Nicholas J Beeching has succinctly summarized the situation with regards hepatitis B in the UK (1). It is however unclear how he arrived at the conclusion that universal immunization should be preferred in Britain. We have serious concerns about this. An assessment of the data provided, shows an unfavourable cost: benefit ratio. The annotation has drawn heavily on one reference (2). In this paper we will also rely on the same source for most of our calculations, so it is not just a matter of using one reference against another, to arrive at slightly different conclusions.
We are told that 430 persons develop hepatitis B related carcinoma in the UK each year and that Hepatitis B costs the NHS &#65533;26m-&#65533;375m per year (UK &#65533; = US $ 1.8).(1) The reference quoted by the author (2) elaborates how this wide range of costs has been arrived at. The lower-limit figure was based on an eight year study in Tayside, Scotland. It projects the resources consumed each year, by the 45,700 people, with diagnosed chronic hepatitis B in all of the UK. The costs for treating patient with chronic hepatitis B in Germany or the USA are very different. The upper-limit figure &#65533;375m, is the cost of treating all the hepatitis B cases in the UK, at the German rate! Obviously the figure of &#65533;26 m is a more realistic estimate of costs in the UK and will be used in this letter.
In his rapid response, Peter MB English calculates that using a hexavalent vaccine that includes hepatitis B (at a marginal programme cost of &#65533;5/dose of hepatitis B) to immunise the UK birth cohort of 695,500 each year, would result in an additional bill of only &#65533;10m. Does this prove that universal immunization is more cost beneficial?
To evaluate this, it is important to look at the proportion of &#65533;hepatitis B related problems&#65533; that can be prevented by universal immunization in the UK. There 7500 new cases of chronic infection with hepatitis B virus in the UK who are consuming these resources but only 4% of these are from among persons born in the UK(2). The remainder are immigrants who have been infected overseas and cannot be helped by the programme of universal immunization in the UK. Thus universal immunization can bring about only a cost reduction of 4% of the total expenditure of &#65533;26m. This works out to be a saving of &#65533;1m per year.
Most hepatitis B infection in the UK occurs in adolescence and it is several years afterwards, that they develop cirrhosis and hepatocellular carcinoma. With a neonatal immunization programme the benefit may be seen more than 40 years later.(3) Using a conservative discounting rate of 3% (4) the discounting factor for 40 years is 0.2. If the benefit is discounted, this works out to savings of &#65533; 0.2m per year . The cost savings through universal immunization with Hepatitis B vaccine is there for not &#65533; 375m nor even &#65533; 26m but &#65533; 0.2m per year and it is against this, that the cost of immunization must be compared.
This is of course only an economic argument. The decision to go for universal immunisation need not be based on economic arguments. Italy undertook universal immunization although a cost effectiveness assessment performed by Demicheli and Jefferson showed an unfavourable cost-benefit ratio.(5) We also know from literature that the phenomenon of ignoring cost benefit analysis is not of recent origin. George Bernard Shaw in the preface of The Doctor&#65533;s Dilemma (6) under the subheading The Perils of Inoculation wrote a follows: &#65533;Suppose it were ascertained that every child in the world could be rendered absolutely immune from all disease during its entire life by taking half an ounce of radium to every pint of its milk. The world would be none the healthier, because not even a Crown Prince - no, not even the son of a Chicago Meat King, could afford the treatment. Yet it is doubtful whether doctors would refrain from prescribing it on that ground. The recklessness with which they now recommend wintering in Egypt or at Davos to people who cannot afford to go to Cornwall, and the orders given for champagne jelly and old port in households where such luxuries must obviously be acquired at the cost of stinting necessaries, often make one wonder whether it is possible for a man to go through a medical training and retain a spark of common sense&#65533;
References 1. Beeching NJ Hepatitis B infections BMJ 2004; 329: 1059-1060
2. Foundation for Liver Research. Hepatitis B: out of the shadows. London, Foundation for Liver Research, 2004. www.ucl.ac.uk/liver- research/hepatitis-report.pdf (accessed 18 November 2004)
3. Acharya AK, Murray CJL. Rethinking discounting of health benefits in cost effectiveness analysis. http://www.sussex.ac.uk/Units/economics/dp/arnab1.pdf accessed on 18/11/2004)
4. Evans D Hurley B. The application of economic evaluation in the Health Sector. The state of art. The Journal of International Development 1995;7:503-24
5. Demicheli V, Jefferson TO. Cost-benefit analysis of the introduction of mass vaccination against hepatitis B in Italy. J Public Health Med. 1992;14:367-75.
6. Shaw GB. The Doctor&#65533;s Dilemma. London Penguin Books 1957 pp33