Prevention of hepatitis B virus transmission by immunization. An economic analysis of current recommendations.

OBJECTIVE: To evaluate the outcome of immunization strategies to prevent hepatitis B virus (HBV) transmission. DESIGN AND SETTING: A decision model was used to determine the incremental effects of the following hepatitis B immunization strategies in a birth cohort receiving immunization services in the public sector: (1) prevention of perinatal HBV infection, (2) routine infant vaccination, or (3) routine adolescent vaccination. MAIN OUTCOME MEASURES: Over the lifetime of the cohort, the reduction in infections and medical and work-loss costs of HBV-related liver disease were determined for each strategy and compared with the outcome without immunization. RESULTS: Prevention of perinatal infection and routine infant vaccination would lower the 4.8% lifetime risk of HBV infection by at least 68%, compared with a 45% reduction for adolescent vaccination. From a societal perspective, each strategy was found to be cost saving, but was not cost saving with respect to direct medical costs. The estimated cost per year of life saved was $164 to prevent perinatal HBV infection, $1522 for infant vaccination, and $3730 for adolescent vaccination. CONCLUSIONS: Routine vaccination of infants in successive birth cohorts to prevent HBV transmission is cost-effective over a wide range of assumptions. While economically less attractive than infant vaccination, adolescent vaccination could serve to protect those children who were not vaccinated as infants.

Trends in maternity care by graduates and the effect of an intervention.

BACKGROUND AND OBJECTIVES: Only 24% of family physicians in the United States deliver babies, a figure that declined remarkably during the decade of the 1980s. This study examines the content of practice, with regard to maternity care, of graduates of the University of California, Davis Family Practice Residency Network over the past 20 years, and the effectiveness of residency training intervention designed to increase maternity care activity among graduates. METHODS: Using a mailed survey instrument, graduates of the UC Davis Family Practice Residency Network have been periodically surveyed on practice characteristics since 1978. Using data from these surveys, maternity care and other practice characteristics of all graduates were analyzed using descriptive statistics. Data on trends in maternity care of two groups of residents who graduated a decade apart were evaluated. A separate evaluation of the two most recent graduating classes was performed to evaluate an intervention at the Network's university-based program. The program had been designed to increase the number of graduates who provide maternity care. RESULTS: Survey responses from previous graduates of the six network programs showed that only 31% included maternity care in their practices at the time of the 1991 survey. Sixty-one percent of a cohort of graduates from a 3-year period from 1979 through 1981 included maternity care upon entering practice. The 3-year cohort of residents graduating a decade later, during the years 1988-1990, had an initial participation rate in maternity care of only 37% in 1991. However, only 11% of the graduates from the university-based program in the 1988-1990 cohort made an initial decision to include maternity care in their practice. For the graduates of this program from 1991 and 1992, a period following the specific intervention, participation in maternity care increased to 50%. CONCLUSIONS: This study documents the decrease in interest in providing obstetrical services by recent family practice residency graduates when compared to graduates a decade earlier. Further, it suggests that residency programs, even with very low rates of participation in maternity care, can increase the interest and participation of residents to include these services in their practices after graduation.

Prevalence rate of hypertension among recent Southeast Asian refugees to northern California.

BACKGROUND: Little is known regarding the prevalence rate of hypertension among recent Southeast Asian refugees to the United States. METHODS: In this randomized, prospective study, four northern California counties with large Southeast Asian refugee populations were screened for the prevalence rates of hypertension and borderline hypertension. A population density method based upon 1988 census data was used to screen a representative sample of subjects from each county. Criteria for hypertension came from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. RESULTS: In all, 964 subjects were screened. We found a prevalence rate of 4.8 percent for hypertension and 10.9 percent for borderline hypertension. CONCLUSIONS: The relatively low prevalence rates of this disease can be explained by the youth of this refugee population, mean age 37.6 +/- 0.36 years, as the presence of hypertension increases with chronological age.

Will family physicians really return to obstetrics if malpractice insurance premiums decline?

