Gastroenterology

Gastroenterology

Volume 138, Issue 2, February 2010, Pages 522-530
Gastroenterology

Clinical—Liver, Pancreas, and Biliary Tract
Screening and Early Treatment of Migrants for Chronic Hepatitis B Virus Infection Is Cost-Effective

https://doi.org/10.1053/j.gastro.2009.10.039Get rights and content

Background & Aims

Persons with chronic hepatitis B virus (HBV) infection are at risk of developing cirrhosis and hepatocellular carcinoma. Early detection of chronic HBV infection through screening and treatment of eligible patients has the potential to prevent these sequelae. We assessed the cost-effectiveness in The Netherlands of systematically screening migrants from countries that have high and intermediate HBV infection levels.

Methods

Epidemiologic data of the expected numbers of patients with active chronic HBV infection in the target population and information about the costs of a screening program were used in a Markov model and used to determine costs and quality-adjusted life years (QALY) for patients who were and were not treated.

Results

Compared with the status quo, a 1-time screen for HBV infection can reduce mortality of liver-related diseases by 10%. Using base case estimates, the incremental cost-effectiveness ratio (ICER) of screening, compared with not screening, is euros (€) 8966 per QALY gained. The ICER ranged from €7936 to €11,705 based on univariate sensitivity analysis, varying parameter values of HBV prevalence, participation rate, success in referral, and treatment compliance. Using multivariate sensitivity analysis for treatment effectiveness, the ICER ranged from €7222 to €15,694; for disease progression, it ranged from €5568 to €60,418.

Conclusions

Early detection and treatment of people with HBV infection can have a large impact on liver-related health outcomes. Systematic screening for chronic HBV infection among migrants is likely to be cost-effective, even using low estimates for HBV prevalence, participation, referral, and treatment compliance.

Section snippets

Patients and Methods

We used a Markov chain model to assess the costs and health outcomes of a cohort of patients who either experienced the natural history of HBV infection or received antiviral treatment. Comparative outcomes of these models, in terms of mortality, quality of life, and health care costs, were entered into a separate cost-effectiveness model containing all relevant variables of the screening program. The status quo includes a baseline level of detection of CHB infections through the existing

Results

The target population of 1.3 million migrants includes an estimated 44,000 HBsAg carriers, of whom 4466 are estimated to have active CHB. In the status quo, only 4% of patients with active CHB (173/4466) are expected to start treatment; the remainder are expected to follow the natural history of disease progression (Table 1). Lifetime follow-up of the cohort of active CHB patients suggests that 1073 (24%) of the 4466 patients will die of HBV-related diseases.

With a one-off screening program,

Discussion

We found that screening migrants for CHB infection with the goal of improving CHB outcome by early detection and treatment is cost-effective compared with the status quo. We estimate that the ICER of screening is approximately €9000 per QALY gained, well below the threshold of €20,000 per QALY gained that is commonly accepted in The Netherlands.45 Under the status quo, we estimated that only 4% of the population eligible for treatment is actually treated. By improving case detection through the

Acknowledgments

The authors thank Dr Ken Redekop from the Institute for Medical Technology Assessment for his help with the sensitivity analyses.

I.K.V. and M.T. contributed equally to the paper.

References (52)

  • Y.F. Liaw et al.

    Hepatitis B virus infection

    Lancet

    (2009)
  • D. Lavanchy

    Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures

    J Viral Hepat

    (2004)
  • S.T. Goldstein et al.

    A mathematical model to estimate global hepatitis B disease burden and vaccination impact

    Int J Epidemiol

    (2005)
  • F. Kanwal et al.

    Treatment alternatives for chronic hepatitis B virus infection: a cost-effectiveness analysis

    Ann Intern Med

    (2005)
  • A.D. Enriquez et al.

    Cost-effectiveness of suppressing hepatitis B virus DNA in immune tolerant patients to prevent hepatocellular carcinoma and cirrhosis

    Aliment Pharmacol Ther

    (2007)
  • D.L. Veenstra et al.

    Cost-effectiveness of entecavir versus lamivudine with adefovir salvage in HBeAg-positive chronic hepatitis B

    Pharmacoeconomics

    (2007)
  • D.E. Spackman et al.

    A cost-effectiveness analysis of currently approved treatments for HBeAg-positive chronic hepatitis B

    Pharmacoeconomics

    (2008)
  • M. Toy et al.

    Potential impact of long-term nucleoside therapy on the mortality and morbidity of active chronic hepatitis B

    Hepatology

    (2009)
  • C. Cohen et al.

    Underestimation of chronic hepatitis B virus infection in the United States of America

    J Viral Hepat

    (2008)

  • Screening for chronic hepatitis B among Asian/Pacific Islander populations—New York City, 2005

    MMWR Morb Mortal Wkly Rep

    (2006)
  • T. Marschall et al.

    High impact of migration on the prevalence of chronic hepatitis B in The Netherlands

    Eur J Gastroenterol Hepatol

    (2008)
  • M. Toy et al.

    Transmission routes of hepatitis B virus infection in chronic hepatitis B patients in The Netherlands

    J Med Virol

    (2008)
  • F.D. Koedijk et al.

    [Hepatitis B surveillance in the Netherlands, 2002–2005: acute infection is mainly via sexual contact while chronic infection is via vertical transmission through mothers from endemic regions]

    Ned Tijdschr Geneeskd

    (2007)
  • D.W. Hutton et al.

    Cost-effectiveness of screening and vaccinating Asian and Pacific Islander adults for hepatitis B

    Ann Intern Med

    (2007)
  • M. Bouma et al.

    [Summary of the practice guideline “Viral hepatitis and other liver diseases” (second revision) from the Dutch College of General Practitioners]

    Ned Tijdschr Geneeskd

    (2008)

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    Conflicts of interest The authors disclose the following: Prof. S.W. Schalm has received research grants and speaker's fees from GlaxoSmithKline and Bristol-Myers Squibb, respectively. The remaining authors disclose no conflicts.

    Funding Supported by EU grant (LSHM-CT-2004-503359) VIRGIL to Erasmus MC and by an unrestricted grant from the Foundation for Liver Research to Erasmus MC.

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