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Economic Analysis of a Child Vaccination Project Among Asian Americans in Philadelphia, Pa
Robert R. Deuson, PhD, MS, MSHS;
Kimberly Goodnow Brodovicz, MPH;
Lawrence Barker, PhD;
Fangjun Zhou, PhD, MS;
Gary L. Euler, DrPH, MPH
Arch Pediatr Adolesc Med. 2001;155:909-914.
ABSTRACT
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Objective To ascertain the cost-effectiveness and the benefit-cost ratios of a
community-based hepatitis B vaccination catch-up project for Asian American
children conducted in Philadelphia, Pa, from October 1, 1994, to February
11, 1996.
Design Program evaluation.
Setting South and southwest districts of Philadelphia.
Participants A total of 4384 Asian American children.
Interventions Staff in the community-based organizations (1) educated parents about
the hepatitis B vaccination, (2) enrolled physicians in the Vaccines for Children
program, and (3) visited homes of children due for a vaccine dose. Staff in
the Philadelphia Department of Public Health developed a computerized database;
sent reminder letters for children due for a vaccine dose; and offered vaccinations
in public clinics, health fairs, and homes.
Main Outcome Measures The numbers of children having received 1, 2, or 3 doses of vaccine
before and after the interventions; costs incurred by the Philadelphia Department
of Public Health and the community-based organizations for design, education,
and outreach activities; the cost of the vaccination; cost-effectiveness ratios
for intermediate outcomes (ie, per child, per dose, per immunoequivalent patient,
and per completed series); discounted cost per discounted year of life saved;
and the benefit-cost ratio of the project.
Results For the completed series of 3 doses, coverage increased by 12 percentage
points at a total cost of $268 660 for design, education, outreach, and
vaccination. Costs per child, per dose, and per completed series were $64,
$119, and $537, respectively. The discounted cost per discounted year of life
saved was $11 525, and 106 years of life were saved through this intervention.
The benefit-cost ratio was 4.44:1.
Conclusion Although the increase in coverage was modest, the intervention proved
cost-effective and cost-beneficial.
INTRODUCTION
AMONG CHILDREN in the United States, hepatitis B virus (HBV) infection
disproportionately affects those in Asian and Pacific Islander (API) populations.1, 2, 3, 4, 5, 6, 7
Many of these children reside in households of first-generation immigrants
from countries where hepatitis B is of high or intermediate endemicity. Until
the mid-1990s, HBV infection rates averaged 1% to 2% per year during the first
decade of life for API children. In 1982, the US Public Health Service Immunization
Practices Advisory Committee first began to encourage hepatitis B vaccination
of APIs.8 Starting in the early 1990s, some
cities conducted programs to increase coverage among API children. These resulted
in an average of 7% to 11% of the unvaccinated children older than 1 year
completing the hepatitis B vaccination series per year.9
In cities that did not implement these special efforts, only 0.7% to 2.6%
were being vaccinated per year.9 Overall, by
1995, fewer than 10% of the estimated 1 million API children in the United
States born from 1984 through 1993 had received the hepatitis B vaccine.1 So, in October 1995, the Advisory Committee on Immunization
Practices recommended hepatitis B vaccination for these high-risk children
born after 1983.1
To our knowledge, the cost implications of catch-up hepatitis B vaccination
interventions have not been evaluated for any racial or ethnic subgroups,
including the Asian American populations in whom the impact of disease is
the greatest. This report documents the cost-effectiveness and the benefit-cost
ratios of a federally funded community-based education and outreach project
designed to increase hepatitis B vaccination coverage among Asian American
children in Philadelphia, Pa; the program targeted children aged 2 to 13 years.
Because the percentage of vaccines administered by the private sector is increasing,
we also explore the impact on the cost-effectiveness and the benefit-cost
of conducting such a project at private sector prices. The cost-effectiveness
and benefit-cost ratios of this project are compared with those of routine
vaccination efforts being conducted nationwide.
