Academic journal article Bulletin of the World Health Organization

Cost-Benefit Analysis of a Nationwide Inoculation Programme against Viral Hepatitis B in an Area of Intermediate Endemicity

Academic journal article Bulletin of the World Health Organization

Cost-Benefit Analysis of a Nationwide Inoculation Programme against Viral Hepatitis B in an Area of Intermediate Endemicity

Article excerpt

The large decrease in the cost of vaccines against hepatitis virus B prompts a re-examination of nationwide vaccination campaign strategies. The present study estimates the costs and benefits that would result from a viral hepatitis B prevention programme (with no prior screening) targeted at all under-16-year-olds in Israel in 1990 and only neonates in the period 1991-2034. Israel is situated in an area of intermediate endemicity, where the majority of HBsAg carriers are anti-HBe positive.

Such a policy would reduce the number of cases of viral hepatitis B in the vaccinated cohort from 654 000 to 270 000 over the period 1990-2059, yielding a benefit-to-cost ratio of 1.88: 1 for the health services only. Inclusion also of the indirect benefits of reduced work absences and mortality would increase the benefit-to-cost ratio to 2.77:1. Even when the benefits arising from the reduction in hepatocellular carcinoma and liver transplants were excluded, the benefit-to-cost ratio for the health services alone would still be 1.41:1. The adoption of such a nationwide inoculation policy appears therefore to be not only medically but also economically justifiable.


A total of 200-300 million people worldwide are carriers of hepatitis B antigen (HBsAg) [1-4]. Morbidity and mortality from acute hepatitis virus B (HBV) infection and its sequelae--chronic active hepatitis, cirrhosis, and primary hepatocellular carcinoma [5-12]--generate not only considerable direct health care costs [13, 14], but also indirect costs in terms of days lost from work [13]. The cost of hepatitis virus B vaccines has, however, declined rapidly over the past decade from US$ 100 for three paediatric doses (including cold chain and administration costs [15] in 1980 to as low as US$ 2.80 in 1989 for children's doses in some countries.(a) This huge decrease in costs prompted us to re-examine the feasibility of expanding the present policy in Israel of vaccinating against HBV infection only specific at-risk groups, such as Ethiopian immigrants under 2 years of age [16] and health service workers, to the nationwide immunization of the entire population aged under 16 years.

Most previous cost--benefit studies of hepatitis B vaccination have either focused on at-risk target populations, such as homosexuals [14, 17], hospital staff [18], and surgical residents [14], or have been confined to neonatal programmes [19]. Some studies limited their perspective to consideration of benefits in terms of reductions in the number of acute cases, but omitted reductions in chronic sequelae [17], or focused only on the impact of programmes on the social security system [18]. Mulley et al., however, also examined screening followed by vaccination of susceptible persons in the general population [15].

The study presented in this article considers all the relevant direct and indirect costs and benefits of a nationwide hepatitis B vaccination programme (with no prior screening) that would be targeted at all under-16-year-olds in Israel in 1990 but only neonates in the period 1991-2034.

Current situation


In Israel, an average of 3484 notified cases of HBV infection (0.90 per 1000 population; 55.2%, male) were reported annually over the period 1971-90 [20-23]. From 1971 to 1986 there were, on average, 13.5 deaths per annum from acute viral hepatitis in the country [20-23].

Initial results from the first 2 months of the newly established system which in January 1992 began reporting hepatitis by type indicate that 17.8% of the reported hepatitis cases in Israel are of type B [24], which is considerably lower than that reported in the USA (30.9% in 1987) [25]. Projections of incidences in the model presented here are based on the average values reported for 1971 to 1990 multiplied by the type B incidence of 17.8%, and adjusted upward because 25-40% of immigrants from the former USSR have been infected with hepatitis virus B prior to their arrival in Israel (D. …

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