Cost-Effectiveness of Hepatitis B Vaccination in Adults With Diagnosed Diabetes

• Autores: Thomas Hoerger, Sarah Schillie, John S. Wittenborn, Christina Bradley, Fangjun Zhou
• Localización: Diabetes care, ISSN-e 0149-5992, Vol. 36, Nº. 1, 2013, págs. 63-69
• Idioma: inglés
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• Resumen

  • Abstract OBJECTIVE To examine the cost-effectiveness of a hepatitis B vaccination program for unvaccinated adults with diagnosed diabetes in the U.S.

    RESEARCH DESIGN AND METHODS We used a cost-effectiveness simulation model to estimate the cost-effectiveness of vaccinating adults 20�59 years of age with diagnosed diabetes not previously vaccinated for or infected by hepatitis B virus (HBV). The model estimated acute and chronic HBV infections, complications, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Data sources included surveillance data, epidemiological studies, and vaccine prices.

    RESULTS With a 10% uptake rate, the intervention will vaccinate 528,047 people and prevent 4,271 acute and 256 chronic hepatitis B infections. Net health care costs will increase by $91.4 million, and 1,218 QALYs will be gained, producing a cost-effectiveness ratio of $75,094 per QALY gained. Results are most sensitive to age, the discount rate, the hepatitis B incidence ratio for people with diabetes, and hepatitis B infection rates. Cost-effectiveness ratios rise with age at vaccination; an alternative intervention that vaccinates adults with diabetes 60 years of age or older had a cost-effectiveness ratio of $2.7 million per QALY.

    CONCLUSIONS Hepatitis B vaccination for adults with diabetes 20�59 years of age is modestly cost-effective. Vaccinating older adults with diabetes is not cost-effective. The study did not consider hepatitis outbreak investigation costs, and limited information exists on hepatitis progression among older adults with diabetes. Partly based on these results, the Advisory Committee on Immunization Practices recently recommended hepatitis B vaccination for people 20�59 years of age with diagnosed diabetes.

    The hepatitis B vaccine was first recommended in the U.S. in 1982 for groups known to be at high risk of hepatitis B virus (HBV) infection. Selective vaccination of adults and infants at increased risk for HBV infection was followed by adoption of universal hepatitis B vaccination for infants (1991) and catch-up vaccination for adolescents up to 18 years of age (1995 and 1999) (1). This incremental and selective vaccination strategy for eliminating HBV transmission was associated with an 84% decrease in reported cases of acute hepatitis B from 1990 to 2009 (from 8.5 to 1.1 incident cases per 100,000). When asymptomatic infection, underdiagnosis, and underreporting are taken into account, the estimated number of new HBV infections is >10 times higher than the number of confirmed acute cases (2,3).

    Despite these impressive improvements, in recent years ~60% of acute hepatitis B cases with risk factor information had none of the previously recognized risks for HBV infection (e.g., employment in a health care field involving contact with human blood; dialysis; injection drug use; multiple sexual partners; men who have sex with men; or household or sexual contact with a confirmed or suspected individual with an HBV infection), suggesting that other risks for HBV infection have not been identified (2). From 1996 to 2011, 29 outbreaks of hepatitis B infection in long-term care institutional facilities were reported to the Centers for Disease Control and Prevention (CDC). Twenty five of the outbreaks involved adults with diabetes receiving assisted blood glucose monitoring (4). From 2008 to 2011, news media reported instances in which >5,700 people were placed at risk for bloodborne infection from misuse of diabetes equipment (infection control lapses related to assisted blood glucose monitoring; use of diabetes equipment [e.g., insulin pens and lancing devices] designed for single-person use on multiple people) (5). These events raised the possibility that diabetes is a marker for increased risk of HBV transmission through exposure to contaminated blood during diabetes care and monitoring.

    The diabetes status of people with acute hepatitis infection is not routinely collected for national hepatitis surveillance purposes. To examine the risk of acute hepatitis B infection among adults with diabetes, diabetes status was obtained for 865 confirmed cases of acute hepatitis B identified during 2009�2010 at eight Emerging Infections Program sites (6). After controlling for demographic characteristics and stratifying by traditional risk factors for HBV infection (injection drug use, multiple sexual partners, and men who have sex with men), adults with diagnosed diabetes 23�59 years of age who lacked traditional risk factors for HBV infection had twice the odds of acute hepatitis B compared with adults without diabetes. Moreover, adults with diagnosed diabetes 60 years of age or older who lacked traditional risk factors had a 50% higher odds of acute hepatitis B compared with adults without diabetes, although the difference was not statistically significant (6). These results were consistent with seroprevalence data from the 1999�2010 National Health and Nutrition Examination Survey, which demonstrated a 60% increase in the seroprevalence of current or past HBV infection among adults with diagnosed diabetes compared with adults without diagnosed diabetes, and a 30% increase for adults with diagnosed diabetes 60 years of age or older, which was statistically significant (CDC, unpublished data). Together, these data support the hypothesis that people with diagnosed diabetes are at increased risk of HBV infection.

    Options for preventing HBV infection among adults with diagnosed diabetes include increased emphasis on infection control practice for diabetes care procedures (4), modifications in the design of diabetes care equipment to reduce the potential for exposure to blood (7), and consideration of pre-exposure hepatitis B vaccination for adults with diabetes. In this article, we examine the cost-effectiveness of a hypothetical hepatitis B vaccination program for unvaccinated adults with diagnosed diabetes.