SUBJECTS AND METHODS
THE PROJECT
The Asian/Pacific Islander Hepatitis B Immunization Demonstration Project
1994-1996, in Philadelphia, was conducted with a grant from the Centers for
Disease Control and Prevention.10 This 2-year
education and outreach project started in the fall of 1994 and was conducted
by the Immunization Program of the Division of Disease Control, Philadelphia
Department of Public Health (DDC), which subcontracted with 2 local community-based
Asian American organizations: Intercultural Family Services, Inc, and the
Southeast Asian American Mutual Assistance Associations Coalition. Before
and during this project, no other promotional hepatitis B vaccination efforts
for API children were conducted in Philadelphia. Data from this study have
been used to assess the effectiveness of a range of interventions in increasing
vaccination coverage among API children, aged 2 to 13 years, living in the
United States and to assess the impact of the interventions on the knowledge
and practices of parents and physicians.11
STUDY POPULATION
A database of 4384 Asian American children aged 2 to 13 years residing
in the south and southwest districts of Philadelphia was created by the DDC
and used during this intervention to track the children's vaccination status.
To locate all Asian American children in the community, names were gathered
from the School District of Philadelphia, the Philadelphia Department of Public
Health District Health Centers, the Children's Hospital of Philadelphia, Mercy
Health Plan (a health maintenance organization), the 2 community-based organizations,
and a Buddhist temple. Preintervention hepatitis B vaccination coverage was
ascertained by reviewing the immunization records of these children. Also,
before intervention activities began, community organization staff conducted
a survey of 212 households. The survey showed that 90% of parents in the estimated
1600 households with children in the study group were born outside the United
States; most were from Cambodia or Vietnam. This survey reinforced the need
for education, as about 90% of the parents said that they knew nothing about
HBV. Only 58% of those who reported knowledge of hepatitis B said they knew
about hepatitis B vaccine. Based on the assessment of the public health department,
most parents in this community used the District Health Centers for their
children's primary care.
Surveys of 73 of the 107 primary care physicians in the communities
(survey instruments are available from the authors) showed that slightly more
than 50% were white, 29% were Asian American, and 11% were African American.
Most of the Asian American physicians were Vietnamese, Asian Indian, or Chinese,
with at least 5 other ethnicities represented. About 54% of patients seeing
Asian American physicians were Asian Americans, compared with 8% of patients
seeing non–Asian American physicians. About two thirds of the physicians
appeared well versed concerning hepatitis B disease, prevalence, and risk
to Asian Americans and about vaccine effectiveness and safety. However, only
about 50% understood the risk of HBV transmission during an invasive medical
procedure, and few (24%) demonstrated knowledge of the risk of developing
chronic HBV infection after being infected at birth.11
About half of the physicians offered 2 or fewer of the following vaccination-promoting
services: early morning, evening, and weekend office hours; walk-in vaccinations;
use of reminder systems; and vaccination without requiring a physical examination.
Vaccination reminders were offered routinely by only one quarter of these
physicians.
INTERVENTIONS
Intervention activities were conducted from March 11, 1995, through
February 11, 1996. During this time, the computerized database of children
enrolled in the study was used to track immunizations administered and to
generate reminder letters for each child due for a vaccine dose. Intervention
activities were culturally and linguistically specific to the primary Asian
ethnicities. Staff educated parents about hepatitis B vaccination at 4 community
health fairs and during 100 educational sessions attended by more than 300
adults at retail locations, schools and day care centers, churches, and public
parks and buildings, on street corners, and in outdoor markets. They also
arranged about 250 in-home educational forums attended by 800 adults to distribute
information and answer questions. In addition to reminder letters, communication
materials included brochures, posters, and an educational videotape. In the
south Philadelphia communities, staff also conducted door-to-door outreach,
and nurses provided in-home vaccination to 95 children in families who did
not respond to the reminder letters.
Weighted results from a postintervention survey of a stratified random
sample of 217 parents indicated that 69% remembered receiving a reminder letter
and 52% remembered receiving a brochure about HBV; 16% attended a health fair
and 9% an in-home forum. In the south Philadelphia community, 45% recalled
receiving a home visit. The estimated percentage of the study population that
knew about hepatitis B and hepatitis B vaccine increased from 11% and 6%,
respectively, in the 2 communities before the intervention to 32% and 29%,
respectively, after the intervention. The low level of formal education in
this population (20% had less than a first-grade level and 78% had less than
a high school level) may have limited the effectiveness of the brochures and
reminder letters.
