Cost–benefit comparison of two proposed overseas programs for reducing chronic Hepatitis B infection among refugees: Is screening essential?

Abstract

Background Refugees are at an increased risk of chronic Hepatitis B Virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status. Methods A cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005–2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost-benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled ‘Screen, then vaccinate or initiate management’ (SVIM) and ‘Vaccinate only’ (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars. Results The estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥ 6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n=58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal. Conclusions Chronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost-beneficial than a ‘Vaccination only’ policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death.

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers

“…Groups of migrants from these countries where hepatitis B is endemic have similar prevalence to their country of origin . There is evidence that Chinese persons in the UK experience greater mortality rate than the background population from liver cancer and that they endure reduced access to healthcare services for chronic hepatitis B (CHB) . This is a growing public health issue for receiving countries, and there is need for better disease surveillance and testing of high‐risk migrant groups as well as effective follow‐up to ensure infected persons access appropriate health care and their close contacts are appropriately protected, an issue recognized in national policies…”

Economic evaluations of HBV testing and treatment strategies and applicability to low and middle-income countries

“…Two studies evaluated HBV testing in the general population [ 23 ] and seven studies in ‘high-risk’ groups in HIC settings (all but one looked at testing in migrant or refugee populations) [ 24 – 30 ]. The studies used different methods of testing the ‘high risk groups’ including, in the clinical setting, [ 27 , 26 ] community outreach methods [ 26 ] and overseas screening [ 30 ]. Eight out of 9 studies were cost-effectiveness analyses using various outcome measures including cost per QALY gained, cost per DALY averted and cost per case screened.…”

“…There were six studies that evaluated the cost-effectiveness of screening and treatment in migrant or refugee populations in HICs [ 24 – 28 , 30 ], and one examined screening all groups classified as ‘high risk’, in accordance with Italian guidelines [ 29 ].…”

“…Another, more recent, US study by Jezwa and colleagues [ 30 ], compared the cost-benefits of two overseas programmes for reducing HBV infection among refugees. They compared two strategies i. vaccination only and ii.…”

Infectious Diseases among Refugee Children

“…Therefore, serologic testing to screen for chronic HBV infection using HBsAg is recommended for all immigrant, refugee, and internationally adopted children regardless of immunization status [23]. Studies have shown that migrant serologic screening for HBV infection is also cost effective [73,74].…”