An appraisal of the efficacy and cost effectiveness of antenatal screening for hepatitis B

Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening

BACKGROUND

Treatment for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is improving but not benefiting individuals unaware to be infected. To inform screening policies we assessed (1) the hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV-Ab) prevalence for 34 European countries; and (2) the cost-effectiveness of screening for chronic HBV and HCV infection.

METHODS

We searched peer-reviewed literature for data on HBsAg and anti-HCV-Ab prevalence and cost-effectiveness of screening of the general population and five subgroups, and used data for people who inject drugs (PWID) and blood donors from two European organizations. Of 1759 and 468 papers found in the prevalence and cost-effectiveness searches respectively, we included 124 and 29 papers after assessing their quality. We used decision rules to calculate weighted prevalence estimates by country.

RESULTS

The HBsAg and anti-HCV-Ab prevalence in the general population ranged from 0.1%-5.6% and 0.4%-5.2% respectively, by country. For PWID, men who have sex with men and migrants, the prevalence of HBsAg and anti-HCV-Ab was higher than the prevalence in the general population in all but 3 countries. There is evidence that HCV screening of PWID and HBsAg screening of pregnant women and migrants is cost-effective.

CONCLUSION

The prevalence of chronic HBV and HCV infection varies widely between European countries. Anti-HCV-Ab screening of PWID and HBsAg screening of pregnant women and migrants have European public health priority. Cost-effectiveness analyses may need to take effect of antiviral treatment on preventing HBV and HCV transmission into account.

Hepatitis B virus transmission in pre-adolescent schoolchildren in four multi-ethnic areas of England

The aim of this study was to estimate the amount of childhood hepatitis B virus transmission in children born in the UK, a very low-prevalence country, that is preventable only by universal hepatitis B immunization of infants. Oral fluid specimens were collected from schoolchildren aged 7-11 years in four inner city multi-ethnic areas and tested for the presence of antibody to hepatitis B core antigen (anti-HBc). Those found positive or indeterminate were followed up with testing on serum to confirm their hepatitis B status. The overall prevalence of anti-HBc in children was low [0.26%, 95% confidence interval (CI) 0.14-0.44]. The estimated average annual incidence of hepatitis B was estimated to be 29.26/100 000 children (95% CI 16.00-49.08). The total incidence that is preventable only by a universal infant immunization programme in the UK was estimated to be between 5.00 and 12.49/100 000. The study demonstrates that the extent of horizontal childhood hepatitis B virus transmission is low in children born in the UK and suggests that schools in the UK are an uncommon setting for the transmission of the virus. Targeted hepatitis B testing and immunization of migrants from intermediate- and high-prevalence countries is likely to be a more effective measure to reduce childhood transmission than a universal infant immunization programme.

Specific health issues in ethnic minority groups

The study of disease patterns in ethnic minority groups offers insights into the causation of disease. Ethnic minorities have wide variations in health conditions and behaviors, and stereotyping can lead to spurious assumptions in caring for patients. This article presents basic information relating to major illnesses such as cardiovascular disease, diabetes, and cancer and common health disorders observed among ethnic groups primarily in the United Kingdom and United States.

Cost-effectiveness of population screening for Helicobacter pylori in preventing gastric cancer and peptic ulcer disease, using simulation

OBJECTIVES

To evaluate the cost-effectiveness of population screening for Helicobacter pylori in preventing gastric cancer and peptic ulcer disease in England and Wales.

METHODS

A discrete event simulation model used parameter estimates, derived from peer-reviewed literature, routine data and statistical modelling. Population screening was compared with no screening but with opportunistic eradication in patients presenting with dyspepsia. Costs included screening, eradication and costs averted to provide costs per life years saved (cost/LYS) for preventing gastric cancer and peptic ulcer disease. Sensitivity analyses were undertaken.

RESULTS

The cost/LYS from screening at age 40 years was Uk pounds 5860 at discount rates of 6%. The outcomes were sensitive to H. pylori prevalence, the degree of opportunistic eradication, the discount rate, the efficacy of eradication on gastric cancer risk, the risk of complicated peptic ulcer disease and gastric cancer associated with H. pylori infection, and the duration of follow-up. In sensitivity analyses, the cost/LYS rarely exceeded UK pounds 20000 over an 80-year follow-up, but did for shorter periods.

CONCLUSIONS

H. pylori screening may be cost-effective in the long term. However, before screening can be recommended further evidence is needed to resolve some of the uncertainties, particularly over the efficacy of eradication on risk of gastric cancer, the risk associated with complicated peptic ulcers, and the effect of more widespread opportunistic testing of patients with dyspepsia.

Hepatitis B surface antigen carrier status and its correlation to gestational hypertension

OBJECTIVE

To determine whether chronic hepatitis B surface antigen (HBsAg) carrier status is associated with an increased incidence of gestational hypertension.

METHODS

A retrospective analysis of all deliveries in a regional obstetric unit over a 4-year period using a comprehensive obstetric database.

RESULTS

The data of 13,792 patients were analysed, of which 1340 (9.71%) were chronic HBsAg carriers. Contrary to our hypothesis, the overall incidence of gestational hypertension was significantly lower in the HBsAg positive group (2.01%) as compared to the negative group (3.58%) (P < 0.01, odds ratio (OR) 0.55, 95% confidence interval (CI) 0.37-0.81). When comparing the incidence of severe preeclampsia, the difference remained significant (0.22 and 0.79%, respectively, P < 0.05, OR 0.28, 95% CI 0.08-0.88). There was otherwise no difference in the incidence of other major obstetric complications between the HBsAg positive and negative groups.