The Vaccines for Children program in Philadelphia began midway through
the intervention, and a campaign was conducted to enroll private physicians
who served the target population. The Vaccines for Children program is a federal
program that provides vaccines to physicians at no cost for eligible low-income
families. At the start of the campaign, none of the 13 physicians who provided
childhood immunizations and served 90% of the target population in the intervention
area were enrolled; after the campaign, all 13 physicians had enrolled.
DOSES ADMINISTERED
During the intervention, 2363 doses of the hepatitis B vaccine were
administered. Most doses were administered by public health clinics (1603
[68%]), at the 4 health fairs sponsored by the DDC (601 [25%]), or in the
home by a public health nurse (95 [4%]). The remaining vaccine doses (64 [3%])
were administered in hospitals, private offices, or offices associated with
health maintenance organizations. At the end of the intervention, the number
of children in the community who had received only the first dose in the series
increased by 385 (Table 1), the
number who had received the first 2 doses in the series increased by 206,
and the number who had completed the series increased by 522. The number of
children who had received at least 1 dose of vaccine increased by 1113.
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Table 1. Marginal Changes in Vaccination Status of 4384 Participants
Following the Intervention*
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MEASUREMENT OF INTERVENTION COSTS
To implement the interventions, the DDC and the community-based organizations
incurred costs for design, education, outreach, and vaccination. Costs for
design included salary and benefits for DDC and community organization personnel.
The development of the computerized tracking system by the DDC is included
in design. Costs for education included salary and benefits for community
organization personnel to develop educational materials, conduct education
sessions for parents, and conduct the Vaccines for Children physician enrollment
campaign. Education costs also included salary and benefits for DDC staff
to update the tracking system and to generate reminder letters. Printing and
postage, health fair advertising, and transportation were included in education
expenses. Outreach costs included salary and benefits for DDC and community
organization personnel, transportation, and the salaries of nurses who provided
in-home vaccinations. Vaccination costs included vaccine (purchased at the
federal contract price by the DDC), the supplies for vaccine administration
at health fairs and in homes, and the salaries of the nurses who administered
vaccine at the health fairs. All costs are reported in 1995 dollars.
COST-EFFECTIVENESS ANALYSIS OF INTERMEDIATE OUTCOMES
Cost-effectiveness ratios for intermediate outcomes are useful for evaluating
the present costs of a project. For example, the cost of immunizing one child
in this project might be compared with the equivalent for another city's intervention.
To examine the cost-effectiveness of intermediate outcomes, 6 cost-effectiveness
ratios were calculated: cost per child receiving any dose; cost per dose delivered;
cost per completed series; and 3 ratios for cost per additional child rendered
seroprotected (antibodies to the hepatitis B surface antigen of  10 mIU/mL),
which vary according to the assumption used for the seroprotection rate after
receiving a single dose of vaccine. To estimate the number of 1-dose recipients
rendered immune, the number of additional children in the population who received
only the first dose was multiplied by 0.20, 0.35, and 0.50.12, 13, 14, 15, 16
Added to each of these 3 estimates were 85% of the additional number of children
covered with the first 2 doses and 95% of the additional number of children
covered with all 3 doses; these are accepted estimates of second- and third-dose
seroprotection rates.12, 13, 14, 15, 16
A range of values was available for some cost estimates. To account
for this, we performed a stochastic risk analysis using the best data available
for input distributions. Because the output showed little variability (the
2.5th and 97.5th percentiles were within about 10% of one another), cost uncertainty
was ignored and all calculations were done deterministically.
COST-EFFECTIVENESS AND BENEFIT-COST ANALYSES OF LIFETIME OUTCOMES
Measures of long-term outcomes are vital for understanding if money
invested in an intervention will be repaid by benefits that accrue over years.
We quantified long-term outcomes in 2 ways: discounted cost per discounted
year of life saved; and benefit-cost over the life expectancy of the children
in this population, when costs of hepatitis B infections or costs savings
from averted infections will become apparent.
