School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 1P8, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 1P8, Canada.
Vaccine. 2019 Mar 7;37(11):1467-1475. doi: 10.1016/j.vaccine.2019.01.070. Epub 2019 Feb 13.
Hepatitis A virus (HAV) causes acute liver infection and is spread through the fecal-oral route. Travel to countries in HAV-endemic regions (e.g., Asia and Latin America) is a well-described risk factor for infection. Currently, Ontario publicly funds hepatitis A vaccination for some populations at high risk of HAV infection but not for all travellers to endemic countries. The objective of this study was to determine the cost-effectiveness of expanding publicly funded HAV vaccination to people planning travel to HAV-endemic regions, from the Ontario healthcare payer perspective.
We conducted a cost-utility analysis comparing an expanded high-risk publicly-funded hepatitis A vaccination program including funded vaccine for travellers to endemic regions to the current high risk program in Ontario. A Markov state transition model was developed, including six possible health states. Model parameters were informed through targeted literature searches and included hepatitis A disease probabilities, utilities associated with health states, health system expenditures, and vaccine costs. Future costs and health outcomes were discounted at 1.5%. Primary outcomes included cost, incremental cost-effectiveness ratio (ICER) and quality adjusted life years (QALYs) over a lifetime time horizon. We conducted one-way, two-way, and probabilistic sensitivity analysis.
The expanded high risk HAV vaccine program provided few incremental health gains in the travel population (mean 0.000037 QALYs/person), at an incremental cost of $124.31. The ICER of the expanded program compared to status quo is $3,391,504/QALY gained. The conclusion of the model was robust to changes in key parameters across reasonable ranges.
The expanded vaccination program substantially exceeds commonly accepted cost-effectiveness thresholds. Further research concerning possible cost-effective implementation of high-risk travel hepatitis A vaccination should focus on a more integrated understanding of the risk of acquiring hepatitis A during travel to endemic regions (e.g., purpose, length of stay).
甲型肝炎病毒（HAV）可引起急性肝感染，通过粪-口途径传播。前往甲型肝炎流行地区（如亚洲和拉丁美洲）旅行是感染的一个明确风险因素。目前，安大略省为某些高风险甲型肝炎感染人群提供公共资金资助的甲型肝炎疫苗接种，但不为所有前往流行地区的旅行者提供。本研究旨在从安大略省医疗保健支付者的角度，确定扩大公共资金资助的甲型肝炎疫苗接种范围，以覆盖计划前往甲型肝炎流行地区旅行的人群的成本效益。
我们进行了一项成本效益分析，比较了包括为前往流行地区的旅行者提供资助疫苗的扩大高危人群公共资助甲型肝炎疫苗接种计划与安大略省目前的高危计划。建立了一个马尔可夫状态转移模型，包括六个可能的健康状态。模型参数通过有针对性的文献检索提供，包括甲型肝炎疾病的概率、与健康状态相关的效用、卫生系统支出和疫苗成本。未来的成本和健康结果以 1.5%的贴现率贴现。主要结果包括终生时间范围内的成本、增量成本效益比（ICER）和质量调整生命年（QALY）。我们进行了单向、双向和概率敏感性分析。
在旅行人群中，扩大高危人群甲型肝炎疫苗接种计划仅提供了很少的增量健康收益（人均 0.000037 QALY），增量成本为 124.31 美元。与现状相比，扩大计划的 ICER 为每获得 1 QALY 需花费 3,391,504 美元。该模型的结论在合理范围内的关键参数变化下是稳健的。
扩大疫苗接种计划大大超过了通常可接受的成本效益阈值。进一步研究应侧重于更全面地了解前往流行地区旅行时感染甲型肝炎的风险（例如，目的、逗留时间），以确定高风险旅行甲型肝炎疫苗接种的可能成本效益实施。
