Economic Evaluation of Delivering Hepatitis B Vaccine to Injection Drug Users

doi:10.1016/j.amepre.2008.03.028

American Journal of Preventive Medicine

Volume 35, Issue 1, July 2008, Pages 25-32

https://doi.org/10.1016/j.amepre.2008.03.028 Get rights and content

Background

Injection drug users (IDUs) are at high risk of hepatitis B (HBV) infection, and hepatitis B vaccination coverage in IDUs is low. Recent studies demonstrate that syringe exchange programs are effective venues to reach and immunize IDUs. The purpose of this paper was to determine if targeting IDUs for HBV vaccination through syringe exchange programs is economically desirable for the healthcare system and to assess the relative effectiveness of several different vaccination strategies.

Methods

Active IDUs in Chicago IL and Hartford and Bridgeport CT (N=1964) were recruited and screened through local syringe exchange programs, randomized to a standard (0, 1, 6 months) or accelerated (0, 1, 2 months) vaccination schedule, and followed from May 2003 to March 2006. Analyses were conducted in 2007. The vaccination program's costs were balanced against future HBV-associated medical costs. Benefits in terms of prevented acute HBV infections and quality-adjusted life years were estimated based on a Markov model.

Results

HBV vaccination campaigns targeting IDUs through syringe exchange programs are cost-saving. The most cost-saving strategies include giving the first dose to everyone at screening, administering the vaccination under the accelerated schedule (0, 1, 2 months), and obtaining highly discounted vaccine from local health departments.

Conclusions

It is economically inappropriate to offer HBV screening in the absence of vaccination. Existing syringe exchange programs in the U.S. should include HBV vaccination.

Introduction

Since the first safe and effective hepatitis B vaccine was approved in 1982, vaccination campaigns have been successful in controlling hepatitis B virus (HBV) infection in the general U.S. population. However, HBV infection remains a major health threat to individuals who engage in high-risk behaviors, especially injection drug users (IDUs).¹ Among the estimated 1.3 million IDUs in the U.S.,2, 3, 4 the prevalence of HBV infection ranges from 40% to 80%,5, 6, 7, 8, 9, 10, 11, 12 and the incidence rate ranges between 8% and 12%.13, 14, 15 The Advisory Committee on Immunization Practices recommended vaccination of IDUs as long ago as 1991,¹⁶ but the current vaccination coverage among IDUs remains low.17, 18, 19 Vaccination programs targeting IDUs are uncommon, mainly due to a lack of funds, the lack of reliable delivery venues, and expectations of poor adherence to a complicated hepatitis B vaccination schedule.

The mortality and morbidity associated with HBV infection (e.g., treatment of serious acute HBV infection and illnesses associated with chronic infection) impose a sizable economic burden on the healthcare system. To date, no study has undertaken a comprehensive evaluation of the costs and benefits of a hepatitis B vaccination program that targeted IDUs. Previous studies have shown that hepatitis B vaccination targeting other high-risk groups is cost effective and even cost saving. The hepatitis B vaccination of prison inmates in the U.S. would realize savings for the healthcare system, although it would cost the prison system $415 per infection averted.²⁰ A recent study in England and Wales found that the vaccination of high-risk adults in genitourinary clinics was more cost effective than universal infant vaccination.²¹ Studies in the U.S. and Italy yielded similar conclusions among hemodialysis patients.22, 23 Therefore, hepatitis B vaccination targeting IDUs was anticipated to be cost effective or cost saving if IDUs could be successfully reached and immunized.

Analysis of recent studies revealed that it is possible to successfully reach and immunize IDUs by implementing vaccination programs through syringe exchange programs and providing modest payments to clients as incentives.24, 25, 26 It was hypothesized that adherence could also be increased by adopting an accelerated (2-month) hepatitis B vaccination schedule without a substantial reduction of immune protection.²⁷ The purpose of the present study was to determine the economic and clinical consequences of vaccinating IDUs against hepatitis B after implementing these approaches. Two vaccination schedules (standard 0, 1, 6 months versus accelerated 0, 1, 2 months) and two screening strategies (giving the first dose only to susceptible people who return following screening versus giving the first dose to every participant at the screening visit) were compared. This study set out to ascertain whether hepatitis B vaccination campaigns targeting IDUs are economically desirable for the healthcare system and which screening strategy would be the most effective.

