Economic Analysis of Promotion of Hepatitis B Vaccinations Among Vietnamese-American Children and Adolescents in Houston and Dallas

Hasymptomatic,epatitis B virus (HBV) infection is most often acute, and resolves without serious long-term effects.1 However, 70% to 90% of infants infected at birth, 30% to 50% of children infected between 1 year and 5 years, and 5% to 10% of people infected after the age of 7 years will develop chronic HBV infection, which often results in chronic hepatitis, cirrhosis, or primary hepatocellular carcinoma.1 Studies have shown that 1 of every 4 people with chronic HBV infection eventually dies of cirrhosis or liver cancer.2 Among children in the United States, HBV infection disproportionately affects those in Asian and Pacific Islander (API) populations, including Vietnamese.3–9 Among US Viet-namese adults, the prevalence of those ever infected with HBV is as high as 80%10 compared with 3.8% in US whites.9 Studies also have documented chronic HBV infection rates ranging from 7% to 14%11–14 among US Vietnamese adults compared with 0.2% in US white adults.15 Vietnamese-American males have the highest liver cancer incidence rate of any racial/ethnic group (41.8 per 100 000), 11 times that among white males,16 and 80% of their liver cancers are caused by HBV infection.17 Hepatitis B vaccination of API infants and children was first recommended in 1982 by the US Public Health Service Advisory Committee on Immunization Practices (ACIP) as a 3-dose series administered over 6 months.18 By 1995, fewer than 10% of the estimated 1 million API children in the United States born in 1984 through 1993 had received the hepatitis B vaccine (HepB) 3-dose series.3 Consequently, in October 1995, “catch-up” vaccination for most API children born after 1983 was recommended.3 In 1997, the ACIP recommended universal vaccination of all children through age 18. These and other increasingly stronger ACIP recommendations have made it easier to provide HepB to API children in the United States. However, effectively conveying the message that HBV infection is a serious problem that can be easily prevented by 3 doses of vaccine to parents of many different cultural and language groups and their physicians, has been a difficult and slow process.19 A previous study of a hepatitis B catch-up vaccination program among an ethnically diverse community of APIs in Philadelphia found that their catch-up intervention was cost-effective and cost beneficial, although the increase in coverage was modest.20 This Philadelphia intervention was conducted in 2 communities with a diverse Southeast Asian population and primarily used community outreach with some donated media assistance. The intervention used a personalized approach in that the investigators formed a registry with the names and addresses of each targeted child and used in-home education and vaccination to accomplish their goals. In this article, we document the cost-effectiveness (CE) and the benefit-cost ratios of a federally funded project designed to raise hepatitis B vaccination coverage among 1 API ethnic group—Vietnamese-Americans—in the Houston and Dallas areas using 2 types of intervention.21–23 One intervention was a community mobilization strategy similar to most local public health interventions without a professionally developed media campaign. A coalition of local leaders conducted educational outreach via registration of physicians as Vaccines for Children (VFC) providers, distribution of referral lists of VFC providers, distribution of health education brochures, health fairs, targeted mailings, educational presentations, and use of free local media. The other intervention was media education that relied only on a professionally developed advertising campaign with billboards, prime-time radio spots, newspaper articles and ads, brochures and calendars, and telephone hot-line. As reported elsewhere, both intervention strategies resulted in statistically significantly increased vaccination coverage among Vietnamese-American children aged 3 to 18 years and increased their parents’ knowledge about hepatitis B.23 Since 1994 when the first ACIP catch-up recommendation was made, the Centers for Disease Control and Prevention (CDC) had monitored progress using the birth cohorts 1984–1993.24 Thus, we chose to confine our economic evaluation to these birth cohorts. The 1984–1993 birth cohorts are a subset of the cohorts analyzed in our companion epidemiology article.23 Here our economic focus is on intervention-related costs, such as vaccine/administration fees, parent time lost, personnel costs, and subcontractor payments. Other important costs and benefits, such as preventing pain and suffering among family and friends of the ill patient are difficult to quantify, and are not included here. Our analyses and conclusions here must be viewed in this context.