Developed countries could pay for hepatitis B vaccination in developing countries

EDITORThe debate about the most cost effective policy for vaccination against hepatitis B in the United Kingdom has centred on the relative merits of selective and universal vaccination. ^{1 2} A more imaginative approach is worth consideration.

The current incidence of acute hepatitis B in the United Kingdom suggests that the lifetime risk of acquiring infection is 0.4% (excepting perinatal transmission, which is controllable by well implemented antenatal screening) (Public Health Laboratory Service, unpublished paper). If 6% of infected people are assumed to develop chronic carriage, the lifetime risk of carriage is roughly 1 in 4000; universal vaccination would need to protect 4000 individuals to prevent one carrier.

An infant dose of vaccine against hepatitis B virus costs about $0.75 in the poorest countries, compared with £9 ($15) in the United Kingdom. If administration costs scale equivalently, the resources required to prevent one carrier in the United Kingdom would enable 80 000 (4000x15/0.75) infants to be vaccinated in a developing country, thereby preventing 4000 people from becoming carriers (assuming the prevalence of carriage is 5%). A vaccination programme would have clear benefits for that country and might also reduce the burden of chronic hepatitis B in the United Kingdom. For example, over 105 000 United Kingdom residents were born in Bangladesh³ (population 110 million⁴), which suggests that over recent decades roughly 1 in 1000 people born in Bangladesh has emigrated to the United Kingdom. At this level of immigration and assuming 5% carriage in Bangladesh, the resources needed to prevent one carrier through universal vaccination in the United Kingdom could prevent 4000 carriers in Bangladesh, of whom four might be expected to emigrate to the United Kingdom. This suggests that it would be four times more cost effective for the United Kingdom to sponsor a vaccination programme against hepatitis B virus in Bangladesh than to introduce its own universal programme.

The global burden of hepatitis B could be reduced more cost effectively if vaccination was targeted at highly endemic areas. Many highly endemic countries, however, do not have the resources to introduce vaccination. In countries with a low incidence of infection, a high proportion of carriers are from highly endemic areas. The most cost effective approach for countries with a low prevalence to reduce their burden of chronic hepatitis B might be to sponsor vaccination programmes in developing countries. Since future migration patterns are impossible to predict, this would require global coordination to enable all highly endemic countries to introduce universal vaccination against hepatitis B virus, to the benefit of both the developed and developing world.

N J Gay, Principal scientist. 
Immunisation Division, Public Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ

W J Edmunds, Research fellow. 
Department of Biological Sciences, University of Warwick, Coventry CV4 7AL

1. Van Damme P, Kane M, Meheus A. Integration of hepatitis B vaccination into national immunisation programmes. BMJ 1997; 314: 1033-1036[Medline].

2. Mortimer PP, Miller E. Commentary: antenatal screening and targeting should be sufficient in some countries. BMJ 1997; 314: 1036-1037[Medline].

3. Office of Population Censuses and Surveys, General Register Office for Scotland. 1991 Census: ethnic group and country of birth, Great Britain. London: HMSO , 1993.

4. United Nations. 1995 demographic yearbook. New York: UN , 1997.