Section snippets

Study Population

The assessment of hepatitis B vaccination of IDUs was based on data from the Hepatitis Vaccine Study (HVS) of active IDUs in Chicago IL and Hartford and Bridgeport CT. Data were collected between May 2003 and March 2006. The primary inclusion criteria were that participants be aged ≥18 years and had injected drugs in the past 30 days as indicated by self-report and the evidence of injection stigmata. The HVS research protocol was approved by the Yale Human Investigation Committee as well as the

Baseline Results

Table 3 presents the baseline results for each strategy. It shows that the accelerated vaccination schedule prevented 17% more acute infections and gained 14%–20% more QALYs per person than the standard vaccination schedule. Also, the vaccination strategy with the first dose administered to everyone at the screening visit prevented 45% more acute infections and saved 43%–50% more QALYs per person than the strategy that administered the first dose only to susceptible persons who returned for

Discussion

This study demonstrated that integrating hepatitis B vaccination into existing syringe exchange programs would realize an economic benefit for the healthcare system. The most cost-saving and cost-effective vaccination strategy included giving the first dose to all screened participants prior to knowing their serological results and administering the vaccination under the accelerated schedule (0, 1, 2 months); this strategy saved almost a half-million dollars, realized a gain of 0.12 QALYs per

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Cited by (36)

