Comparative cost-effectiveness of a 2-dose versus 3-dose vaccine for hepatitis B prevention in selected adult populations

Determinants of vaccine adherence among non-dialysis chronic kidney disease patients in Qatar

INTRODUCTION

Chronic kidney disease (CKD) is a global health problem. Reduced innate and adaptive immunological responses predispose CKD patients to infections. Despite the clinical and epidemiological importance of CKD and the great value of vaccination as a prophylactic measure, the utilization of recommended vaccines in Qatar has not yet been evaluated.

METHODS

We conducted a cross-sectional study to estimate the level of influenza, pneumococcal, and hepatitis B vaccination and the predictors of adherence to these recommended vaccines among non-dialysis CKD patients receiving renal ambulatory care in Qatar from 1 September 2020 to 30 April 2021. Complete vaccination was defined as receiving the three vaccines, and partial vaccination was defined as receiving one or two vaccines. The full and partial vaccination predictors were assessed using multivariate logistic regression and reported as odds ratio (OR) with p<0.05 indicating statistical significance.

RESULTS

416 non-dialysis CKD patients were included in our analysis. 73% were males; the mean age was 56 ± 15 years. More than 50% of the patients were from the Middle East, followed by 36% from Asia. Most patients had concurrent hypertension, concurrent diabetes mellitus, and were stage V CKD. Only 12% of the patients were fully vaccinated, while 73% received partial vaccination. The predictors of vaccination included age, gender, Asian origin, employment, living conditions, concurrent medical conditions, CKD stage, allergy to medications, and use of injectable medications. Only stage V CKD positively predicted adherence to full and partial vaccinations in non-dialysis CKD patients.

CONCLUSION

There is very low adherence to the recommended vaccines in CKD patients, with a prevalence of complete vaccination of 12% only. Increased public awareness about the importance of vaccination in CKD may improve the adherence rates among these patients in Qatar.

Hepatitis B in Healthcare Personnel: An Update on the Global Landscape

Despite the outstanding progress that has been made in the prevention, detection, and management of hepatitis B during the past decades, hepatitis B remains a problem among healthcare personnel (HCP) in many countries. We reviewed studies on all aspects of hepatitis B in HCP published from 2017 through April 2023. They revealed wide variations on the prevalence of infection among HCP, ranging from 0.6% in Europe to >8.7% in Africa, almost always in association with very low vaccination rates. Many studies found a significant association between HCP's knowledge about hepatitis B and hepatitis B vaccines, their vaccination status, and practices. This research also discloses global inequities regarding vaccination policies against hepatitis B, free-of-charge vaccinations, and access to post-exposure prophylaxis (PEP). Strategies to prevent and manage accidental exposures are needed in order to reduce the burden of hepatitis B on HCP, while written policies for all aspects of infection prevention, protective equipment, and PEP should be available. Lastly, HCP should be accordingly educated. These are all imperative given the decline of routine vaccinations in the COVID-19 era, particularly in countries with fragile vaccination programs, and the disruptions of interventions for hepatitis B that are expected to provide a pool of virus transmission to future generations.

Delays in Hepatitis B Immunization Series Completion in People With Human Immunodeficiency Virus

Background

Studies have demonstrated low hepatitis B virus (HBV) vaccine series completion among persons with human immunodeficiency virus (HIV).

Methods

We conducted a retrospective record review of persons entering HIV care at 2 clinics in Houston, Texas, between 2010 and 2018. Kaplan-Meier curves summarized time to receipt of HBV vaccines for those eligible for vaccination. We estimated the proportions of patients who had received 1, 2, or 3 HBV vaccine doses at 12 and 24 months after entry to care. A Prentice Williams and Peterson total time model was used to evaluate associations between patient characteristics and time to vaccination.

Results

Of the 5357 patients who entered care, 2718 were eligible for HBV vaccination. After 2 years of follow-up, 51.2% of those eligible had received 1 HBV vaccine, 43.2% had received 2, and 28.4% received 3 vaccines. With adjustment for significant cofactors, patients whose CD4 cell count was ≥200/μL (adjusted hazard ratio [aHR], 1.43 [95% confidence interval (CI), 1.29-1.59]) and transgender patients (1.49 [1.08-2.04]) received any given vaccine dose sooner than those with CD4 cell counts <200/μL or cisgender patients, respectively. Compared with non-Hispanic whites, Hispanic patients were vaccinated sooner (aHR, 1.28 [95% CI, 1.07-1.53]). Those with an active substance use history had a significantly longer time to vaccination than those with no substance use history (aHR, 0.73 [95% CI, .62-.85]).

Conclusions

Strategies are needed to increase HBV vaccine completion rates in our study population, particularly among those with CD4 cell counts <200/μL or with a substance use disorder.

