To compare the cost-effectiveness of hepatitis B virus (HBV) control strategies combining universal vaccination with hepatitis B immunoglobulin (HBIG) treatment for neonates of carrier mothers.
Drawing on Taiwan's experience, we developed a decision-analytic model to estimate the clinical and economic outcomes for 4 strategies: (1) strategy V—universal vaccination; (2) strategy S—V plus screening for hepatitis B surface antigen (HBsAg) and HBIG treatment for HBsAg-positive mothers' neonates; (3) strategy E—V plus screening for hepatitis B e-antigen (HBeAg), HBIG for HBeAg-positive mothers' neonates; (4) strategy S&E—V plus screening for HBsAg then HBeAg, HBIG for all HBeAg-positive, and some HBeAg-negative/HBsAg-positive mothers' neonates.
Strategy S averted the most infections, followed by S&E, E, and V. In most cases, the more effective strategies were also more costly. The willingness-to-pay (WTP) above which strategy S was cost-effective rose as carrier rate declined and was <$4000 per infection averted for carrier rates >5%. The WTP below which strategy V was optimal also increased as carrier rate declined, from $1400 at 30% carrier rate to $3100 at 5% carrier rate. Strategies involving E were optimal for an intermediate range of WTP that narrowed as carrier rate declined.
HBIG treatment for neonates of HBsAg carrier mothers is likely to be a cost-effective addition to universal vaccination, particularly in settings with adequate health care infrastructure. Targeting HBIG to neonates of higher risk HBeAg-positive mothers may be preferred where WTP is moderate. However, in very resource-limited settings, universal vaccination alone is optimal.
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In the current issue Chen et al, on the basis of theoretical models of hepatitis B (HepB) in different pasts of the world, propose various cost effective strategies for screening and managing the disease in pregnancy and in the offspring. For developed countries, presumably including the United States (US), with a low incidence of HepB the authors propose a future program labeled as Strategy S. This consists of screening all pregnant women for HepB surface antigen (HbsAg) and treating all the infants of positive mothers with HepB immune globulin (HBIG)in the immediate neonatal period as well as giving a course of HepB vaccine. The authors were apparently unaware that such a program was not just a hypothesis for the future, but has been ongoing as standard of care at Kaiser Permanente of Northern California (KP) for 25 years. This HepB management policy was commended by the CDC in 1997 as a result of published evidence of it's effectiveness MMWR 46(17); 378-80). KP had instituted a prenatal HepB screening program in 1985, and soon discovered that although we identified the HbsAg positive mothers, an estimated 25% of newborns failed to get appropriate post exposure prophylaxis. To address this problem, in 1988 we developed a centralized case-management and tracking system similar to the one now being recommended by Chen et al. From 1990-95 we screened over 180,000 pregnant women, identify 1721 infants born to HbsAg positive mothers and were able to give appropriate HBIG and HepB immunization to 99.8% of these infants. By now about 7000 offspring from 750,000 pregnancies have benefited from the program.
Our experience has confirmed the efficacy of Model S proposed by Chen et al. It is important to emphasize that screening alone is not sufficient. It is necessary to have an integrated care management plan that assure that the results of screening are thoroughly tracked and acted on.
Edgar J. Schoen, MD
Steve Black, MD
Conflict of Interest:
None declared