BACKGROUND: The loss of family physicians as obstetrics providers during the last decade has had a significant impact on access to obstetric services, especially for rural populations. The expense of malpractice premiums has been cited often as a reason for physicians' discontinuation of this service. METHODS: Seventy-six family physicians in northern California who recently discontinued obstetrics were surveyed regarding their decisions related to obstetric practice. Those physicians who indicated that a decrease in malpractice premiums would allow them to consider resuming obstetrics were resurveyed by telephone the following year. This telephone survey occurred following a 25 percent decrease in malpractice premiums for obstetrics by the major malpractice insurance carrier for family physicians practicing obstetrics in the study area. RESULTS: Twenty-nine of the 76 physicians in the original survey who had recently discontinued obstetrics stated they would consider resuming if conditions changed. Twenty-six (90 percent) of these physicians indicated that malpractice premiums needed to change for them to consider resuming obstetrics. Following the reduction in premiums, none of these physicians reported plans to resume obstetrics or even a likelihood that they would be resuming obstetrics. CONCLUSION: This study found that family physicians who discontinued obstetrics and cited malpractice premiums as a barrier to resuming obstetrics are unlikely to resume when rates decline. This finding suggests that other issues might be equally or more important in this decision.

Prevalence of hepatitis B in an indigent, multi-ethnic community clinic prenatal population.

Perinatal infection of hepatitis B virus (HBV) from an infected asymptomatic woman to her offspring is now a preventable disease. A chart review was undertaken to document the prevalence of asymptomatic HBV infection in a high-risk, predominantly minority, indigent, and immigrant family practice clinic population and to evaluate the frequency of accepted known risk factors for those subjects with positive hepatitis B surface antigen (HBsAg) screening tests. Records for 464 pregnant women entering the prenatal program between January 1, 1983, and April 30, 1987, were reviewed. Twenty-three (5.3%) were found positive for the HBsAG, all were asymptomatic. Results of a logistic regression on multiple risk factors for HBV infection revealed that ethnicity was the sole predictor of a positive HBsAg screening test, with 13% of the Asian patients and 1% of the Latino subjects positive for HBsAg. Other historical factors such as previous sexually transmitted disease and past history of transfusion were not predictive. These results reaffirm that a screening program for asymptomatic HBV infection in selected prenatal populations can identify a significant number of infants at risk for risk for perinatal infection.

Hepatitis B in pregnancy.

Chronic infection with the hepatitis B virus can result in the development of serious liver disease such as chronic active hepatitis, cirrhosis, and hepatocellular carcinoma. Vertical transmission from infected mothers to infants is thought to be partially responsible for the high prevalence of infection in certain high-risk groups. Immunoprophylaxis using hepatitis B vaccine and hepatitis immune globulin has been highly effective in decreasing the probability of chronic hepatitis B virus infection in infants with exposure. Previously, the Centers for Disease Control recommended screening pregnant women considered at high risk of hepatitis B infection to detect newborns who would benefit from postnatal immunizations directed at preventing the HBV carrier state. Because of the poor sensitivity of high-risk criteria in distinguishing pregnant women who harbor the hepatitis B virus, these recommendations have recently been revised to call for the routine screening of all pregnant women in the United States.

Cost-effectiveness of prenatal screening and immunization for hepatitis B virus.

Perinatal transmission of hepatitis B virus is associated with substantial morbidity and mortality, yet controversy still exists regarding the value of routine screening of pregnant women in the United States and subsequent immunization of their at-risk neonates. To evaluate the cost-effectiveness of such a screening and immunization program, we developed a decision analysis model and obtained data from published reports, chart review, and a Delphi survey to determine outcome probabilities and costs. When considering direct and indirect costs, routine screening and immunization would be cost-effective at a prevalence of 0.06%, significantly lower than the national prevalence of 0.2%. At an annual national birth rate of 3.5 million births, a national policy of routine screening of all pregnant women would result in an annual net savings of more than $105 million. In the high-risk groups, as many as 140 cases of acute neonatal hepatitis and as many as 1400 cases of chronic liver disease would be prevented yearly per 100,000 pregnant women screened, at a net annual savings of as much as $765 million.

