Comparing Proposed Hepatitis B Screening Policies for Refugees Newly Arriving to the United States Open Access

Jazwa, Amelia (2013)

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Background: Chronic Hepatitis B Virus (HBV) infection is a serious and costly disease that affects over 2 million people worldwide. Refugees arriving to the United States are at an increased risk of chronic HBV infection due to high prevalence rates in their countries of origin and high-risk settings in refugee camps. In addition, refugees are at increased risk of serious sequellae from chronic HBV infection because they are not screened for the virus overseas and may reside for years in the United States without knowing their infection status.

Methods: A cohort of 26,548 refugees who arrived in Minnesota and Georgia between the years 2005-2010 was analyzed for prevalence of chronic HBV infection. Logistic modeling was used to determine differences in odds of disease by age, sex, and arrival year. This prevalence information was used to perform a cost-benefit analysis of two overseas screening policies: 'Screen and vaccinate' and 'Vaccinate only'.

Results: The estimated period prevalence of chronic HBV infection was 6.8% for the overall arriving refugee population and 7.1% in those ages 6 and older. Females had 0.66 times the odds of being HBsAg positive compared to males, controlling for age and arrival year (p<0.001). The odds of being HBsAg positive increased 1.01 times with each year of age, controlling for sex and arrival year (p<0.001). The 'Screen and vaccinate' policy was cost-beneficial compared to the 'Vaccinate only' policy. While the up-front costs of the 'Screen and vaccinate' policy are higher ($154,083.72 vs. $73,757.88, n=58,538 refugees), the 'Screen and Vaccinate' policy displays a positive net benefit, even after only 5 years from policy initiation.

Conclusions: Refugees arriving to the United States bear a moderate-to-high burden of chronic HBV infection. The main benefits of the 'Screen and vaccinate' policy come from early medical management of chronic HBV infection. An overseas screening policy to reduce the effects of long-term sequellae can reduce costs for the refugee and society as a whole. Further, while not quantified, controlling chronic HBV improves quality of life for resettled refugees.

Table of Contents


Biology, Transmission, and Clinical Features...2
Chronic HBV Infection Epidemiology among Refugees in the United States...2
Cost Burden of Chronic Hepatitis B Virus Infection...4
Screening and Vaccination Processes...5
Pilot Study and Population Focus...6


Study Population...9
Original Data Sources...9
Secondary Data Sources...11
Epidemiologic Analysis...12
Economic Analysis...14

Decision Tree...17
Markov Model...19
Cost-Benefit Analysis...20

Ethical Considerations...21


Epidemiology of HBsAg Positivity in Refugees Arriving to the US...22
Cost-Benefit Analysis...26


Areas for Further Study...33

Appendix A. Variables from Minnesota and Georgia Datasets Used in Chronic Hepatitis B Virus Infection analysis...41
Appendix B. Decision Tree Model from TreeAge Pro Used for Cost-Benefit Analysis of 'Screen and vaccinate' and 'Vaccinate only' Policies...43
Appendix C. Parameter Estimates for Chronic HBV Prevalence and Annual Disease Transition Probabilities for Treatment-related Progression and Natural Progression of Disease for Cost-Benefit Model...45
Appendix D. Cost Estimates for Chronic HBV Infection Overseas Screening and Domestic Treatment for Cost-Benefit Model...46
Appendix E. Logistic Modeling of HBsAg positivity by gender, age, and arrival year, ages 6+, years 2005-2010...47
Appendix F. Net Benefits of 'Screen and vaccinate' compared to 'Vaccinate only' Program, 90% and 30% domestic screening in 'Vaccinate only' Program...47

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