Five-test universal HBV screening strategy most cost-effective in China

A nationally representative study led by researchers from the University of Hong Kong and Xi’an Jiaotong University Health Science Centre, China, has shown that a five-test (ie, serum HBsAg/HBsAb/HBeAg/HBeAb/HBcAb) universal screening strategy in people aged 18–70 years is the most cost-effective hepatitis B virus (HBV) screening option in China.

“Initiation of five-test universal HBV screening in 2021 could identify 86.8 percent of Chinese adults infected with HBV, and could prevent liver-related death in 3.46 million Chinese individuals,” the researchers highlighted. “It is now the prime time to start universal HBV screening, which will improve the HBV diagnostic rate in China.” [Lancet Glob Health 2022;10:e278-e287]

Only 19 percent of individuals infected with HBV are diagnosed in China because current HBV screening eligibility is limited to couples undergoing premarital testing, pregnant women, and individuals with clinical symptoms. [Lancet Gastroenterol Hepatol 2018;3:383-403; Bull World Health Organ 2019;97:230-238] Following reformation of medical insurance policies, China’s HBV guidelines for primary care recommend universal HBV screening for all individuals aged ≥18 years. [Chin J Gen Pract 2021;20:137-149] “[However,] how to implement a universal screening programme … remains unclear. We [therefore] evaluated the cost-effectiveness of universal HBV screening and identified optimal screening strategies in China,” the researchers noted.

To calculate the incremental cost-effectiveness ratio (ICER; ie, cost/quality-adjusted life-years [QALY] gained) of various screen strategies, they constructed 180 screening scenarios based on years of screening initiation (2021, 2026 and 2031) and adult age groups (18–70 years). Children and adolescents aged <18 years were not considered because of the high coverage rate of HBV vaccination (95 percent) since 2002.

Based on a willingness-to-pay threshold of 3 times China’s gross domestic product (GDP) per capita (USD 30,828), all universal screening strategies were cost-effective vs the current screening strategy. If universal screening started in 2021, the most cost-effective strategy would be the five-test strategy for individuals aged 18–70 years (ICER, USD 18,295/QALY gained), followed by the two-test strategy (ie, HBsAg/HBsAb) for those aged 18–70 years (USD 2,783/QALY gained) and the two-test strategy for those aged 18–60 years (USD 1,950/QALY gained).

Notably, the five-test strategy for those aged 18–70 years remained cost-effective, but to a lesser extent, if delayed by 5–10 years. If started in 2026 and 2031, the ICER increased to USD 20,183/QALY gained and USD 23,123/QALY gained, respectively. The reduced cost-effectiveness of HBV screening is associated with an increasing proportion of young people who have received HBV vaccination.

“Diagnosis of HBV [in 2021] at a younger age substantially reduces the risk of liver-related complications,” the researchers concluded. “Initiating universal HBV screening in China as soon as possible is highly recommended for prevention of complications.”

However, some commented that it could be difficult to implement a universal screening strategy in a large population, such as China. [Lancet Glob Health 2022;10:e792]

“Mass screening for COVID-19 has been used for pandemic control in Wuhan, for example, in a short time. [Also,] population-based cervical cancer screening has been implemented worldwide with good population impacts and cost-effectiveness,” the researchers explained. [Lancet Glob Health 2022;10:e793]

The proposed universal HBV screening strategy in China is consistent with the Global Health Sector Strategies (GHSS) released by WHO in June 2022. Action 65 in GHSS mentioned that national guidelines should define testing strategies according to epidemiology in the country, and should tailor testing to the needs of the affected population in different settings. [https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies]