5 percent annual attack rate for five years would, compared with no vaccination, prevent 4,092 cases of icteric hepatitis, 335 cases of chronic active hepatitis, and 15 deaths from fulminant hepatitis. For a strategy of waiting two years, the number of cases prevented would decrease by about 40 percent. Persons in groups with an annual attack rate lower than 5 percent appear to benefit from vaccination. The known health risks of hepatitis B virus vaccination are low, and the hypothesized risks would have to be frequent to justify delay in vaccination. From an individual perspective, even persons at low risk of hepatitis B virus infection should seriously consider immediate vaccination.     

Hepatitis A and B vaccination and public health

Summary.  The introduction and implementation of hepatitis B vaccination programmes in areas of high endemicity has been very stressful. However, this initial accomplishment has led to the reassessment of priorities in some countries which could undermine these early successes. Work still remains to be done to support and implement interventions that will bring us closer to the WHO goal and to the control of hepatitis B in the community at large. Hepatitis A vaccine strategy for immunizing toddlers is shifting to those countries with intermediate endemicity where increasing morbidity in adults is being observed. Accumulating evidence indicates that such programmes can result in impressive reductions in the incidence of hepatitis A by herd immunity. Monitoring of these populations to determine durability of protection will be important to avoid shifting the infection to the older age population, when symptoms are more likely to occur. National policies need to consider hepatitis A vaccination in the context of other public health priorities.     

Serological survey of viral hepatitis A, B, and C at Thai Central Region and Bangkok: a population base study

Hepatitis A, B, and C are important viral hepatitis infections in the Thai population. Hepatitis B vaccination was included in the Thai Expanded Program on Immunization (EPI) 10 years ago. In addition, the seroprevalence of hepatitis A has significantly changed in the last two decades. This study was done to evaluate current risk groups for hepatitis A and B infections and identify the magnitude of hepatitis C infection in the general population of Bangkok and six provinces in the Central Region of Thailand, during the period October 2000 to January 2002. This study revealed that the prevalence of anti-HAV in people younger than 25 years was low but very high in people older than 25 years. The prevalence of anti-HAV was 1.95% in Bangkok and 12.7% in other provinces in people younger than 25 years (p<0.001) while 90.9% in Bangkok and 88.2% in other provinces among people older than 25 years. Therefore, people who are older than 25 years should have a blood test for anti-HAV before getting a hepatitis A vaccination. Approximately 80% of people who are not covered by hepatitis B vaccination from EPI are at risk of hepatitis B infection and its complications. This group of people should receive hepatitis B vaccination. For hepatitis C, the prevalence is lower than 2% across age groups and areas. Therefore, current good primary prevention via blood donor screening and health education must be maintained.     

Proceedings of the 12th International Symposium on Viral Hepatitis and Liver Disease. July 1-5, 2006. Paris, France

Summary. The introduction and implementation of hepatitis B vaccination programmes in areas of high endemicity has been very stressful. However, this initial accomplishment has led to the reassessment of priorities in some countries which could undermine these early successes. Work still remains to be done to support and implement interventions that will bring us closer to the WHO goal and to the control of hepatitis B in the community at large. Hepatitis A vaccine strategy for immunizing toddlers is shifting to those countries with intermediate endemicity where increasing morbidity in adults is being observed. Accumulating evidence indicates that such programmes can result in impressive reductions in the incidence of hepatitis A by herd immunity. Monitoring of these populations to determine durability of protection will be important to avoid shifting the infection to the older age population, when symptoms are more likely to occur. National policies need to consider hepatitis A vaccination in the context of other public health priorities.     

The cost-effectiveness of vaccinating chronic hepatitis C patients against hepatitis A

OBJECTIVES: Although hepatitis A vaccination is recommended for persons with chronic liver disease, the cost-effectiveness of vaccinating patients with chronic hepatitis C virus has not been extensively studied. We evaluated its costs and benefits. METHODS: A Markov model was used to assess cost-effectiveness from the health system and societal perspectives. Costs of hepatitis A screening and vaccination were compared with savings from reduced hepatitis A treatment and work loss to determine net costs of a "screen and vaccinate" strategy. Net costs were compared with longevity gains to assess cost-effectiveness. RESULTS: Based on hypothetical cohorts of 100,000 patients, vaccination would reduce the number of hepatitis A cases 63-72%, depending on patient age. Screening and vaccination costs of $5.2 million would be partially offset by $1.5-$2.8 million reductions in hepatitis A treatment costs and $0.2-$1.0 million reductions in work loss costs. From the health system perspective, vaccination would cost $22,256, $50,391, and $102,064 per life-year saved for patients vaccinated at ages 30, 45, and 60 yr, respectively. Cost-effectiveness ratios improve when work loss prevention is considered. Results are most sensitive to hepatitis A infection and hospitalization rates, and the rate used to discount future benefits to their present values. CONCLUSIONS: Hepatitis A vaccination of chronic hepatitis C patients would substantially reduce morbidity and mortality in all age groups examined. Consistent with other medical interventions for chronic hepatitis C patients, cost-effectiveness is most favorable for younger patients.     