Vaccination barriers and opportunities at syringe services programs in the United States, June–August 2021—A cross-sectional survey
2022, Drug and Alcohol Dependence
Citation Excerpt :
Other strategies to maximize the convenience of vaccinations have been shown to improve vaccination rates. These include providing vaccinations on site rather than by referral and, for hepatitis B, offering screening and vaccination simultaneously (Bowman et al., 2014; Campbell et al., 2007; Des Jarlais et al., 2001; Hu et al., 2008). SSPs are established to meet the needs of PWID.
Syringe services programs (SSPs) are an important venue for reaching people who inject drugs (PWID) to offer preventive services; however, not all SSPs offer vaccinations. We aimed to describe barriers and opportunities for SSPs to offer vaccinations.
During June–August 2021, we conducted a descriptive, cross-sectional survey of SSP providers in the United States. SSPs were recruited from national listservs using purposive sampling to ensure geographic diversity. The survey included questions about SSP characteristics, client demographics, existing vaccination resources, resource needs, and staff perspectives on client vaccination barriers. Statistical comparisons were made using Pearson’s chi-square test.
In total, 105 SSPs from 34 states responded to the survey; 46 SSPs (43.8%) offered on-site vaccinations. SSPs without on-site vaccinations were more likely operated by community-based organizations (81.4% vs 30.4%, p < 0.001) in urban areas (71.4% vs 40.0%, p = 0.002) than SSPs offering on-site vaccinations. The most common staffing need was for personnel licensed to administer vaccines (74/98, 75.5%). Over half of SSPs reported vaccine supply, administration supplies, storage equipment, and systems to follow-up clients for multidose series as important resource needs. The most common resource need was for reminder/recall systems for vaccines with multidose series (75/92, 81.5%). Vaccine safety concerns (92/95, 96.8%) and competing priorities (92/96, 95.8%) were the most common staff-reported client barriers to vaccinations.
Addressing missed opportunities for offering vaccinations to PWID who use SSPs will require increased numbers of on-site personnel licensed to administer vaccines and additional training, vaccination supplies, and storage and handling equipment.
Opioid use disorder and Chronic Hepatitis B
2020, The Opioid Epidemic and Infectious Diseases
Chronic hepatitis B virus (HBV) infection affects over 240 million individuals worldwide. Detection of the disease is dependent on active surveillance and testing by healthcare providers. The Center for Disease Control (CDC) recommends HBV screening in all individuals with opioid use disorders. Prompt identification of chronic infection and vaccination of susceptible persons at initial point of contact with the healthcare system is a priority. HBV diagnosis and prevention strategies should be coupled with effective harm reduction programs. Safe and well-tolerated oral antiviral therapy is available and is highly efficacious at suppressing viral replication and ameliorating long-term complications; however, there is at present no cure. Successful navigation of chronically infected individuals through the HBV care cascade is critical to reduce HBV-related morbidity and mortality.
Modeling indicates efficient vaccine-based interventions for the elimination of hepatitis C virus among persons who inject drugs in metropolitan Chicago
2019, Vaccine
Citation Excerpt :
Our study has several limitations. First, the cost of a HCV vaccine was set to $200 based on hepatitis B vaccine cost among in the U.S. [44] which is within the range used (or noted) in previous modeling efforts [51–53] and thus could be considered as a conservative assumption. In particular, we assume a single scenario — rapid uptake of a one dose vaccine that confers long-term protection.
Persons who inject drugs (PWID) are at highest risk for acquiring and transmitting hepatitis C (HCV) infection. The recent availability of oral direct-acting antiviral (DAA) therapy with reported cure rates >90% can prevent HCV transmission, making HCV elimination an attainable goal among PWID. The World Health Organization (WHO) recently proposed a 90% reduction in HCV incidence as a key objective. However, given barriers to the use of DAAs in PWID, including cost, restricted access to DAAs, and risk of reinfection, combination strategies including the availability of effective vaccines are needed to eradicate HCV as a public health threat. This study aims to model the cost and efficacy of a dual modality approach using HCV vaccines combined with DAAs to reduce HCV incidence by 90% and prevalence by 50% in PWID populations.
We developed a mathematical model that represents the HCV epidemic among PWID and calibrated it to empirical data from metropolitan Chicago, Illinois. Four medical interventions were considered: vaccination of HCV naive PWID, DAA treatment, DAA treatment followed by vaccination, and, a combination of vaccination and DAA treatment.
The combination of vaccination and DAAs is the lowest cost-expensive intervention for achieving the WHO target of 90% incidence reduction. The use of DAAs without a vaccine is much less cost-effective with the additional risk of reinfection after treatment. Vaccination of naïve PWID alone, even when scaled-up to all reachable PWID, cannot achieve 90% reduction of incidence in high-prevalence populations due to infections occurring before vaccination. Similarly, the lowest cost-expensive way to halve prevalence in 15 years is through the combination of vaccination and DAAs.
The modeling results underscore the importance of developing an effective HCV vaccine and augmenting DAAs with vaccines in HCV intervention strategies in order to achieve efficient reductions in incidence and prevalence.
Cost-effectiveness of adult vaccinations: A systematic review
2019, Vaccine
Citation Excerpt :
The 78 abstracted publications yielded 161 outcomes (Table 1). All the identified outcomes from the publications in the final set of records are summarized in the appendix [66–133]. The percent of outcomes associated with age-based vaccination recommendations by vaccine group was 75 for influenza, 62 for pneumococcal, 74 for HPV, 100 for HZ, and 72 for Td/Tdap.
Coverage levels for many recommended adult vaccinations are low. The cost-effectiveness research literature on adult vaccinations has not been synthesized in recent years, which may contribute to low awareness of the value of adult vaccinations and to their under-utilization. We assessed research literature since 1980 to summarize economic evidence for adult vaccinations included on the adult immunization schedule.
We searched PubMed, EMBASE, EconLit, and Cochrane Library from 1980 to 2016 and identified economic evaluation or cost-effectiveness analysis for vaccinations targeting persons aged ≥18 years in the U.S. or Canada. After excluding records based on title and abstract reviews, the remaining publications had a full-text review from two independent reviewers, who extracted economic values that compared vaccination to “no vaccination” scenarios.
The systematic searches yielded 1688 publications. After removing duplicates, off-topic publications, and publications without a “no vaccination” comparison, 78 publications were included in the final analysis (influenza = 25, pneumococcal = 18, human papillomavirus = 9, herpes zoster = 7, tetanus-diphtheria-pertussis = 9, hepatitis B = 9, and multiple vaccines = 1). Among outcomes assessing age-based vaccinations, the percent indicating cost-savings was 56% for influenza, 31% for pneumococcal, and 23% for tetanus-diphtheria-pertussis vaccinations. Among age-based vaccination outcomes reporting $/QALY, the percent of outcomes indicating a cost per QALY of ≤$100,000 was 100% for influenza, 100% for pneumococcal, 69% for human papillomavirus, 71% for herpes zoster, and 50% for tetanus-diphtheria-pertussis vaccinations.
The majority of published studies report favorable cost-effectiveness profiles for adult vaccinations, which supports efforts to improve the implementation of adult vaccination recommendations.
A large proportion of people who inject drugs are susceptible to hepatitis B: Results from a bio-behavioural study in eight German cities
2018, International Journal of Infectious Diseases
Citation Excerpt :
Options to increase vaccination coverage among PWID, as recommended by the WHO and EMCDDA, include the immediate availability of on-site vaccination during information and vaccination campaigns targeting PWID, prison-based vaccination programmes, cash incentives, and accelerated immunization schedules (Campbell et al., 2007; Sutton et al., 2006; Weaver et al., 2014; Shah et al., 2015); however, these are not routinely implemented in Germany. Integrating vaccination campaigns into needle exchange programmes may also be a cost-effective option (Hu et al., 2008). The self-reported HBV infection and vaccination status had limited validity, with 71% of participants reporting their HBV status and only 45% reporting their HBV vaccination status in concordance with the laboratory tests.
People who inject drugs (PWID) are at high risk of hepatitis B virus (HBV) infection by sharing needles and drug use paraphernalia. In Germany, no routine surveillance of HBV prevalence and vaccination coverage among PWID exists.
Socio-demographic and behavioural data were collected between 2011 and 2014 through face-to-face interviews, during a bio-behavioural survey of PWID recruited in eight German cities. Dried blood spots (DBS) prepared with capillary blood were tested for HBV markers. Factors associated with past/current HBV infection and vaccination status were analysed by univariable and multivariable analysis using logistic regression. The validity of self-reported HBV infection and vaccination status was analysed by comparison to the laboratory results.
Among 2077 participants, the prevalence of current HBV infection was 1.1%, of past HBV infection was 24%, and of vaccine-induced HBV antibodies was 32%. No detectable HBV antibodies were found in 43%. HBV infection status was significantly associated with study city, age, years of injecting, use of stimulants, migration status, and homelessness; HBV vaccination status was significantly associated with study city, age, and level of education. Correct infection status was reported by 71% and correct vaccination status by 45%.
HBV seroprevalence among PWID was about five times higher than in the general population in Germany, confirming PWID as an important risk group. Targeted information campaigns on HBV and HBV prevention for PWID and professionals in contact with PWID need to be intensified. Routinely offered HBV vaccination during imprisonment and opioid substitution therapy would likely improve vaccination rates among PWID.
Hepatitis B Vaccines
2017, Plotkin's Vaccines