Preventing Hepatitis B Virus Infection Among U.S. Military Personnel: Potential Impact of a 2-Dose Versus 3-Dose Vaccine on Medical Readiness

INTRODUCTION

Hepatitis B, a major public health issue worldwide, has been associated with serious clinical outcomes. Military personnel are at particular risk for hepatitis B, such that hepatitis B vaccination is part of the accession process for new recruits. Although lost time costs and medical cost avoidance have been used by the U.S. Military to guide their decision-making protocols, this has not been applied to hepatitis B vaccination costs. Herein, a decision-analytic model is used to compare the effective vaccine protection rates and vaccine and operational costs of 2-dose versus 3-dose hepatitis B vaccine regimens in a population of recruits from the U.S. Marine Corps Recruit Depot, Parris Island.

METHODS

A decision-analytic model was developed to assess the expected levels of adherence, seroprotection, and vaccination and operational costs of a cohort of recruits vaccinated with either a 2-dose (HepB-CpG) vaccine for those eligible (scenario 1) or a 3-dose (HepB-Alum) vaccine (scenario 2). De-identified data from 23,004 recruits at the Marine Corps Recruit Depot, Parris Island, in 2018 and 2019 were used to provide real-world data on age distribution and vaccination status. Other inputs included published data on adherence for hepatitis B vaccines and seroprotection rates for HepB-CpG and HepB-Alum in relation to the number of doses received. Costs included direct medical costs of the hepatitis B vaccination and operational costs such as missed training time.

RESULTS

After receipt of two vaccine doses, 92% of recruits in scenario 1 (HepB-CpG group) were expected to be protected against hepatitis B within 1 month of receiving the second dose, compared with 24% of recruits in scenario 2 (HepB-Alum group), leaving 76% of Marine recruits unprotected if using HepB-Alum during the intervening 5-month period between doses 2 and 3. Over the study period, HepB-CpG was estimated to provide cost savings of $744,509 (17.3% cost reduction) compared with HepB-Alum, with the cost of missed training time being the most influential driver of the cost difference between the two vaccination schedules.

CONCLUSIONS

Findings from this model suggest that vaccination with the 2-dose HepB-CpG vaccine may provide earlier and higher protection against hepatitis B compared with the 3-dose vaccine (HepB-Alum). A 2-dose vaccination strategy incorporated as part of individual medical readiness has the potential to not only increase protection but also confer economic savings among military recruits at risk for hepatitis B infection.

Cost-effectiveness of a 3-antigen versus single-antigen vaccine for the prevention of hepatitis B in adults in the United States

OBJECTIVES

The first 3-antigen hepatitis B vaccine was approved by the United States (US) Food and Drug Administration in November 2021 and was recommended by the Centers for Disease Control and Prevention in 2022. We estimated the cost-effectiveness of this 3-antigen vaccine (PreHevbrio™) relative to the single-antigen vaccine, Engerix-B^TM, to prevent hepatitis B virus (HBV) infection among US adults.

METHODS

A cost-effectiveness model was developed using a combined decision-tree and Markov structure to follow 100,000 adults over their remaining lifetimes after vaccination with either the 3-antigen or single-antigen vaccine. Outcomes from societal and healthcare sector perspectives were calculated for adults aged 18-44, 45-64, and ≥65 years; adults with diabetes; and adults with obesity. Seroprotection rates were obtained from the phase3, head-to-head PROTECT trial (NCT03393754). Incidence, vaccine costs, vaccine adherence rates, direct and indirect costs, utilities, transition probabilities, and mortality were obtained from published sources. Health outcomes and costs (2020USD) were discounted 3% annually and reported by vaccine and population. One-way sensitivity and scenario analyses were conducted.

RESULTS

In the model, the 3-antigen vaccine led to fewer HBV infections, complications, and deaths compared with the single-antigen vaccine in all modeled populations due to higher rates and faster onset of seroprotection. Compared with the single-antigen vaccine, the 3-antigen vaccine had better health outcomes, more quality-adjusted life-years (QALYs), and lower costs in adults aged 18-64 years, adults with diabetes, and adults with obesity (dominant strategy). For adults aged ≥65 years, the 3-antigen vaccine was cost-effective compared with the single-antigen vaccine ($26,237/QALY gained) below common willingness-to-pay thresholds ($50,000-$100,000/QALY gained). In sensitivity analyses, results were sensitive to vaccine cost per dose, incidence, and age at vaccination.

CONCLUSION

The recently approved 3-antigen vaccine is a cost-saving or cost-effective intervention for preventing HBV infection and addressing the long-standing burden of hepatitis B among US adults.