We computed 4 base-case estimates of discounted cost per discounted
year of life saved and 4 base-case estimates of lifetime benefit-cost, from
combinations of 3% and 5% discount rates17
and estimated 30% and 60% infection rates among susceptible persons. These
discount rates are the standard used for economic analysis in the United States,
and these infection rates are estimated to be within the conservative range
of rates likely to prevail among first-generation immigrant Asian American
children in unvaccinated populations. The use of a discount rate to calculate
net present value of the project reflects project or program administrators'
and planners' time preference for outcomes and costs.
The net present value of benefits was quantified through the following
assumptions: vaccination produces protective levels of antibody in 20% to
50%, 85%, and 95% of vaccinees after 1, 2, and 3 doses, respectively12, 13, 14, 15, 16;
60% of infections are asymptomatic and 40% are symptomatic; 15% of those infected
as adolescents are at risk of chronic liver disease; those with asymptomatic
chronic infection incur no lifetime disease costs or adverse outcomes; those
with chronic liver disease were equally distributed among the chronic liver
disease categories (chronic persisting hepatitis, chronic active hepatitis,
cirrhosis, and primary hepatocellular carcinoma); and the outcome for those
with chronic persisting hepatitis did not include death.
The costs of infection included direct (medical) and indirect (work
loss) costs. Direct medical costs included the inpatient, outpatient, scanner,
and laboratory costs for acute and chronic HBV infection. Indirect costs included
medical visits and loss of earnings due to HBV-related illness and due to
premature mortality caused by chronic active hepatitis, cirrhosis, and primary
hepatocellular carcinoma.
All cost data in the model come from the Bureau of Labor Statistics,
the Bureau of the Census, the MEDSTAT Marketscan database, refereed publications,
interviews of experts in the field, and Centers for Disease Control and Prevention
data.18, 19, 20, 21
We used a spreadsheet program (BENCOST) developed at the Centers for Disease
Control and Prevention and based on the work of Margolis et al.3
To calculate discounted cost per discounted year of life saved, the
net present value of costs incurred in the project was divided by the discounted
years of life saved by the intervention. To calculate benefit-cost, the net
present value of benefits was divided by the net present value of costs incurred
in the project.
For this intervention, 100% of the vaccine supply was purchased at public
sector prices. However, since the percentage of vaccines delivered by the
private sector in Philadelphia is increasing (to 40% in 1999), adjustments
must be made in the analysis to account for price differences between vaccines
purchased in the private and public sectors. Two hypothetical scenarios are
examined: 60% and 100% of the vaccines purchased in the private sector.
For the discounted cost per discounted year of life saved and the benefit-cost
ratio (for the actual project and the 2 hypothetical scenarios), we performed
sensitivity analyses to explore the effect of the assumptions for discount
rate and infection rate on the estimates of discounted cost per discounted
year of life saved and the benefit-cost ratio. We computed ratios for all
combinations of 3% and 5% discount rates and 15% to 75% infection rate, at
increments of 15%. We used a broad range of infection rates to account for
the potential variability resulting from differences in baseline vaccination
levels and risk levels within countries of origin and the United States and
from different ages at immigration.
RESULTS
COVERAGE
The number of additional children protected by vaccination was estimated
from the known numbers receiving 1, 2, and 3 doses in Table 1 and from estimates of vaccine seroprotection rates. At 20%
first-dose seroprotection, the estimated number of additional immune vaccine
recipients is 748 (17.1%). At 35% and 50% first-dose seroprotection, the estimates
are 806 (18.4%) and 864 (19.7%), respectively.
INTERVENTION COSTS
At the time of the intervention, the federal contract price for the
vaccine was $7.09 per dose for children younger than 11 years and $7.75 per
dose for children 11 years and older. The private sector price was $16.17
per dose for children younger than 11 years and $18 per dose for children
11 years and older.
Intervention costs totaled $268 660 and are summarized by task
in Table 2. The percentage distribution
across major groupings of cost centers was as follows: salary, benefits, overhead,
and transportation, 87%; vaccines and supplies, 8%; and printing, postage,
and advertising, 5%. The percentage distribution of costs by task is shown
in Figure 1.
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Table 2. Intervention Costs*
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Federally funded program and vaccination costs of the Asian/Pacific
Islander Hepatitis B Immunization Demonstration Project 1994-1996. The project
was conducted in Philadelphia, Pa.
