Krahn M, Guasparini, R (1998) Costs and Cost-Effectiveness of a Universal Hepatitis B Vaccination Program. J Public health, p 1638-1644?


The researcher’s main goal is to evaluate the cost-effectiveness and the cost of a school based universal vaccination program. This program targets grade six students in the vaccination against hepatitis B.  The researchers carried out a cost-effectiveness analysis, and a descriptive cost study on a vaccination program. The program was in British Columbia between 1994 and 1995. Schools have these programs on hepatitis B vaccination since 1992. The vaccination is provided to grade six students.  The researcher’s goal was to measure the cost of vaccine administration, of the vaccine and the total cost the program. In carrying out the measurement, the researchers used the valid Markov model in calculating the program’s cost effectiveness.

They found out that the cost of vaccine per student is approximately $44, and the cost of vaccine administration was $24. Each person’s net cost was $9 in consideration of the productivity cost. The net saving per person was found to be $75. Each year, the gained marginal cost for a person is at $2100. The researchers found out that, in the United States, the universal vaccination directed to the adolescents, was much more attractive compared to other countries. These are countries that have little Hepatitis B incidences. These are countries with an incidence rate below three in every 100, 000 cases on a yearly basis. The researchers conclude that the provision Hepatitis B vaccine to schools in North America is at a reasonable cost. In this region, the vaccination for the adolescents is economically attractive. This is because it experiences high incidence rate of Hepatitis B.  This analysis indicates that, the vaccination of adolescents is appropriate since many adolescents face the risk of infection of Hepatitis B virus.

The research question for this study is based on the need to establish the economic attractiveness of vaccinating adolescents and school going children. The study aims to find out the actual cost of a large scale vaccination program for schools in North America. It aims to estimate this program’s economic attractiveness. The study was conducted when the Canadian advisory groups had opted to leave children, and non –high –risk neonates vaccinated. Instead they opted to select the adolescents for universal vaccination.   The research design used involved two components to be analyzed.  First is on the cost- effectiveness analysis based on the analytic model on Markov cohort. The second component is based on a descriptive cost study.  The cost study approach is based on the estimation of unit cost and utilization for the 1994 data.  The cost effectiveness analysis is carried out on societal perspective.  The data received was used in the calculation of the health state in relation to hepatitis B.   The calculation considered the exclusion and inclusion of production cost. The life years and future cost were calculated with a discount of 3%.

The vaccination is given to all the sixth graders and the program personnel were responsible in administering the vaccination.  The cost of the vaccine in each does is that of the 1994 contract price that was paid by the ministry of Health of British Columbiana. The health ministry had to estimate the cost of supplies and pamphlets of the surveillance. The time for the provision of activity reports is also calculated based on the report provided by the public health nurses in the areas of the province except the Greater Vancouver region.  The time for vaccine administration further includes the time for teaching activities and counseling. The time spent by the nurses is also calculated. Other calculations involve the time spent by the clerical and aide   in their survey in nine different health units.  The benefits and salaries are included in the estimation of the cost of clerical and nursing services that the ministry of health pays.  This further includes the isolation, transportation and other overhead cost.The cost effectiveness analysis is estimated by considering two different strategies.  The first   strategy involves the one utilized by grade six programs. The eligible students selected for the vaccination were   provided with three vaccinations at no cost.  The alterative strategy   is that which signified the period before the enactment of this policy. This strategy involves the lack   of any vaccination to the adolescents, but vaccination to children born by carrier mothers and maternal screening.

The alternative strategy also considered vaccination provided to   individual at high risk. The Markov cohort analysis is the decision model.  The outcomes are viewed as the various health states, and over time the changes of these health states are modeled.  The Markov cohort model comprises of five different health states that relate to hepatitis B immunization. It further had a set of six different health states relating to chronic and acute outcomes of hepatitis (Poorolajal, et al 2010). The resource utilization is assessed based on three techniques. First is the filling of questionnaires by four different herpetologists. They are to describe scenarios for four chronic and four acute states of hepatitis.  The charts showing the outpatient and inpatient care is then reviewed. These charts show the reports provided by 148 individuals suffering six diagnoses related to hepatitis. Lastly the researchers reviewed all the admissions to Canadian Hospital  related  to  hepatitis B. these are  admissions of  a period of ten years by use  of  Health Information  of the Canadian Institute for  hospital discharge database.

Perspective assumed

Kahn and his colleagues (1998) have assumed the perspective that in the evaluation of risk factors relating to Hepatitis B Virus among the infected people, it is essential to design strategies to control the disease. This study supports the universal hepatitis B vaccination directed towards the adolescents and school going children for its economic attractiveness.    They also assume the fact that all estimates of effects and costs are accompanied by uncertainties and sources can have a wide range of categories.  Such an assumption arises from the model of   uncertainty, parameter uncertainty and uncertainty based on a generalization.  The way policy makers make decisions are generally based on these three categories of uncertainties. Kranh’s and colleagues work is generally based on parameter uncertainty that is caused by two main aspects. First is that the sample variation based around variables estimates is used on the calculation of CER  such as adherence rates, unit costs and an intervention’s efficacy (Hung, & Chen 2009).