The A's and B's of vaccine-preventable hepatitis: improving prevention in high-risk adults

Acute hepatitis A and acute hepatitis B are associated with significant morbidity, time away from work or usual activities, substantial cost to the healthcare system, and some mortality. Despite the availability of vaccines against hepatitis B and hepatitis A since 1981 and 1995, respectively, and a combined hepatitis A and B vaccine since 2001, immunization rates against these vaccine-preventable diseases are appallingly low. In particular, several groups of adults, such as men who have sex with men, heterosexuals with multiple partners, injection drug users, persons with human immunodeficiency virus infection, travelers to endemic areas, and persons with chronic liver disease, are at particularly high risk for acute hepatitis A and B or for a more severe illness or a higher rate of chronicity in the case of hepatitis B. Studies have confirmed that hepatitis A and hepatitis B vaccines are safe and immunogenic in patients in these populations, although patients with more advanced disease may respond less well. These observations have led to the recommendation that patients falling into the above risk groups undergo hepatitis A and B vaccination early in the natural history of their underlying risk behavior or diseases. Vaccination rates are low in clinical practice, and public health and educational programs are needed to overcome barriers to facilitate timely implementation of these recommendations. The use of a combined vaccination, possibly using an accelerated administration schedule, provides convenience and may increase compliance.     

Prevention of travel-related infectious diseases: knowledge, practices and attitudes of Swedish travellers

More Swedish residents travel to countries where they are at risk for contracting malaria, hepatitis, and other serious travel-related diseases. To safeguard the public's health, it is important to determine if travellers accurately perceive health risks and take appropriate preventative measures before and during their trips. This study examined travel health knowledge, attitudes and practices among Swedish residents traveling to destinations with risk of malaria and hepatitis. Self-administered anonymous questionnaires were distributed to Swedish residents (n=957) waiting to board intercontinental flights at the Stockholm-Arlanda International Airport. A majority of travellers sought general information (74%) and travel health advice (59%) prior to departure. Most perceived vaccination as safe and effective, but only 40% and 3% of travellers reported adequate vaccine coverage against hepatitis A or hepatitis B, respectively. Although most did not know the actual malaria risk at the destination, 97% of persons flying to high-risk areas were carrying malaria medication. The study results were in line with those found in surveys conducted in other countries, and demonstrate need for further health education among travellers to risk destinations. Efforts should focus on reaching more travellers, providing clear information and improving compliance with recommended travel health advice.     

Results of an enhanced-outreach programme of hepatitis B vaccination in the Netherlands (1998-2000) among men who have sex with men,hard drug users,sex workers and heterosexual persons with multiple partners

BACKGROUND/AIMS: The Dutch Ministry of Health funded a pilot vaccination project targeting groups at high risk for sex- and drug-related hepatitis B transmission. METHODS: In seven Municipal Health Service (MHS) areas, three-part hepatitis B vaccination was offered free to men who have sex with men (MSM), drug users (DUs), and heterosexuals with multiple partners, including sex workers (SWs). Four intervention areas recruited participants through care-givers and opinion leaders and offered vaccination at non-MHS sites. Three control areas only used flyers to offer vaccination at MHS during regular hours. RESULTS: Over 18 months, 13808 persons enrolled for the first vaccination, representing 63% of the targeted population in the intervention areas and 23% in control areas. In intervention areas, only 19% of DUs enrolled, versus 4% in control areas. In both areas, enrollment of the targeted heterosexual population (64%) was satisfactory. MSM were most compliant in having the full series. Of vaccination sources, general practitioners (GPs) attained highest compliance (71%, odds ratio 1.82). CONCLUSIONS: Dutch MHS facilities can reach high-risk individuals, but DUs require additional outreach. Vaccine coverage was disappointing, but our experience will be deployed nationwide and successful strategies might be employed elsewhere in countries of low endemicity.     

