The Effectiveness and Cost-Effectiveness of Screening for and Vaccination Against Hepatitis B Virus among Migrants in the EU/EEA: A Systematic Review

Migrants from hepatitis B virus (HBV) endemic countries to the European Union/European Economic Area (EU/EEA) comprise 5.1% of the total EU/EEA population but account for 25% of total chronic Hepatitis B (CHB) infection. Migrants from high HBV prevalence regions are at the highest risk for CHB morbidity. These migrants are at risk of late detection of CHB complications; mortality and onwards transmission. The aim of this systematic review is to evaluate the effectiveness and cost-effectiveness of CHB screening and vaccination programs among migrants to the EU/EEA. We found no RCTs or direct evidence evaluating the effectiveness of CHB screening on morbidity and mortality of migrants. We therefore used a systematic evidence chain approach to identify studies relevant to screening and prevention programs; testing, treatment, and vaccination. We identified four systematic reviews and five additional studies and guidelines that reported on screening and vaccination effectiveness. Studies reported that vaccination programs were highly effective at reducing the prevalence of CHB in children (RR 0.07 95% CI 0.04 to 0.13) following vaccination. Two meta-analyses of therapy for chronic HBV infection found improvement in clinical outcomes and intermediate markers of disease. We identified nine studies examining the cost-effectiveness of screening for CHB: a strategy of screening and treating CHB compared to no screening. The median acceptance of HB screening was 87.4% (range 32.3–100%). Multiple studies highlighted barriers to and the absence of effective strategies to ensure linkage of treatment and care for migrants with CHB. In conclusion, screening of high-risk children and adults and vaccination of susceptible children, combined with treatment of CHB infection in migrants, are promising and cost-effective interventions, but linkage to treatment requires more attention.

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The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph15092013 ◽

2018 ◽

Vol 15 (9) ◽

pp. 2013 ◽

Cited By ~ 12

Author(s):

Christina Greenaway ◽

Iuliia Makarenko ◽

Claire Abou Chakra ◽

Balqis Alabdulkarim ◽

Robin Christensen ◽

...

Keyword(s):

Cost Effectiveness ◽

Hepatitis C ◽

Lower Risk ◽

Linkage To Care ◽

Cost Effective ◽

Screening Tests ◽

European Economic Area ◽

The European Union ◽

Wide Range ◽

The Eu

Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.

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Nurse Volunteers in School-Based Hepatitis B Immunization Programs

The Journal of School Nursing ◽

10.1177/10598405010170040301 ◽

2001 ◽

Vol 17 (4) ◽

pp. 185-188 ◽

Cited By ~ 4

Author(s):

Hayley Mark ◽

Verna G. Conklin ◽

Margaret C. Wolfe

Keyword(s):

Hepatitis B Virus ◽

Hepatitis B ◽

School Health ◽

Cost Effective ◽

Local Health ◽

Vaccination Programs ◽

School Year ◽

School Based ◽

B Virus ◽

And Training

School districts across the nation are implementing school-based hepatitis B virus vaccination programs. Because adolescents are at risk of contracting hepatitis B virus, these programs are important in preventing infections. Critical to the success of these programs is having qualified and cost-effective health professionals to administer the vaccine. This article describes the recruitment and training of professional nurse volunteers to administer vaccines in school-based clinics. During the 1998–1999 school year, approximately 60 nurses in Durham, North Carolina, volunteered 300 hours of time to the program. In the first year, the cost of recruiting and training volunteers exceeded the savings from salaried school nurse time. However, savings are expected in future years. Other benefits of recruiting volunteers to administer vaccine include allowing school nurses to remain in their usual assignments, increasing awareness of the health department’s mission and school health in the community, and improving collaboration among local health agencies.