Evaluating the cost-effectiveness of hepatitis B vaccination strategies in high-impact settings for adults

Adults at increased risk for hepatitis B virus (HBV) infection are recommended to receive vaccination. We conducted a cost utility analysis to evaluate approaches for implementing that recommendation in selected high-risk settings: community outreach events with a large proportion of immigrants, syringe service programs, substance use treatment centres, sexually transmitted infection (STI) clinics, tuberculosis (TB) clinics and jails. We utilized a decision tree framework with a Markov disease progression model to compare quality adjusted life-years and cost in 2021 United States dollars from four strategies: a 3-dose vaccination regimen with prevaccination screening and testing (PVST; baseline comparison); PVST at the initial encounter followed by a 2-dose series (Intervention 1); PVST with the first dose of a 2-dose vaccination series at the initial encounter (Intervention 2); and a 2-dose vaccination series without PVST (Intervention 3). In all settings, Intervention 1 resulted in worse health outcomes compared with the baseline strategy. Intervention 2 averted incident chronic HBV infections in all settings (range -9.4% in TB clinics, -14.8% in syringe service programs) and was a cost-saving approach in settings with higher risk of infection (i.e. jails, -$266 per person; syringe service programs, -$597; substance use treatment centres, -$130). Providing a 2-dose vaccination series without any screening (Intervention 3) averted incident HBV infections and was cost-saving in all settings but resulted in more HBV-related deaths in settings with higher HBV prevalence. These results demonstrate a 2-dose vaccine series is a cost-effective approach in these high-impact settings, even if prevaccination testing is not possible.

Global Implications for COVID-19 Vaccine Series Completion: Insights from Real-World Data from the United States

This retrospective cohort analysis leveraged vaccination data for BNT162b2, mRNA-1273, and Ad26.COV2.S in the United States from the Komodo Healthcare Map database, the TriNetX Dataworks USA Network, and Cerner Real-World EHR (electronic health record) Data to evaluate rates of adherence to and completion of COVID-19 vaccination series (November 2020 through June 2021). Individuals were indexed on the date they received the first dose of a COVID-19 vaccine, with an adherence follow-up window of 42 days. Adherence/completion rates were calculated in the overall cohort of each database and by month of initiation and stratified by age, race/ethnicity, and urban/rural status. Overall adherence and completion to 2-dose COVID-19 mRNA vaccine schedules ranged from 79.4% to 87.4% and 81.0% to 89.2%, respectively. In TriNetX and Cerner, mRNA-1273 recipients were generally less adherent compared with BNT162b2 across sociodemographic groups. In Komodo, rates of adherence/completion between mRNA-1273 and BNT162b2 were similar. Adherence/completion were generally lower in younger (<65 years) versus older recipients (≥65 years), particularly for mRNA-1273. No other sociodemographic-based gaps in vaccine adherence/completion were identified. These data demonstrate high but incomplete adherence to/completion of multidose COVID-19 vaccines during initial vaccine rollout in the United States. Multidose schedules may contribute to challenges associated with successful global vaccination.

Hepatitis vaccination adherence and completion rates and factors associated with low compliance: A claims-based analysis of U.S. adults

Poor compliance with multi-dose vaccine schedules by adults for whom hepatitis (Hep) A and B vaccines are recommended contributes to major Hep A and B disease burdens among high-risk U.S. adults. Evidence on hepatitis vaccine series adherence, completion, timeliness of completion, and factors associated with these outcomes, is limited and not readily generalizable for U.S. adults. This retrospective, observational study examined adherence, completion, its timeliness, and the impact of sociodemographic and clinical factors on these outcomes among a large, geographically representative sample of U.S. adults. We analyzed the Optum Clinformatics SES administrative claims database (1/1/2010-6/30/2020) for recipients of 2-dose (HepA, HepB2) or 3-dose (HepB3, HepAB) hepatitis vaccines. Adherence was defined as receipt of booster doses within specified assessment periods, per label-recommended schedules. Completion (receipt of all doses) was assessed at 6, 12, 18, and 24 months.The study included 356,828 adults ≥19 years old who were continuously enrolled in a medical benefit plan for one (HepB2), six (HepB3; HepAB), or 18 months (HepA) prior to and following the index date (first observed vaccine dose). Adherence and 24-month completion rates were: HepA (27.0%, 28.4%), HepB2 (32.2%, 44.8%), HepB3 (14.3%, 37.3%), HepAB, (15.3%, 33.8%). Kaplan-Meier completion curves plateaued after about 6 months for HepB2 and about 12 months for HepA, HepB3, and HepAB vaccines. Logistic regression analyses showed risk for low adherence/completion was generally associated with male gender, younger age, Black or Hispanic race/ethnicity, lower educational or household income attainment, and more comorbidities. Adherence and completion rates for all hepatitis vaccine series are low, especially for males, younger adults, those with lower socio-economic status and more comorbidities. To our knowledge, this is the largest claims-based analysis of adherence and completion rates for U.S. adults initiating all currently available HepA and HepB vaccines. Findings may inform hepatitis vaccination programming.