Success Story: Costs and Effectiveness of Hepatitis B Screening and Vaccination

Background

There are 880,000 prevalent cases of chronic hepatitis B in the United States (U.S.) based on data from 2013 to 2018, with a modeled estimate of 1.89 million. It is estimated that 20,700 acute infections occurred in 2019 alone.

Vaccination, screening, and linkage to care are effective tools to reduce hepatitis B infection.

The CDC Advisory Committee on Immunization Practices (ACIP) recommended hepatitis B vaccination in 1982 in the U.S. for high-risk groups. High risk groups include men who have sex with men (MSM), persons who inject drugs (PWID), and heterosexual persons with multiple partners.

In 1984, the recommendation was expanded to include infants born to persons infected with the hepatitis B virus. Infants were to be given the hepatitis B vaccine and hepatitis B immune globulin at birth and complete the hepatitis B vaccine series.

By 2005, universal birth dose vaccination was recommended.

Hepatitis B vaccines have demonstrated safety, immunogenicity, and efficacy over the past 40 years. Vaccination is a valuable tool in preventing hepatitis B in the U.S., but it is underutilized.

Coverage of hepatitis B is high among children (greater than 90%) but is especially low for adults aged 19 or older. Self-reported coverage of 3 doses of hepatitis B vaccine was only 30% among adults in 2018. At the same time, an increase in acute hepatitis B in the U.S. has occurred due to more injection use behavior.

Challenges

Chronic hepatitis B can be averted with early diagnosis, monitoring, and treatment. However, hepatitis B screening remains low in the U.S. Between 2011 and 2016, only one-third of infected individuals were aware of their infection.

Between 15% and 25% of undiagnosed and untreated cases will lead to premature death from liver cirrhosis, liver failure requiring liver transplant, or liver cancer.

Obstacles to testing include access to non-health information not routinely recorded in medical records and triangulation of this information with existing medical records.

Approach

Several NEEMA studies have addressed key information gaps on health and economic benefits of hepatitis B screening.

Coalition for Applied Modeling for Prevention (CAMP) collaborations

Cost analysis of single-dose hepatitis B revaccination among infants born to infected mothers not responding to initial vaccine series

This project compared single dose revaccination strategies to the recommended 3-dose strategy for infants not responding to the initial vaccine series. The goal of interest was the cost per person for vaccination assuming a similar overall risk of infection in both strategies.

The study found that the incremental cost per infant was lowest when all 3 vaccination visits were assumed to occur during a previously scheduled well-child visit. Specifically, it was cost effective if all 3 vaccination visits occurred during a previously scheduled well-child visit. This reduced the cost of single dose revaccination by $28.29 to $52.73 in 2016 U.S. dollars (USD).

Alternatively, if all revaccination vaccine visits were previously unscheduled, the decrease in cost per individual reached $119.81 to $155.72 in 2016 USD.

Based on this data and the benefit of the additional three dose vaccination series, new recommendations were made by ACIP in January 2018. ACIP recommended a single-dose revaccination for infants born to HBsAg-positive mothers not responding to the initial hepatitis B vaccine series.

Assessing cost-effectiveness of universal hepatitis B vaccination for adults

This project modeled a decision analytic model with Markov disease progression with a simulation of one million adults. It explored how prospective universal hepatitis B vaccination among adults with either 3-dose or 2-dose vaccine would affect health benefits and cost for each vaccine strategy.

The study found that universal hepatitis B vaccination may be a good strategy to reducing hepatitis B incidence and improving health outcomes. Compared to the current strategy, it found that the 3-dose strategy reduced 24.8% of acute hepatitis B cases and 22.8% of hepatitis B-related deaths. The 2-dose strategy, by comparison, reduced cases by 24.6% and deaths by 22.2%.

The cost per quality adjusted life year gained was similar among both strategies. In 2019 USD, the 3-dose strategy cost $152,722 and the 2-dose cost $155,429.

Based on this study, ACIP concluded in November 2021 that universal hepatitis B vaccination provided more advantages than the previously used risk-based approach for adults.

PPML collaboration

Cost-effectiveness of one-time universal screening for chronic hepatitis B in US adults

This project used a Markov model to calculate costs, population impact, and cost-effectiveness of a 1-time universal screening for hepatitis B for U.S. adults.

The study found that universal hepatitis B screening for adults aged 18-69 would save $262,857 in 2020 USD and gain 135 quality adjusted life years per 100,000 adults.

Lessons learned

These NEEMA studies address key information gaps on the value of hepatitis B vaccination and screening. NEEMA recipients and collaborators from NCHHSTP's Division of Viral Hepatitis actively work to inform future guidelines for hepatitis B prevention and care.