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Cost-Effectiveness of Universal Hepatitis B Virus Screening in Patients Beginning Chemotherapy for Solid Tumors

Journal of Clinical Oncology ◽

10.1200/jco.2011.35.1635 ◽

2011 ◽

Vol 29 (24) ◽

pp. 3270-3277 ◽

Cited By ~ 47

Author(s):

Fiona L. Day ◽

Jonathan Karnon ◽

Danny Rischin

Keyword(s):

Cost Effectiveness ◽

Hepatitis B Virus ◽

Hepatitis B ◽

Universal Screening ◽

Cost Effective ◽

Screening Strategy ◽

Sensitivity Analyses ◽

B Virus ◽

The Cost ◽

Hbv Screening

PurposeUniversal screening for chronic hepatitis B virus (HBV) infection before chemotherapy has been recommended. We evaluated the cost-effectiveness of HBV screening before chemotherapy given for nonhematopoietic solid tumors (STs).MethodsA decision-analytic model was used to compare the cost-effectiveness of universal screening conducted per professional guidelines versus no screening in hypothetical patient cohorts beginning adjuvant chemotherapy for early breast cancer or palliative chemotherapy for advanced non–small-cell lung cancer. Survival times were extrapolated using Markov models. Probabilities were derived from published studies and costs estimated from the perspective of the Australian health care system. One-way and probabilistic sensitivity analyses were performed, including with the application of an alternative HBV screening strategy.ResultsUsing an incremental cost-effectiveness ratio threshold of $50,000 (Australian dollars) per life-year (LY) saved, universal HBV screening was not cost-effective for adjuvant patients ($88,224/LY, 13% probability of being cost-effective), palliative patients ($1,344,251/LY, 0%), or pooled (all) patients ($149,857/LY, 1%). Sensitivity analyses found that screening approached cost-effectiveness among adjuvant patients with the highest reported rates of undiagnosed chronic HBV (65%, $59,445/LY) or HBV reactivation with chemotherapy (41%, $56,537/LY). Cost- effectiveness was also significantly influenced by HBV population prevalence. An alternative screening strategy using hepatitis B surface antigen testing only produced the most economically favorable results, with $30,126/LY (80% probability) for adjuvant patients and $51,201/LY (43%) for the pooled cohort.ConclusionUniversal HBV screening conducted per current guidelines is not cost-effective in patients with STs. Screening may be economically favorable in selected patient subpopulations and/or with simplification of the screening strategy.

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Cost-effectiveness of antiviral therapy during late pregnancy to prevent perinatal transmission of hepatitis B virus

PeerJ ◽

10.7717/peerj.1709 ◽

2016 ◽

Vol 4 ◽

pp. e1709 ◽

Cited By ~ 11

Author(s):

Wenjun Wang ◽

Jingjing Wang ◽

Shuangsuo Dang ◽

Guihua Zhuang

Keyword(s):

Cost Effectiveness ◽

Hepatitis B Virus ◽

Hepatitis B ◽

Antiviral Therapy ◽

Late Pregnancy ◽

Cost Effective ◽

Sensitivity Analyses ◽

B Virus ◽

The Cost ◽

Hbv Transmission

Background.Hepatitis B virus (HBV) infections are perinatally transmitted from chronically infected mothers. Supplemental antiviral therapy during late pregnancy with lamivudine (LAM), telbivudine (LdT), or tenofovir (TDF) can substantially reduce perinatal HBV transmission compared to postnatal immunoprophylaxis (IP) alone. However, the cost-effectiveness of these measures is not clear.Aim.This study evaluated the cost-effectiveness from a societal perspective of supplemental antiviral agents for preventing perinatal HBV transmission in mothers with high viral load (>6 log10copies/mL).Methods.A systematic review and network meta-analysis were performed for the risk of perinatal HBV transmission with antiviral therapies. A decision analysis was conducted to evaluate the clinical and economic outcomes in China of four competing strategies: postnatal IP alone (strategy IP), or in combination with perinatal LAM (strategy LAM + IP), LdT (strategy LdT + IP), or TDF (strategy TDF + IP). Antiviral treatments were administered from week 28 of gestation to 4 weeks after birth. Outcomes included treatment-related costs, number of infections, and quality-adjusted life years (QALYs). One- and two-way sensitivity analyses were performed to identify influential clinical and cost-related variables. Probabilistic sensitivity analyses were used to estimate the probabilities of being cost-effective for each strategy.Results.LdT + IP and TDF + IP averted the most infections and HBV-related deaths, and gained the most QALYs. IP and TDF + IP were dominated as they resulted in less or equal QALYs with higher associated costs. LdT + IP had an incremental $2,891 per QALY gained (95% CI [$932–$20,372]) compared to LAM + IP (GDP per capita for China in 2013 was $6,800). One-way sensitivity analyses showed that the cost-effectiveness of LdT + IP was only sensitive to the relative risk of HBV transmission comparing LdT + IP with LAM + IP. Probabilistic sensitivity analyses demonstrated that LdT + IP was cost-effective in most cases across willingness-to-pay range of $6,800 ∼ $20,400 per QALY gained.Conclusions.For pregnant HBV-infected women with high levels of viremia, supplemental use of LdT during late pregnancy combined with postnatal IP for infants is cost-effective in China.

