Elsevier

Vaccine

Volume 25, Issue 51, 12 December 2007, Pages 8536-8548
Vaccine

Cost-utility of universal hepatitis A vaccination in Canada

https://doi.org/10.1016/j.vaccine.2007.10.001Get rights and content

Abstract

Hepatitis A (HA) vaccination in Canada is currently targeted toward high-risk groups. The cost-effectiveness and expected health outcomes of universal vaccination relative to targeted vaccination in low-incidence countries such as Canada are currently unknown. Here, we conducted a cost-utility analysis for this situation, with Canada as the study population. We included vaccine costs, time costs, infection costs, and public health costs. We assessed a range of possible universal vaccination strategies over an 80-year time horizon using multiple cost perspectives. A dynamic model was used to account for herd immunity. Aggregate health gains from switching to universal vaccination are modest (10–30 QALYs per year). However, a “9 + 9” strategy that replaces two doses of monovalent hepatitis B (HB) vaccine at 9/10 years (universally administered in most provinces) with two doses of bivalent HA/HB vaccine is cost-saving from the societal perspective. At a willingness to pay threshold of $50,000/QALY, mean net benefit is +49.4 QALYs (S.D. 12.6) from the societal perspective and +3.8 QALYS (S.D. 3.0) from the payer perspective for the “9 + 9” strategy. Net benefit from the payer perspective is sensitive to the marginal cost of HA/HB vaccine relative to HB vaccine. Similar conclusions may apply in other countries with low incidence and a targeted vaccination policy.

Introduction

Hepatitis A (HA) virus is a common cause of acute hepatitis and causes a substantial economic burden [1]. Vaccines have been used for universal childhood immunization programmes since 1994 in parts of the United States, Spain, Italy, and Israel, where a substantial reduction in HA incidence has been observed and where universal vaccination appears to be cost-effective [2], [3], [4], [5], [6], [7]. Although HA vaccine is highly safe and effective [8], the current policy in Canada is to vaccinate only groups at risk [9]. Factors in favour of continuing a targeted HA vaccination policy include (1) low disease burden, (2) an already crowded vaccination schedule, and (3) the costs of a universal programme. Reported incidence in Canada has declined from an average of 6.3 per 100,000 per year for 1980–1994 to an average of 3.9 per 100,000 per year for 1995–2003. However, the drawbacks of targeted vaccination include unknown or unsatisfactory coverage in target groups [10] and continuation of occasional outbreaks with the consequent need for public health intervention [11], [12], [13]. Moreover, half of all infected individuals have no identifiable risk factors, thus targeted vaccination leaves behind a large group of susceptible adults who are vulnerable to clinically severe infection [1].

Hence, it is reasonable to investigate whether universal HA vaccination would produce better health and economic outcomes relative to the current targeted programme. Previous cost-effectiveness analyses (CEAs) do not shed light on the situation in Canada or in many other low-incidence countries, either because they analyze countries with significantly higher incidence, because they do not account for herd immunity [14], or because they compare universal vaccination to no vaccination at all rather than the current policy of targeted vaccination. The goal of this study was to determine the optimal strategy of universal HA vaccination in Canada using cost-utility analysis. A dynamic model was used to account for herd immunity [15]. The study compared health and economic outcomes for continuing the current targeted programme relative to implementing universal vaccination, from both third party payer and societal perspectives.

Section snippets

Methods

In the following sections we describe the dynamic and economic models. The supplementary file contains additional information that describes additional details regarding the study methodology, as well as supplemental results and additional discussion (Sections S1–S5).

Results

Table 4, Table 5 summarize the health and economic outcomes for the current, “4 + 9”, and “9 + 9” strategies. The health benefits (cases, deaths, and liver transplants averted) and QALY gains are modest under both universal strategies. However, the “9 + 9” strategy provides positive net benefit from both payer and societal perspectives. The “4 + 9” strategy provides better health outcomes than the “9 + 9” strategy, but is not cost-effective from the payer perspective. Both “4 + 9” and “9 + 9” strategies are

Discussion

This paper describes a detailed and carefully constructed model developed to assess the health and economic outcomes of universal hepatitis A vaccination in Canada. Previous cost-effectiveness analyses of hepatitis A vaccination have compared universal vaccination to no vaccination in countries with moderate HA incidence. To our knowledge, this is the first study that demonstrates fairly good cost-effectiveness of universal vaccination relative to targeted vaccination in a low incidence

Acknowledgements

This study was funded by an industry-partnered grant from the Canadian Institutes of Health Research in conjuction with GlaxoSmithKline Canada. The funders had no role in the study design, collection, analysis or interpretation of data, writing of the paper, or the decision to submit the paper for publication. Dr. Krahn was supported by the F. Norman Hughes Chair in Pharmacoeconomics, Faculty of Pharmacy, University of Toronto. Dr. Bauch received additional support from the Natural Sciences and

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