Current issues of ACP Journal Club are published in Annals of Internal Medicine

Health Economics

Screening newborns plus universal vaccination of 10-year olds was the most cost effective hepatitis B vaccination strategy

ACP J Club. 1993 May-June;118:93. doi:10.7326/ACPJC-1993-118-3-093

Source Citation

Bloom BS, Hillman AL, Fendrick AM, Schwartz JS. A reappraisal of hepatitis B virus vaccination strategies using cost-effectiveness analysis. Ann Intern Med. 1993 Feb 15;118:298-306.



To determine the clinical and economic consequences of 3 alternative vaccination strategies in 4 populations for preventing hepatitis B virus (HBV) infection.


Decision analysis based on published data, expert opinion, and health insurance data.


United States.


4 target populations were studied: newborns; 10-year-old adolescents; a high-risk adult population with a HBV infection incidence of 5% per year; and the general adult population (12 to 50 years old). A mixed population strategy was also studied. Each analysis followed a cohort of 10 000 persons for 3 consecutive 10-year periods.


3 different HBV prevention strategies were compared: no vaccination, universal vaccination, and screening with selective vaccination. The mixed population strategy included prenatal screening for evidence of active HBV infection, administration of HBV vaccine and hepatitis B immune globulin to the newborns of mothers who test positive, and vaccination of all children at age 10 with a booster 10 years later.

Main cost and outcome measures

Deaths prevented, years of life saved, and number and costs of cases prevented. Information on HBV incidence and prevalence, clinical course, and management of acute illness and chronic sequelae was obtained from the literature and a panel of experts. Costs were obtained from Blue Cross/Blue Shield and local pharmacies.

Main results

The incremental cost per year of life saved for each vaccination strategy was compared with no vaccination. The cost per year of life saved was $3066 (discounted for costs and not for outcomes) to $38 632 (discounted for both) for newborns with a universal vaccination strategy, $13 938 to $97 256 for adolescents, and $54 524 to $257 418 for adults. The cost per year of life saved with or without screening was similar for both newborns and adults. The cost per year of life saved for the mixed strategy of vaccinating babies born to mothers with positive screening tests and vaccinating all children at age 10 and again 10 years later was $375 to $3695. There was a net saving with vaccination of high-risk adults with or without screening.


For the general population, a strategy of screening newborns combined with universal vaccination of 10-year-old adolescents had the lowest cost per year of life saved.

Source of funding: SmithKline Beecham.

For article reprint: Dr. B.S. Bloom, University of Pennsylvania, 2L Nursing Education Building, Philadelphia, PA 19104-6020, USA. FAX 215-573-5315.


Despite the availability for over a decade of a safe and effective vaccine against hepatitis B, the burden of disease in North America continues to increase. The failure of current screening and vaccination policies has led to a series of consensus recommendations in favor of universal vaccination. The disease is uncommon and the vaccine expensive, however, which renders an economic evaluation of vaccination policy vital.

The study by Bloom and colleagues adds to existing knowledge in several ways. First, it confirms and updates the findings of earlier studies that current policies are economically attractive, such as the vaccination of adult high-risk groups and maternal screening and selective vaccination of high-risk newborns. Second, it substantiates the findings of a recent study showing that universal neonatal vaccination is moderately economically attractive (1).

The authors' ultimate recommendation, that universal vaccination of adolescents (a new policy) be added to high-risk vaccination of newborns (an existing policy), is somewhat more difficult to evaluate. A direct comparison is not provided in terms of incremental costs and incremental benefits between the proposed combination and the current high-risk strategy for newborns. Estimates of vaccine administration costs seem low. Favorable cost-effectiveness ratios for universal vaccination of adolescents alone are contingent on accepting the authors' view that health benefits should not be discounted, a defensible but minority viewpoint (2).

The study provides more impetus to the movement toward expanded hepatitis B immunization. Evidence confirming the long-term efficacy of the vaccine in reducing the serious sequelae of HBV infection and the declining costs for vaccine associated with widespread vaccination would substantially enhance the economic attractiveness of all expanded immunization policies.

Murray Krahn, MD
Toronto General Hospital Toronto, Ontario, Canada