HBV in the UK: economic aspects

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1 HBV in the UK: economic aspects J Edmunds 1, R Siddiqui 1, S Hahne 2, N Gay 1, A Sutton 1, M Ramsay 2 1 Modelling & Economics Unit, HPA Centre for Infections 2 Immunisation Dept., HPA Centre for Infections 12 VHPB August 2003 Edinburgh 2005

2 Outline Review epidemiology Universal options - Economic model - Parameterisation - Results & sensitivity analyses Alternative options Discussion

3 Review of epidemiology (Hahne et al. 2004) Incidence is low in England & Wales ~670 laboratory reports / yr ~3,800 infections / yr ~ 280 chronic carriers / yr Most cases occur in risk groups Most (~95%) carriers living in UK acquired infection abroad Infections per 100,000 per year ('95-'00) age groups Males Females ~6,500 new carriers immigrate Implications Vaccination of risk groups may be more cost-effective Universal vaccination will not lead to a significant reduction in resource use Laboratory reports acute HBV (>15 yrs old) IDU Heterosexual contact Homosexual contact Other risks NRI

4 Cohort model from Fenn et al. 1996, & Anderson, unpublished Cohort of individuals followed from birth (either vaccinated or not) - Susceptible - Acute infection Cirrhosis - Acute (fulminant) liver failure Carrier - Chronic carrier - Cirrhosis Susceptible - Decompensated cirrhosis Immune - HCC - Immune Acute Acute Liver Failure - Death Costs and benefits (life-years lost) compared in two cohorts Vaccination occurs in infancy (3 doses) or adolescence (2 doses) Males and females treated separately (incidence & progression differs) Transmission ignored (benefits underestimated) Decompensated Cirrhosis HCC HBV-associated Death

5 Cohort model epidemiological & demographic parameters Incidence taken from Hahne et al. (assume stable through time) Also used South Asian estimates as part of sensitivity analysis Background mortality from ONS Most transition probabilities taken from literature Incidence chronic infection per 1,000,000 per year Age group Females Males E.g. Cirrhosis to decomp cirrhosis and HCC from Fattovich et al. 1993

6 Cohort model epidemiological & demographic parameters Little data on key progression (carrier to cirrhosis) Estimates of % per yr Progression rates chosen to give ~25% developing HCC over lifetime Do not fit observed data on time-course of progression (data from Taiwan and US) Estimated transition probabilities by fitting model to (male) data Taiwanese (higher) estimates US (lower) estimates Estimated rates for younger & older adults & when progression rates change Incidence per 100,000 carriers Incidence per 100,000 carriers Taiwan Fenn Anderson Age (years) USA Fenn Anderson Age (years)

7 Cohort model epidemiological & demographic parameters Estimated lower progression rates for females Based on difference in HBV mortality (HCC & cirrhosis) observed in The Gambia Rates 5 times lower than for men Annual incidence of HCC per 100,000 carriers Gambia data (males) Gambia data (females) Model (males) Model (females) Age (years)

8 Cohort model other assumptions (base-case) Vaccine coverage = 90% Both infant and adolescent Vaccine efficacy = 90% Both infant and adolescent Life-long immunity Adolescent vaccination given at 12 years of age Future costs and health benefits are discounted at 3.5% per annum (as recommended by NICE)

9 Cohort model cost parameters NHS perspective Base-case cost per vaccine course Infant = 15 (3 5) Adolescent = 15 (2 doses plus 5 administration) Treatment costs taken from literature & standard sources often HCV Inflated to 2003 Item Acute HBV (no transplant) Compensated cirrhosis Decompensated cirrhosis Units (per) Cost ( ) Source Episode 1,747 Struve & Giesecke (1993) Year 1,674 Grieve & Roberts (2002) Year 10,114 Grieve & Roberts (2002) HCC Year 9,729 Grieve & Roberts (2002) Fulminant hepatitis Episode 4,401 NHS Reference Costs (2003) Liver transplant Episode 50,518 Grieve & Roberts (2002)