Seroprevalence of hepatitis A and cost evaluation of different vaccination strategies against hepatitis A virus in patients with chronic hepatitis C in France

OBJECTIVES: To prospectively determine the prevalence of total hepatitis virus A antibodies in patients with chronic hepatitis C and to evaluate the direct costs of several vaccination strategies against hepatitis A virus in these patients. METHODS: From April 1 to July the 31 1998, 219 patients with hepatitis C virus antibodies underwent a systematic testing for total hepatitis virus A antibodies (MEIA-AXSYM, Abbott laboratories). The prevalence of hepatitis A virus antibodies was evaluated according to age and suspected way of hepatitis C contamination. This prevalence has been compared to that in individuals undergoing a check-up provided by the national health insurance system stratified by age. Direct costs of 2 vaccination strategies "A" and "B" were evaluated according to age (<40 vs > 40 years) and number of vaccine doses (1 or 2). "A" strategy included the systematic vaccination of all patients without determining the presence of total hepatitis A antibodies. "B" strategy included testing for total hepatitis A antibodies and vaccination of seronegative patients. The costs of these two strategies (A and B) were calculated with one and two vaccine doses. RESULTS: The prevalence of total hepatitis A antibodies was 76% in the entire population. It increased after the age of 35 and was statistically higher in patients who were older than 40 than in patients younger than 40. This prevalence was not significantly different from that in individuals who underwent a check-up provided by the national health insurance system stratified according to age. "B" strategy with 2 vaccine doses was less expensive that A strategy in the whole population and in patients younger than 40. This strategy was less expensive with 1 vaccine dose except in patients who had recently screened positive for hepatitis C antibodies younger than 40 when it induced an increased in direct cost due to the low prevalence of total hepatitis A antibodies in these patients. CONCLUSIONS: In patients with hepatitis C antibodies with a high prevalence of total hepatitis A antibodies, testing for the prevalence of these antibodies before vaccination decreases the direct cost of this vaccination.     

Prospects for hepatitis B virus eradication and control of hepatocellular carcinoma

Hepatitis B virus infection is the most common cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. In areas hyperendemic for HBV infection, the related complications occur mostly during adulthood. However, nearly half of all primary infection in chronic carriers occurs in the perinatal period through maternal transmission, the other half arising from horizontal transmission mainly through intrafamilial spread or injection using unsterilized needles. A universal vaccination programme is better than immunization for at-risk groups. Hepatitis B vaccination should be integrated into the Expanded Programme on Immunization in children. Universal immunization against hepatitis B virus has proved to be effective in reducing the hepatitis B carrier rate to one-tenth of the prevalence before the vaccination programme in highly endemic areas, and the incidence of hepatocellular carcinoma in children has also been shown to be significantly reduced. Continued efforts to implement universal vaccination programmes worldwide will very likely reduce the incidence of hepatitis B virus-related diseases, particularly liver cirrhosis and hepatocellular carcinoma.     

Hepatitis B immunisation in travellers: poor risk perception and inadequate protection

OBJECTIVES: A survey of European travellers was conducted during 2006 to determine travellers' immunisation status and risk for exposure to hepatitis B while travelling. DESIGN: A first telephone (Omnibus) survey established the prevalence of travel in the previous five years as well as demographic profile of travellers amongst the general population. A second online survey targeted travellers to moderate or high hepatitis B endemicity countries, using data from the first survey to ensure a final sample representative of the travelling population in each country. Self-reported vaccination status and participation in activities/situations at high risk of exposure to hepatitis B were recorded. PARTICIPANTS: A total of 5948 interviewees participated in the first (Omnibus) survey and 4151 travellers completed the online survey. SETTING: Belgium, Italy, Finland, Germany, Netherlands, Spain, Sweden and UK. RESULTS: Only 15% of 4151 travellers to endemic countries recalled specifically receiving hepatitis B vaccination. Fifty-one percent of travellers to endemic countries visited a health care professional (HCP) before travelling. Of these, 54% did not receive any hepatitis B vaccination. Fifty percent of all respondents had never discussed risk factors for hepatitis B infection with a health care professional. Altogether, 1 in 4 travellers were at increased risk for exposure to hepatitis B due to hospitalisation, sexual activity or body piercing/tattooing amongst others. Three percent of travellers to high risk destinations were health tourists of which 65% did not recall being vaccinated against hepatitis B. CONCLUSION: Compared to a previous survey, this follow on survey 7 years later indicates the risk of exposure to hepatitis B has increased, but not hand-in-hand with the protection of travellers against hepatitis B through vaccination: travellers to at risk destinations continue to be unvaccinated against hepatitis B, including those who visit health care practitioners prior to travelling. Advice regarding hepatitis B immunisation for travel is received infrequently and travellers remain unaware of the risks of hepatitis B associated with travel. Many high risk situations are not predictable prior to travel, supporting an all-inclusive approach to hepatitis B vaccination in travellers.     