CONCLUSION

The findings presented did not support a positive association between HbsAg carrier status and gestational hypertension. The data from the present study, and re-evaluation of similar published data, in fact suggest the contrary observation of a lower than normal incidence of gestational hypertension in HbsAg positive mothers.

Economic evaluations of hepatitis B immunization: a global review of recent studies (1994-2000)

A search was carried out for economic evaluations of hepatitis B (HBV) vaccination, published between 1994 and 2000. The results of these studies are discussed according to the level of HBV endemicity. The great majority of these evaluations were carried out for industrialized countries, for the most part situated in areas of low to very low HBV endemicity. In countries of very low endemicity economic evaluations have yielded contradictory results, depending on the type of epidemiological model they used. The cost-effectiveness of adding universal to selective vaccination strategies in these countries depends on the selective strategies' ability to sufficiently identify, reach and fully vaccinate persons in various risk groups. In areas of low, intermediate and high endemicity, universal vaccination seems justifiable on the basis of economic evaluation. In general, the accuracy of the models has improved over the years, but still the transparency, completeness and comparability of analyses could improve considerably. By noting this, the suitability of different methodologies for different areas of endemicity and vaccination strategies is discussed. It is recommended that specific guidelines for economic evaluation of the prevention of infectious diseases be developed to guarantee the relevance of and to improve the comparability between studies.

Cost effectiveness of expanded antenatal HIV testing in London

BACKGROUND

Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing).

OBJECTIVE

To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy.

DESIGN

Incremental cost-effectiveness analysis.

METHODS

Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies.

RESULTS

Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40.

CONCLUSION

Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

[Mother-child transmission of hepatitis B virus. State of the problem and prevention]

Hepatitis B virus (HBV) infection is a worldwide problem of public health. Mother/child transmission of the virus represents a major factor in maintaining the infection, which is often transmitted during delivery, the risk of transmission of the HBV depending on the degree of maternal infectiosity, the genomic type of the virus, and the rate of maternal antibodies. Evolution towards chronicity of the infected newborn is frequent. The available means to prevent the mother/child transmission of the virus are efficient. Once HBV maternal infection is diagnosed during pregnancy, joint administration of vaccine and specific immunoglobulins to the baby in the early neonatal period efficiently prevent the mother/child transmission of the virus.

Universal HIV screening of pregnant women in England: cost effectiveness analysis

OBJECTIVE

To estimate the cost effectiveness of universal, voluntary HIV screening of pregnant women in England.

DESIGN

Cost effectiveness analysis. Cost estimates of caring for HIV positive children were based on the stage of HIV infection and calculated using data obtained from a London hospital between 1986 and 1996. These were combined with estimates of the health benefits and costs of antenatal screening so that the cost effectiveness of universal, voluntary antenatal screening for HIV infection in England could be estimated.

MAIN OUTCOME MEASURES

Lifetime, direct costs of medical care of childhood HIV infection; life years gained as a result of the screening programme; net cost per life year gained for different pretest counselling costs; and different prevalence rates of pregnant women who were unaware that they were HIV positive.

RESULTS

Estimated direct lifetime medical and social care costs of childhood HIV infection were pound178 300 using a 5% discount rate for time preference (1995-6 prices). In high prevalence areas screening pregnant women for HIV is estimated to be a cost effective intervention with a net cost of less than pound4000 for each life year gained. For areas with comparatively low prevalence rates, cost effectiveness could be less than pound20 000 per life year gained, depending on the number of pregnant women who are unaware that they are infected and local screening costs.

CONCLUSIONS

Our results confirm recent recommendations that universal, voluntary antenatal HIV screening should be implemented in the London area. Serious consideration of the policy should be given for other areas in England depending on local prevalence and screening costs.

Antenatal screening for hepatitis B infection and syphilis in the UK

OBJECTIVES

To assess antenatal hepatitis B and syphilis screening policies in the UK.

DESIGN

Postal questionnaire survey.

SETTING

One hundred and ninety-two obstetric units and 116 Public Health directorates.

MAIN OUTCOME MEASURES

Antenatal screening policy and line of responsibility for ensuring vaccine uptake in hepatitis B virus exposed children.

RESULTS

Replies were received from 140 (73%) obstetric centres and 99 (85%) Public Health directors. Forty per cent of obstetric centres now offer hepatitis B virus tests to all pregnant women, and nearly one-quarter (24.1%) of all births in the UK in 1996 occurred in centres with a universal testing policy. The prevalence of chronic hepatitis B virus ranged from 0.3 to 17.5 per 1000 deliveries. Universal antenatal screening for serological evidence of syphilis was the norm, but five obstetric centres respondents and three Public Health directors were considering its discontinuation. In the nine London centres, syphilis prevalence was 2.06 per 1000 pregnant women, compared with 0.24 per 1000 elsewhere. Responses from Public Health directors indicated the nonspecific nature of the antenatal care contract. Responsibility for hepatitis B virus vaccination of the newly born infant rests with the hospital paediatrician, with transfer of responsibility to the community usually occurring through a discharge letter. Only two areas had a monitoring system to ensure full hepatitis B virus vaccination coverage of exposed infants.

CONCLUSIONS

If antenatal screening policies are to be equitable there is a need for a clear national policy, and systems need to be established to monitor local policy and practice.