Should Canada and the United States universally vaccinate infants against hepatitis B? A cost-effectiveness analysis

This paper examines the economic attractiveness of universal vaccination of infants with hepatitis B virus (HBV) vaccine by calculating the incremental cost-effectiveness of this strategy when compared with the currently recommended strategy of screening all pregnant women and vaccinating only infants born to HBsAg+ mothers. A decision-analytic model involving a Markov process to model the long-term sequelae of HBV infection was constructed to estimate the expected costs and life expectancies for a cohort of newborns under two strategies: the current screening policy (SELECTIVE), which involves active and passive vaccination of infants born to carrier mothers, and a policy that combines the current screening strategy (including active and passive vaccination of infants born to carriers) with active vaccination alone for children of non-carriers (UNIVERSAL). A hypothetical cohort of children born in either Canada or the United States in 1991 was examined. Cost estimates were derived for Ontario. From a societal perspective, the incremental cost required to achieve one extra life year was found to be $30,347, comparable to the cost-effectiveness of other health care strategies commonly used in North America. The result is sensitive to the duration of vaccine effectiveness and particularly to the price of the vaccine. Universal vaccination results in net cost saving at a vaccine price of approximately $7 per dose, from a societal perspective. It is concluded that universal vaccination against HBV in infancy is economically attractive, comparable in cost-effectiveness to existing health care interventions. Lower vaccine prices would substantially improve the attractiveness of such a program. Implementation of universal vaccination should be considered in North America, contingent on vaccine price reduction. A monitoring program to ensure the long-term efficacy of the vaccine should be part of such a program.