Effectiveness and Cost Comparison of Two Strategies for Hepatitis B Vaccination of Schoolchildren

Article excerpt


Context: In 1994, immunization against hepatitis B was implemented in schools in Quebec, targeting grade 4 students. In 1996-1997 and 1997-1998, one Local Community Service Centre (CLSC) replaced the school-based program in its district with vaccination offered in community clinics after school hours. The aim of the current study was to compare the effectiveness and costs of school-based and clinic-based programs.

Methods: Vaccination coverage data were collected in the CLSC with the clinic-based program (CBP), and in three matched CLSCs with a school-based program (SBP), from 1994 to 2000. Surveys were conducted to estimate costs to parents, to schools and to CLSCs in 1997-1998.

Results: With the implementation of the CBP, the vaccination coverage fell to 73%, compared with over 90% in the SBPs. Coverage increased to 90% when the CBP was abandoned. Costs to the CLSC were not much lower in the CBP. Societal costs were $63 per student vaccinated in the CBP, and <= $40 in the SBPs.

Conclusion: Results demonstrate the advantage of SBP over a CBP for the immunization of schoolchildren.

In 1994, a school-based hepatitis B vaccination program targeting grade 4 students was implemented in the Province of Quebec.1 School nurses from Local Community Service Centres (CLSC) provide vaccination during school hours in all schools in their territory. In 1996, for organizational reasons, the authorities of one CLSC in the Monteregie Health Region decided to offer vaccination at special vaccination clinics after school hours. When this decision was made, it was assumed that costs to the health system would be reduced, and that coverage of the target population would be minimally affected.

Many studies, mostly descriptive, have examined school-based hepatitis B vaccination for its feasibility or practical aspects,2-7 and some economic analyses looked at the costs of hepatitis B vaccination for different populations.8-14 Only two studies examined costs of school-based vaccination programs, and both were on hepatitis B vaccination.15,16 One study found the cost per dose of a school-based program to be significantly less than that of a HMObased program; however, vaccine coverage was not measured in this study.15 The second study found the costs of a schoolbased hepatitis B vaccination program to be lower than administration during regular health visits (estimated in another economic evaluation).11,16 Review of the scientific literature found little evidence of the effectiveness of school-based strategies for improving vaccine uptake other than laws or regulations requiring vaccination for school entry. 17-20

Starting from the quasi-experiment conducted by one CLSC in Monteregie, we performed a study aimed at comparing the effectiveness and costs of a community clinic-based program (CBP) versus a school-based program (SBP) for vaccinating school-aged children against hepatitis B.


Study population

Monteregie is the second largest of the 18 health regions in the Province of Quebec. Public health services are provided by 19 CLSCs. From the beginning of the provincial immunization program against hepatitis B in 1994, Grade 4 students were eligible and immunization was offered at school during school hours. Parents were contacted via letters sent from school with information on the hepatitis B vaccination program and consent forms. Follow-up phone calls were done by school nurses for children not having the returned consent forms. No hepatitis B vaccine was provided by physicians in the region.

In 1996, one CLSC in the region, in agreement with the local school board, decided to offer vaccination by appointment at three different times for each dose: two on Saturdays between 9 am and 4 pm at one community site and one on Wednesday nights between 4 and 9 pm at another community site. Parents were contacted via letters from school. Children had to be accompanied by an adult at the time of vaccination. …