OCT. 19, 2009

Increased hepatitis vaccination in China would save thousands of lives, hundreds of millions of dollars, Stanford study shows

BY DAVID ORENSTEIN

Aaron Kuo-Deemer description of photo

Although Chiina aims to give all newborns free hepatitis B vaccines, this child getting the shot and millions more fell through the cracks. A documentary about a pilot test of the vaccination program in China is available here.

A massive new program in China to provide “catch-up” inoculations against hepatitis B to more than 100 million unvaccinated children could prevent millions of infections, save tens of thousands of lives and return twice as much in savings to the Chinese economy as the program costs, according to a new study by engineering and medical researchers at Stanford University.

Hepatitis B is a pandemic in much of East Asia because it is easily transmitted from mother to child by blood or between sexual partners by other bodily fluids as well as blood. Meanwhile, the symptoms, until resulting diseases becomes life-threatening, are subtle, said Samuel So, MD, professor of surgery and the Lui Hac Minh Professor at Stanford, who is one of the study’s senior authors. Although many patients can fight off the virus, up to 300,000 a year die in China from hepatitis B-related liver cancer and other liver diseases.

“That means more people die in China each year from hepatitis B-related liver diseases than HIV/AIDS, tuberculosis and malaria combined,” said So.

In the paper posted online Oct. 19 by the journal Hepatology, the researchers predict that if China spent $423 million to inoculate an estimated 150 million unvaccinated children ages 1 to 19, it would produce a net return in the economy of $840 million from lower health-care costs. Moreover, their model indicates that inoculations would prevent 8 million infections along with 65,000 deaths. China’s program, designed by officials who have seen the Stanford research, will inoculate all unvaccinated children under age 15.

“It’s a virus that can be prevented with a safe and cheap vaccine, so stopping it is really a question of global public health action,” said Margaret Brandeau, PhD, professor of management science and engineering at Stanford and the other senior author of the study. She and So guided the work of the study’s lead author, management science and engineering doctoral student David Hutton, who developed the model used in the study.

China has provided free hepatitis B vaccines to all newborns since 2002, but millions of poor and rural youngsters have nevertheless not been inoculated. Children born before that initiative went into effect could benefit from “catch-up” shots as well. The vaccine has been available since 1986.

So has been working with Chinese and world health officials for years to combat hepatitis B. The Asian Liver Center at Stanford, which So directs, worked with Chinese officials in 2006 and 2007 to demonstrate the feasibility and effectiveness of a widespread catch-up vaccination program. In the remote Qinghai province, local governments, schools and the ALC provided more than 550,000 children with a free regimen of the vaccine’s three doses, as well as comprehensive education about the disease.

“Besides protecting future generations from this disease, one major impact of this is an effort to eliminate discrimination,” said So. “People who become chronically infected, often called hepatitis B carriers, are widely discriminated against in China. A lot of schools from kindergarten on up will test the children, and if they are positive, they will not be admitted.”

So’s experience and judgment about the need to expand vaccinations in China — and screening of immigrant populations in the United States — have made him an influential advocate within the world public health community. But there has been little data to guide policymakers.

“If you want a government to change a policy, you need to have cost-effectiveness data, but there was none,” So said.

In 2006, through a mutual student, Daniel Tan, So connected with Brandeau, whose specialty in the field of operations research is developing mathematical and economic models of programs to combat infectious diseases. Brandeau and Hutton began gathering data and building a model to determine the cost effectiveness of various measures to slow the spread of hepatitis B.

“As engineers, we could make a real difference by creating this model and proving, or disproving, that it’s a good thing to do,” Brandeau said.

In the study, the authors factored in many variables including the cost of the vaccine; likely infection, disease and mortality rates; current health-care costs in China; the vaccine’s effectiveness (about 95 percent); and vaccine compliance rates. The study also models what would happen if currently unvaccinated children are not inoculated.

The bottom line result, based on the most likely values of the variables, shows that the program will meet the international standard of “highly cost effective,” meaning that each additional year of life saved will cost less than the per capita gross domestic product in China, about $2,500.

The model allows for manipulating any of the variables to determine the program’s effectiveness under different conditions. What if, for instance, the price of the vaccine doubled? What if the virus became more virulent? In all but the most extreme cases, the program remains cost effective, Hutton said.

The research can be applied to other nations with similar hepatitis B pandemics, such as Vietnam, Myanmar, Laos and Cambodia, Hutton said.

“It would be easy to take data from a different country and put it into this model,” said Hutton, who recently won an award from the Institute for Operations Research and the Management Sciences for his hepatitis B modeling research.

The team performed the China study with no external funding.

“This is just something we thought was the right thing to do,” said So.

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