In recent years, China has made great strides in protecting newborns from HBV infection, but many children and adolescents still remain unprotected, particularly those born before 2003. Incomplete vaccination coverage is particularly acute in rural areas (8
), so catch-up vaccination efforts in such areas could be especially cost-effective, and could help reduce regional disparities in the burden of disease caused by HBV.
Our study is the first cost-effectiveness analysis of catch-up HBV vaccination for children in an endemic country. We found that free nationwide catch-up vaccination for children and adolescents in China is likely to be cost-saving, or to cost less than $2,500 [17,000 RMB] per QALY gained for many combinations of parameter values.
Previous studies of childhood vaccination for other diseases in Asia have reported a wide range of cost-effectiveness estimates. Some vaccinations, such as those for Japanese encephalitis, are estimated to be cost-saving (39
). Vaccination of infants and children for rotavirus is estimated to be cost-saving or to cost less than about $10,000 [68,000 RMB] per DALY gained (40
). Catch-up vaccination for HBV compares very favorably with these programs.
Our analysis has several limitations. Because of limited quality-of-life studies in China, we used health-related quality-of-life data from several international studies. However, in sensitivity analysis we showed that catch-up vaccination is cost-saving even with significantly different quality-of-life estimates. We did not include the costs of time spent by vaccine recipients or their parents. We did not include the effects of catch-up vaccination on future hepatitis B incidence (as more people are vaccinated, there will be fewer infectious people to transmit the disease). Because our model ignores this effect, our analysis underestimates the value of the catch-up program. Our analysis is based on current treatment options and current costs. However, chronic HBV infection is a disease that individuals may live with for many years. As treatments for chronic HBV infection evolve, the costs and health benefits of HBV treatment may change. We showed in sensitivity analysis that higher HBV treatment costs make catch-up vaccination even more economically attractive because vaccination helps avert those costs.
A free, nationwide catch-up vaccination program for children and adolescents in China is likely to be cost-saving – and feasible. Recent pilot programs for HBV catch-up vaccination in China, including an aggressive vaccination program in Beijing (20
), have been successful in increasing vaccination coverage. In addition, a demonstration program in the remote, rural province of Qinghai provided HBV education and free vaccination to 54,680 grade school students at 331 schools between September 2006 and April 2007 (26
)(S So, manuscript submitted). The program led to an unprecedented 99.4% three-dose HBV vaccine coverage. The program was expanded in 2007-2008 to educate and provide free vaccination to the remaining 500,000 kindergarteners and grade school children in the province (26
). Replication of such school-based catch-up vaccination efforts implemented by existing provincial health department staff nationwide is likely to be both feasible and highly cost-effective, and can disseminate vaccination programs even to isolated regions of China, where the need for catch-up vaccination is particularly urgent.
The overall health and economic impacts of catch-up vaccination could be immense. Approximately 150 million children and adolescents in China ages 19 and younger are unprotected from HBV (8
). We estimate that the cost to vaccinate these children against HBV would be on the order of $423 million [2.9 billion RMB] ($2.82 [19 RMB] per three-dose vaccination series × 150 million vaccinations), and would lead to net present cost savings of almost $840 million [5.7 billion RMB] (calculated using our model) (). Even if some HBV-infected or immune children were vaccinated in such a program (thus leading to cost for extra vaccination), and even if such a one-time vaccination program incurred significant setup costs, it would still be highly cost-saving. Such catch-up vaccination could prevent as many as 8.2 million people from becoming HBV-infected, 390,000 from developing chronic HBV infection, and 65,000 from dying of HBV-related liver disease and liver cancer. This study provides strong evidential support for the new national program introduced by China in 2009 to immunize all children under 15 years old who have not received hepatitis B vaccination.
Figure 5 Estimated vaccination program costs, healthcare savings, and net savings for a hypothetical free catch-up vaccination program for children and adolescents age 1-19 in China. Negative numbers represent costs; positive numbers are net savings. All numbers (more ...)