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COST-EFFECTIVENESS OF INTERMEDIATE OUTCOMES
The cost per child and per dose was $64 and $119, respectively. Under
the assumptions of 20%, 35%, and 50% first-dose seroprotection rates, the
costs per immunoequivalent patient were $375, $348, and $325, respectively.
Finally, the cost per completed series was $537.
COST-EFFECTIVENESS AND BENEFIT-COST ANALYSES OF LIFETIME OUTCOMES
In the base-case analysis, years of life saved by this intervention
ranged from 106 (30% infection rate) to 213 (60% infection rate); the discounted
cost per discounted year of life saved ranged from $5763 (60% infection rate
and 3% discount rate) to $27 691 (30% infection rate and 5% discount
rate). Benefit-cost ratios ranged from 2.08:1 (30% infection rate and 5% discount
rate) to 8.88:1 (60% infection rate and 3% discount rate) (Table 3).
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Table 3. Years of Life Saved, Cost-effectiveness Ratios, and Benefit-Cost
Ratios for Lifetime Outcomes, 15% to 75% Infection Rates, and 3% and 5% Discount
Rates*
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In the sensitivity analyses of the actual intervention (100% of vaccines
purchased at the federal contract price), years of life saved ranged from
53 to 266, as the assumed infection rate increased from 15% to 75%. The discounted
cost per discounted year of life saved ranged from $4610 (75% infection rate
and 3% discount rate) to $55 381 (15% infection rate and 5% discount
rate) (Table 3). The benefit-cost
ratios ranged from 1.04:1 (15% infection rate and 5% discount rate) to 11.10:1
(75% infection rate and 3% discount rate). All of these benefit-cost ratios
are more than the threshold point (1.0) at which benefits cover costs exactly.
The results of the sensitivity analyses are similar for the 2 hypothetical
scenarios. Assuming that 60% of the vaccines are purchased at the higher private
sector price, the discounted cost per discounted year of life saved ranged
from $4836 to $58 135; for 100% purchased in the private sector, the
discounted cost per discounted year of life saved ranged from $4988 to $59 964.
Benefit-cost ratios for the 60% private purchase scenario ranged across the
infection rates from 0.99:1 to 10.58:1; and for the 100% private purchase
scenario, from 0.96:1 to 10.25:1. For both hypothetical scenarios, only at
the lowest infection rate did the ratios decline slightly below the threshold
point, indicating a small net cost rather than a net benefit.
COMMENT
The intervention was labor intensive, with relatively high intervention
costs and a relatively low marginal change in vaccination status; however,
it proved cost-effective and cost-beneficial for all ratios reported in Table 3. Moreover, if education, outreach,
and planning costs are held constant, examining each of the ratios suggests
that if more children completed the 3-dose series, cost per completed series
would decline appreciably, since 91% of the costs of the intervention are
not related to the vaccination itself and would be spread among more children.
Assuming higher coverage (60% receiving at least 1 dose, 50% at least 2 doses,
and 40% all 3 doses) in the base-case scenario, model simulations (not shown
herein) suggest that 242 years of life would be saved by the intervention,
that the cost per discounted year of life saved would be $5530, and that the
benefit-cost ratio would likely be 9.25:1 for the targeted population.
The increase in hepatitis B vaccination rates among the target population
in this study has been attributed to the effects of the intervention for 2
reasons: (1) the increases observed in other cities before implementation
of special catch-up efforts have only been about 1%9
and (2) no other catch-up efforts were conducted in Philadelphia before or
during this project.
These economic models may be used to evaluate intermediate- and long-range
outcomes of past or ongoing projects as shown in this study and may also be
useful for planning and policy making. In addition, planners may conduct sensitivity
analyses—as we did for our point estimate long-range model—to
test how strongly the outcomes depend on assumptions. This is particularly
useful in cases for which input values cannot be precisely defined. In the
case of this study, because most of the ratios calculated in the sensitivity
analyses (for the base case and for the 2 hypothetical vaccine purchase scenarios)
show a net benefit, we may conclude that the results of the model are not
qualitatively affected by differing assumptions about discount rates and infection
rates or by the difference in public and private sector purchase prices. In
this investigation, more detailed accounting of nonvaccine program costs would
have allowed more in-depth analysis of the impact of administering some or
all of the vaccines in the private sector. Because hepatitis B vaccine accounted
for only 8.7% of the total cost of the program, and we only varied the cost
of vaccine (but not other costs, ie, community education, outreach, and planning),
the analyses of the impact of private vs public sector administration of vaccine
are somewhat limited.