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Chronic hepatitis B virus case-finding in UK populations born abroad in intermediate or high endemicity countries: an economic evaluation

BMJ Open ◽

10.1136/bmjopen-2019-030183 ◽

2019 ◽

Vol 9 (6) ◽

pp. e030183 ◽

Cited By ~ 1

Author(s):

Natasha K Martin ◽

Peter Vickerman ◽

Salim Khakoo ◽

Anjan Ghosh ◽

Mary Ramsay ◽

...

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Hepatitis B Virus ◽

Hepatitis B ◽

Cost Effective ◽

Case Finding ◽

Hbsag Prevalence ◽

Migrant Populations ◽

Additional Qaly ◽

B Virus

ObjectivesThe majority (>90%) of new or undiagnosed cases of hepatitis B virus (HBV) in the UK are among individuals born in countries with intermediate or high prevalence levels (≥2%). We evaluate the cost-effectiveness of increased HBV case-finding among UK migrant populations, based on a one-time opt out case-finding approach in a primary care setting.DesignCost-effectiveness evaluation. A decision model based on a Markov approach was built to assess the progression of HBV infection with and without treatment as a result of case-finding. The model parameters, including the cost and effects of case-finding and treatment, were estimated from the literature. All costs were expressed in 2017/2018 British Pounds (GBPs) and health outcomes as quality-adjusted life-years (QALYs).InterventionHepatitis B virus case-finding among UK migrant populations born in countries with intermediate or high prevalence levels (≥2%) in a primary care setting compared with no intervention (background testing).ResultsAt a 2% hepatitis B surface antigen (HBsAg) prevalence, the case-finding intervention led to a mean incremental cost-effectiveness ratio of £13 625 per QALY gained which was 87% and 98% likely of being cost-effective at willingness to pay (WTP) thresholds of £20 000 and £30 000 per additional QALY, respectively. Sensitivity analyses indicated that the intervention would remain cost-effective under a £20 000 WTP threshold as long as HBsAg prevalence among the migrant population is at least 1%. However, the results were sensitive to a number of parameters, especially the time horizon and probability of treatment uptake.ConclusionsHBV case-finding using a one-time opt out approach in primary care settings is very likely to be cost-effective among UK migrant populations with HBsAg prevalence ≥1% if the WTP for an additional QALY is around £20 000.

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The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review

Eurosurveillance ◽

10.2807/1560-7917.es.2018.23.14.17-00543 ◽

2018 ◽

Vol 23 (14) ◽

Cited By ~ 5

Author(s):

Christina Greenaway ◽

Manish Pareek ◽

Claire-Nour Abou Chakra ◽

Moneeza Walji ◽

Iuliia Makarenko ◽

...

Keyword(s):

Systematic Review ◽

Cost Effectiveness ◽

Health Benefit ◽

Latent Tuberculosis ◽

High Sensitivity ◽

Skin Tests ◽

European Economic Area ◽

The European Union ◽

Care Cascade ◽

The Eu

Background Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

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