The second contributing factor for this uncertainty is based on the lack of an agreement concerning value judgment needed in the analysis of CEA, such as, the choice of an appropriate rate of discount.  This kind of uncertainty occurs from an overlap arising from the point of estimating the ratio of incremental cost effectiveness before the universal hepatitis vaccine program and after as denoted in the movement from b1 to b2. This assumption indicates that the movement from b1 to b1 is more likely to occur than the movement to ab1.  Mostly using such an interpretation, one will never be 100% surge in that one can never actually say that the best stagey is to move from b1 to ab1 and not to b2.  Such an assumption makes it hard to interpret the possibility of correlation in the effects and costs in the intervention program (Tan-Torres, Balttussen, et al, 2003).

Assumptions, cost and effectiveness measures

The model used by the researchers predicts that 4,100 out of 46, 000 students at the grade six levels were at risk of getting Hepatitis B infection without the vaccine. This means about 8.9% of the British Columbian students were at risk of contracting this infection if they are not vaccinated.  Another 0.789% (400) of them will be at risk of becoming chronically infected. Therefore, to the researchers the program will play a significant role in preventing acute infections by 63% and chronic infections by 47%.  The researchers also found out that the program is likely to eliminate death causes by various forms of hepatitis B infection by 51%.  Generally, the program will prevent all form s of events that can be avoidable to individuals aged above 12 years.

The future health expenditure is further assumed that it will decease to $35 per an adolescent from $44.  Therefore, the program, will result to cost saving of about $75 per each vaccinated individual. The cost –effectiveness analysis for the researchers is based on the clinical outcomes. The  researchers assumed that the  incremental cost effective ratio for this program is less than $50000  in a life year, and this is economically attractive  (23) based on the direct cost alone,  the results of vaccination for an increasing costs of $2,135 and  $161 for every chronic and  acute   infection  under prevention,  respectively, and amount of  $2,145  for every added  life year. The consideration for the researchers is that the program is economically attractive due to the idea that the cost of each event prevented is reasonable. Therefore, the cost of a life year achieved is within the economic attractiveness thresholds. The program will lead to the generation of net cost savings when there is the consideration of productivity loss (De Wit, G & Welte, 1999).

Strengths and weakness:

The researchers have managed to present evidence that indicate the economical attractiveness of the universal vaccination against hepatitis B to adolescents and school going children.  This program can be repeated in many other regions facing the burden of high cost of vaccination and hepatitis infection. The use of the universal vaccination against this infection becomes economically attractive to such regions and leads to an increase cost saving when there is consideration to the loss of productivity and other related mortality and morbidity cases related to hepatitis B virus.  The authors have also managed to present three conditions under which the results can be replicated in other regions. These aspects are that there are increasing incidences of new hepatitis B infection, second is that there health care cost of treating the infection is high and lastly is that there is a high cost of vaccination. Such regions with similar aspects stand a high chance of benefiting from the universal vaccination program and these programs will be economically attractive (Krahn, Guasparini, Sherman, & Detsky 1998).

Based on the difference in health care cost and the disease epidemiology, the authors have managed to suggest that the adolescents and school, going children are the appropriate group to receive the vaccination. This is due to the idea that the adolescents are the ones at a much a higher risk and is more economical to vaccinate them. The results of the study provide accurate calculation of the cost of vaccine delivery within a large scale population. The validated prognostic model utilized by the researchers unlike the ones used earlier might have a much higher degree of prognostic accuracy and clinical fidelity.   The study suffered from some methodological shortcomings as seen in the use of primary data for estimation of the program’s effectiveness, compliance and program’s cost in opposition to using secondary data or expert opinion. The researcher’s analysis is neither based on supportability optimistic assumption nor the unduly pessimistic assumptions on the vaccine efficacy duration. The analysis has further not managed to resolve the controversial debate on the right age that a person should be vaccinated for hepatitis B virus infection.


De Wit, G & Welte, R (1999) economic evaluation of hepatitis B vaccination strategies. Retrieved from

              On November 14, 2012

Hung H, Chen T (2009) Probabilistic cost-effectiveness analysis of the long-term effect.Vaccine.  Vol 27, 6770–6776

Krahn M, Guasparini, R, Sherman, M and Detsky A (1998) Costs and Cost-Effectiveness of a Universal. Is J Public health, p 1638-1644?

Poorolajal J, Majdzadeh R, Haghdoost A, & Fotouhi A (2010) Long-term protection provided by hepatitis B vaccine and need for booster dose. Vaccine, Vol 28, p 623–631

 Tan-Torres, E, Baltussen T et al, 20003; WHO guide to cost effectiveness analysis. Retrieved from

              On November 14, 2012  

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