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Research articleEconomic Evaluation of Delivering Hepatitis B Vaccine to Injection Drug Users

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study Population

Baseline Results

Discussion

J Subst Abuse Treat

Drug Alcohol Depend

Vaccine

Vaccine

Drug Alcohol Depend

Gastroenterology

Transplant Proc

Hepatology

A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the U.S.: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents

MMWR Recomm Rep

Global overview of injecting drug use and HIV infection among injecting drug users

Aids

Estimating numbers of injecting drug users in metropolitan areas for structural analyses of community vulnerability and for assessing relative degrees of service provision for injecting drug users

J Urban Health

The estimated prevalence and incidence of HIV in 96 large US metropolitan areas

Am J Public Health

Prevalence of hepatitis B and C infection in a methadone clinic population: implications for hepatitis B vaccination

N Z Med J

Predictors of hepatitis B and C infection in injecting drug users both in and out of drug treatment

Addiction

Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses

Am J Public Health

Seroepidemiology of hepatitis B virus in a population of injecting drug usersAssociation with drug injection patterns

Am J Epidemiol

Prevalence of HIV and hepatitis B and self-reported injection risk behavior during detention among street-recruited injection drug users in Los Angeles County, 1994–1996

Addiction

Age-specific seroprevalence of HIV, hepatitis B virus, and hepatitis C virus infection among injection drug users admitted to drug treatment in 6 U.S. cities

Am J Public Health

Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA

Epidemiol Infect

HIV and hepatitis virus infections among injecting drug users in a medically controlled heroin prescription programme

Eur J Public Health

Case-reporting of acute hepatitis B and C among injection drug users

J Urban Health

Variability in the incidence of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among young injecting drug users in New York City

Am J Epidemiol

Syringe exchange and risk of infection with hepatitis B and C viruses

Am J Epidemiol

Update on adult immunizationRecommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Recomm Rep

Poor validity of self-reported hepatitis B virus infection and vaccination status among young drug users

Clin Infect Dis

Targeted hepatitis B vaccination—a cost effective immunisation strategy for the UK?

J Epidemiol Community Health

Recombinant hepatitis B vaccine use in chronic hemodialysis patientsLong-term evaluation and cost-effectiveness analysis

Nephron

Adherence to hepatitis B virus vaccination at syringe exchange sites

J Urban Health

Research article
Economic Evaluation of Delivering Hepatitis B Vaccine to Injection Drug Users