Occupational exposure to needlestick injuries and hepatitis B vaccination coverage among health care workers in Egypt

BACKGROUND: The health care worker (HCW) is at substantial risk of acquiring bloodborne pathogen infections through exposure to blood or infectious body fluids. Hepatitis B vaccination of HCWs and optimal HCW practices regarding management of sharps can minimize these risks. This study explores the frequency of exposure to needlestick injuries and the hepatitis B vaccination coverage among HCWs in Egypt. METHODS: All HCWs available in a 25% random sample of different types of health care facilities from 2 governorates in Egypt (Nile Delta and Upper Egypt) were included in the study. A total of 1485 HCWs were interviewed. History of exposure to needlestick injuries, vaccination status, and socioeconomic data were collected. RESULTS: Of the 1485 HCWs interviewed, 529 (35.6%) were exposed to at least 1 needlestick injury during the past 3 months with an estimated annual number of 4.9 needlesticks per worker. The most common behavior associated with needlestick injuries was 2-handed recapping. Overall, 64% of HCWs disposed of needles unsafely in nonpuncture-proof containers. Overall 15.8% of HCWs reported receiving 3 doses of hepatitis B vaccine. Vaccination coverage was highest among professional staff (38%) and lowest among housekeeping staff (3.5%). Using Kane's model to predict infections after needlestick exposures, we estimate 24,004 hepatitis C virus and 8617 hepatitis B virus infections occur each year in Egypt as a result of occupational exposure in the health care environment. CONCLUSION: High rates of needlestick injuries and low vaccination coverage contribute highly to the rates of viral hepatitis infections among HCWs. Prevention of occupational infection with bloodborne pathogens should be a priority to the national program for promotion of infection control. Training of HCWs on safe handling and collection of needles and sharps, and hepatitis B vaccination of all HCWs is required to reduce transmission.     

A qualitative study among injection drug using women in Rhode Island: attitudes toward testing, treatment, and vaccination for hepatitis and HIV

HIV and hepatitis C virus infection are serious and prevalent health conditions among many women who inject drugs. Qualitative interviews with 20 injection drug using women at a short term drug treatment center in Rhode Island revealed six primary barriers and facilitators for testing and receiving results and treatment for hepatitis and HIV, as well as for hepatitis vaccination. The primary barriers were prioritization of drug use; low level of disease-specific knowledge; stigmatization; accessibility of testing, results and treatment; and psychological factors. The primary facilitator was interest in promoting one's health. Our findings indicate that injection drug using women experience multiple barriers to HIV and hepatitis testing, results, treatment and vaccination. Methods for improving the motivators for health, facilitating infectious disease prevention, and decreasing unnecessary disease complications of injection drug using women need to be utilized. These methods should include strategies that minimize stigma and facilitate accessibility of health care.     

Public knowledge about hepatitis B-related issues in Korea

Hepatitis B infection is endemic in many parts of the world, including Korea. Basic knowledge of the hepatitis B virus by the public is a prerequisite for the development of a successful vaccination program. A survey was conducted in rural Korea to examine public knowledge of hepatitis B etiology, symptoms, transmission, risk factors and prevention. It was found that knowledge independently correlated with education and female sex, but that overall knowledge of hepatitis B was poor. The preferred information sources in order of preference were physicians, television and public health nurses. This information may be useful in designing public health education and vaccination programs in developing populations.     

