Question

• In children, is routine immunization for hepatitis A compared to targeted immunization of high risk groups, more cost effective?

Clinical Bottom Lines

1. Mass immunization was not found to be cost-effective in this study.¹
   
2. This is in agreement with current CDC recommendations, which recommend mass immunization only for areas with an incidence > 20 per100,000 and targeted immunization for travelers to areas of intermediate or high endemic rates of Hepatitis A.²

Summary of Key Evidence

1. 1997 economic analysis finds the added cost to the health care system of mass vaccination of children to be about $8,300 at an incidence of 0.1%.¹
   a. The selective immunization approach for an adolescent would produce a cost savings if the incidence approached 4%.
   b. Strengths of the study include broad societal perspective, data based decision tree, and sensitivity analysis.
   c. Weaknesses include estimates of immunization costs that are high, because the authors assumed three shots, not the currently recommended two and underestimated the length of immunity provided by the vaccine. Disease costs appear too low; a case of fulminant hepatitis requiring liver transplant is estimated at less than $11,000.
2. The ACIP (Advisory Committee on Immunization Practices) is in agreement with the CDC recommendations, but also recommends considering immunization of children in areas where the incidence of hepatitis A is >10 per 100,000.³
3. JAMA reports a study in which 66.2% of an estimated 44,982 children in Butte County, CA received at least one shot of Hep A vaccine. The incidence decreased from 57 cases in 1995 to 4 in 2000. The incidence of 1.9 per 100,000 was the lowest for any county in the state.⁴
   

Additional Comments

• The incidence of Hepatitis A is much less in the US (0.01%) than it is in Spain (0.1%-0.2%)
• Hepatitis A doesn't typically lead to chronic liver disease
• Hepatitis A is much like varicella in that it is much less likely to be severe in children than adults.
  

Citation

1. Arnal J. Cost effectiveness of hepatitis A virus immunisation in Spain. Pharmacoeconomics 1997; :12:361-373.
2. http://www.cdc.gov
3. Prevention of Hepatitis A through Active or Passive Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999; 1:48(RR-12):1-37.
4. Averhoff F. Control of hepatitis A through routine vaccination of children. JAMA 2001; 286:2968-73.
   
   

CAT Author: Jan Rourk, MD

CAT Appraisers: John Frohna, MD

Date appraised: July 22, 2002