Economic analyses of projects such as this are feasible and practical,
because recipients of most grants are required to provide detailed records
of tasks, costs, and outcomes for the grant-financed program. Such data can
be used as shown herein to help policy makers compare programs to assess their
relative effectiveness and to maximize the return on investment by selecting
the most effective programs.
While this analysis results from the accurate measurement of all program
costs, and reflects the epidemiological conditions prevailing in Philadelphia,
caution should be exercised in comparing the cost analyses of this study with
others. For example, in this study, we calculated ratios using years of life
saved, rather than quality-adjusted life years, a frequently used weighting
procedure that quantifies the extent to which illness or disability lowers
the quality of life.22 In addition, we did
not consider the cost of adverse events due to the vaccination (because these
are rare23) and we did not use estimates of
wage and workforce participation rates specific to Philadelphia. Analyses
of similar programs that use dissimilar methods or sources of data may have
limited comparability.
In general, costs for this intervention compare favorably with other
life-saving health interventions, despite a relatively low increase in hepatitis
B vaccine coverage. Tengs et al24 reported
the cost-effectiveness of 587 life-saving interventions in the United States.
The median medical intervention cost per year of life saved was $19 000.
Hence, while the intervention appears modest by some measures (ie, 25.4% more
children received 1 or more doses and 11.9% completed the hepatitis B vaccine
series), the base-case intervention costs of $11 525 per year of life
saved falls well below the median (more cost-effective) reported by Tengs
et al.
The cost-effectiveness of the catch-up hepatitis B vaccination efforts
reported herein may be compared with the cost-effectiveness of infant vaccination
efforts to control the ongoing transmission in the United States of the bacterium Bordetella pertussis. Some aspects of the diseases and
the vaccine programs are similar enough to permit comparison. For example,
despite widespread use of the vaccine, the incidence of pertussis has averaged
about 3700 cases per year since 1980. As with hepatitis B, adolescents and
adults are an important reservoir for B pertussis
and are often the source of infection for infants and susceptible children.
The diphtheria and tetanus toxoids with acellular pertussis vaccine is given
in a primary series of 4 doses administered by the age of 18 months, followed
by a booster. The benefit-cost ratios for the diphtheria and tetanus toxoids
with acellular pertussis vaccine series from a societal and health care system
perspective were 27:1 and 8.5:1, respectively.25
Recent articles published in the American Journal
of Public Health26 and in the ARCHIVES27, 28 indicate that the measurable impact
of most public health interventions is usually relatively small, and often
statistically nonsignificant. In this instance, even though the intervention
only increased series-complete coverage by 12 percentage points by the end
of the 12 months, the impact was cost-effective and cost-beneficial. Nationwide,
further improvement in the efficiency of outreach methods within API communities
by community-based organization/public health department partnerships could
increase API child hepatitis B vaccination coverage while reducing program
costs and increasing benefit-cost ratios.
AUTHOR INFORMATION
Accepted for publication March 16, 2001.
We thank Barbara Watson, MD, James Lutz, MHA, and Robert Levenson, MBA,
for their contributions to this study; and Mary McCauley, NTSC, for improving
the original document to its present form.
From the National Immunization Program, Centers for Disease Control
and Prevention, Public Health Service, US Department of Health and Human Services,
Atlanta, Ga (Drs Deuson, Barker, Zhou, and Euler); and the Philadelphia Department
of Public Health, Philadelphia, Pa (Ms Brodovicz). Dr Deuson is now with Merck
& Co, Inc, Whitehouse Station, NJ; and Ms Brodovicz is now with Merck
Research Laboratories, Blue Bell, Pa.
Corresponding author and reprints: Robert R. Deuson, PhD, MS, MSHS,
Merck & Co, Inc, One Merck Dr, PO Box 100, Mail Stop WS1B-72, Whitehouse
Station, NJ 08889 (e-mail: robert_deuson{at}merck.com).
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