Do we practice what we preach? Health care worker screening and vaccination

OBJECTIVE: To describe the current screening and immunization practices in New South Wales (NSW) hospitals and the experience of NSW nurses in relation to screening and immunization and to identify areas that can be targeted for improvement. DESIGN: This was a cross-sectional survey. SETTING: The study was performed in NSW, Australia. METHODS: We used a written questionnaire to survey the infection control/occupational health coordinators of all of the 85 private hospitals and 204 eligible public hospitals in NSW and 800 randomly sampled registered nurses. RESULTS: Response rates were high (hospitals [90%], nurses [70%]). Hospitals almost universally offered hepatitis B vaccination to nurses (251/261, 96%), but more than one quarter (132/473, 28%) of nurses reported incomplete vaccination. Provision to physicians was relatively poor (142/261, 54%). The majority of nurses (> 80%) had been vaccinated with bacille Calmette-Guérin vaccine, but hospitals reported variable tuberculosis screening practices. Both hospitals and nurses reported low rates (< 30%) of screening and vaccination provision for varicella and measles-mumps-rubella. Two thirds of NSW hospitals (174/261, 67%) provided annual influenza vaccination. CONCLUSIONS: Even though hepatitis B immunization programs were widespread, their effectiveness could be improved by ensuring that vaccination schedules are completed and by targeting physicians. Varicella and measles-mumps-rubella screening and immunization programs are currently lacking. Better strategies are needed to improve the implementation of health care worker protection guidelines in hospitals.     

Sexual transmission of hepatitis B

PURPOSE OF REVIEW: Hepatitis B virus infection is prevalent worldwide and is a significant cause of morbidity and mortality particularly in Asia. Adults chronically infected with hepatitis B virus remain a significant potential source of sexually transmitted hepatitis B. The purpose of this article is to review the recent literature relating to hepatitis B virus transmission with particular emphasis on sexual transmission and efforts to prevent spread. RECENT FINDINGS: The introduction of hepatitis B virus vaccine and the implementation of universal childhood vaccination for hepatitis B in some countries have led to a dramatic reduction in the number of children with chronic hepatitis B. However, recent reports suggest that we are not as successful in preventing infection by sexual transmission. It is clear that sexual transmission of hepatitis B virus is still widespread and is a major problem in certain high-risk groups such as men who have sex with men, intravenous drug users, prisoners and sex workers. Significant problems remain with respect to education and vaccination within these groups. SUMMARY: Hepatitis B virus remains a major health burden but it is preventable by education and vaccination. Greater resources are required to expand vaccination to the at-risk, sexually active adult populations if the World Health Organization ideal of hepatitis B virus eradication is to be realized and the burden of hepatitis B virus-related morbidity and mortality contained.     

Legend of hepatitis B vaccination: the Taiwan experience

Hepatitis B, a disease entity currently affecting more than 350 million persons worldwide, is also a serious health problem in Taiwan. Liver cirrhosis and hepatoma, which are both closely correlated with hepatitis B, are among the 10 leading causes of death in Taiwan. A mass hepatitis B vaccination program, conducted by the government of Taiwan, was started in 1984. Prior to this vaccination program, a series of viral epidemiological surveys, transmission pattern studies, and pilot immunization trials proved the clinical, economic, and strategic benefits of mass immunization, thus providing the impetus for the implementation of this mass vaccination program. The success of this program has led to a decline in hepatitis B carrier rates among children in Taiwan from 10% to <1%. Furthermore, the mortality rate of fulminant hepatitis in infants and the annual incidence of childhood hepatoma have also decreased significantly in recent years. This is one of the most remarkable success stories in the field of public health.     

Response to vaccination against hepatitis B in patients with Behcet's disease

BACKGROUND AND AIM: Hepatitis B virus infection is an important public health problem in Turkey. Although hepatitis B vaccination is regarded as safe and effective for the general population, recommendations for hepatitis B immunization in patients with Behcet's disease are not clear. The aim of the present study was to elucidate the response of patients with Behcet's disease to hepatitis B vaccination and to determine whether hepatitis B vaccination has any adverse effects on the course of the disease. METHODS: Thirteen patients with Behcet's disease and 15 healthy individuals were enrolled into a prospective study. All subjects received the 3-dose series of routine hepatitis B vaccine. Anti-hepatitis B surface response was evaluated 1-3 months after the third dose of vaccine. RESULTS: The responder rates for patient and control groups were 12/13 (92.8%) and 14/15 (93.8%), respectively. Statistical analysis showed no significant difference between the two groups in terms of both the responder rates and mean antibody titers. CONCLUSIONS: These preliminary findings might suggest that the majority of patients with Behcet's disease develop protective antibody response after hepatitis B vaccination and that the immune response against hepatitis B surface antigen is adequate, efficient and intact.