10 Base-case results: universal infant vaccination Estimated number of HBV associated deaths and acute morbidity in cohort with and without universal infant vaccination 30 Number of Cases Decomp Cirrhosis Death HCC Death Acute hepatic failure Acute Death Taiwan-no vaccination USA-no vaccination Taiwan-infant vaccination USA-infant vaccination ~80 % reduction in HBV associated deaths

11 Base-case results: universal adolescent vaccination Estimated number of HBV associated deaths and acute morbidity in cohort with and without universal adolescent vaccination 30 Number of Cases Decomp Cirrhosis Death HCC Death Acute hepatic failure Acute Death Taiwan-no vaccination USA-no vaccination Taiwan-adolescent vaccination USA-adolescent vaccination ~60 % reduction in HBV associated chronic deaths

12 Cost-effectiveness Base-case results Cost ( ) per discounted life year gained of vaccination compared with current strategy Infant Adolescent Taiwan (high progression) USA (lower progression) 41,000 30, ,000 73,000

13 Cost-effectiveness Sensitivity to discount rate Cost ( ) per discounted life year gained of vaccination compared with current strategy. No discounting of benefits Infant Adolescent Taiwan (high progression) USA (lower progression) 41,000 30,000 5,700 6, ,000 73,000

14 Cost-effectiveness Sensitivity to cost per course Cost per Life Year Gained ( ) 160, , , ,000 80,000 60,000 40,000 20,000 - Infant (Taiwan) Infant (USA) Adolescent (Taiwan) Adolescent (USA) Cost per Vaccine Course ( )

15 Cost-effectiveness: Sensitivity to incidence Cost per life-year gained of infant vaccination compared with current strategy for UK population and South Asians Cost per Life Year Gained ( ) 160, , , ,000 80,000 60,000 40,000 20,000 - Overall, Taiwan Overall, USA South Asian, Taiwan South Asian, USA Cost per Vaccine Course ( )

16 Cost-effectiveness: Length of immunity Cost per life-year gained of infant vaccination compared with current strategy for UK population and South Asians Cost per Life Year Gained ( ) 1,400,000 1,200,000 1,000, , , , ,000 - Overall South Asian Vaccine-induced immunity (years)

17 Cost-effectiveness Adolescent vaccination less effective, but more costeffective As vaccine given closer to age at which risk is highest Assumes costs per course for infant & adolescent are the same - At 33 per course (Wallace et al.) - cost per LYG ~ 70,000 (base-case, Taiwan) South Asian incidence is higher than overall UK population More cost-effective to vaccinate South Asians (& other ethnic groups) If 40% of population with higher incidence (assumed = South Asians) Cost per LYG (infant) = 30,000 (Taiwanese progression rates) May be cost-effective to target populations with high ethnic minority population

18 Alternative (selective strategies) Prison vaccination (A Sutton) IDUs are major risk group for HBV More likely to be imprisoned than others HBV vaccination is being offered on reception to prisons in England & Wales 3 dose programme (0, 7, 21 days) Model developed to assess Coverage expected in IDUs over time Impact on HBV transmission over time

19 Parameterising the models Characteristics of IDUs - UA survey Imprisonment rates - Routine data, UA, Prison Survey Vaccine coverage - Scenario & routine surveillance Force of infection - UA survey Force of Infection (/IDU/Year) % Vaccination Coverage on Prison Reception % 60% 50% 40% 30% 20% 10% 0% Scenario A Scenario B Scenario C Year The FOI for HBV <1 1+ Injecting Career Length (yrs) All IDUs Unvaccinated IDUs

20 Model results Estimated % IDUs vaccinated through prison programme % IDU Population Receiving 2+ Doses o Vaccine 70% 60% 50% 40% 30% 20% 10% 0% Year Scenario / Age B: B: B: 30+ C: C: C: 30+ Estimated impact on acute HBV HBV Acute Infection A Scenario A Scenario B Scenario C Time (Years)

21 Discussion Low incidence of HBV in the UK Vaccination will have little impact on burden of HBV associated chronic disease Universal Infant / adolescent vaccination unlikely to be costeffective Vaccination by risk group more likely to be cost effective (perhaps geographically selective?) Improving selective programme (e.g. through prisons) has potential to reduce transmission Will adversely affect C/E of universal programmes

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