KIE: Using their own decision analysis model, with available data supplemented by the results of a Delphi survey, the authors evaluated the cost-effectiveness of routinely screening all pregnant women in the U.S. for the hepatitis B virus and then immunizing high-risk neonates. They concluded that such a routine national program is economically justified when considering the direct and indirect costs, and that it would result in an annual net savings of more than $105 million. For known high-risk groups, such a screening and immunization program is cost-effective when evaluated on the basis of only direct costs incurred, and could yield a net annual savings of as much as $765 million.

Ethnic variability in cholelithiasis--an autopsy study.

By reviewing 3,506 autopsy records to determine the prevalence of gallbladder disease among San Francisco county coroner cases for 1981 and 1982, we found an overall prevalence rate of 92.7 per 1,000. After confirming age as a significant risk factor (P

Vasectomy: views of Latinos and white men.

Vasectomy has gained wide acceptance as a safe, effective, and efficient method of birth control. Knowledge regarding the satisfaction of patients who have undergone the procedure has been well documented. In contrast, there is little data examining the attitude of men in general to the procedure or attempting to interpret these attitudes in a cultural context. Moreover, there appears to be widespread belief by providers that acceptance of the operation is poor among ethnic minorities such as Latinos and blacks. A questionnaire was distributed to 50 white and 50 Latino men at a large county hospital to determine ethnic differences in attitudes toward vasectomy. Only 54 percent of the Latino respondents stated they knew what a vasectomy was compared with 96 percent of the white respondents. Among respondents who knew what a vasectomy was, 50 percent of Latinos and 61 percent of whites stated they would not consider vasectomy in the event that they did not want more children. There was little support for the hypothesis that machismo played an important part in the negative responses by the Latino men or that fears of impotence played a role in the attitudes of both groups. This study suggests that a stronger emphasis on education regarding this procedure should be directed to the Latino male population.

PIP: A 4-page questionnaire was distributed to white and Latino men using the waiting room of the San Francisco General Hospital outpatient department in a consecutive manner (until 50 usable questionnaires were collected from each ethnic group) in an effort to document ethnic or cultural differences in attitudes toward vasectomy among lower economic class white and Latino men not considering vasectomy at the time. Respondents were limited to men ranging in age from 20-60 years. Men indicating a homosexual lifestyle were excluded. The questionnaire requested data on both current and past contraceptive practices and demographic characteristics. Approximately 40 men (27 white and 13 Latino) refused to respond to the questionnaire; 14 turned in unusable questionnaires. Combining refusals with incomplete questionnaires, which was a form of refusal, the response rate was 63% for whites and 72% for Latinos. The respondents were similar in age, income, and education. 94% of the whites and 16% of the Latinos were born in the US. The majority of the Latino foreign-born were from EL Salvador, Nicaragua, Mexico, and Puerto Rico. 22% of the white men and 66% of the Latino men were married, and 49% white and 63% Latino were Roman Catholic. The most common contraceptive method for both groups was oral contraception (OC) followed by condoms. The item about the use of the IUD was inadvertently omitted from the Spanish version of the questionnaire. 15 (42%) of the 36 white respondents answering the contraception questions reported their partners using the IUD currently or in the past. 48 (96%) of the white respondents and 27 (54%) of the Latino respondents indicated they knew the term vasectomy. The majority of the 44 white and 26 Latino respondents who indicated they knew what a vasectomy was anawered that they would not have a vasectomy even if they did not want more children. Both groups expressed an aversion to this type of surgery, and over 2/5 of respondents in both groups indicated that they would never want to be sterile. There was little endorsement of items designed to elicit the masculinity issue or the association of vasectomy with impotence. 34% of the whites and 27% of the Latinos would consider vasectomy. Latinos differed significantly from whites in that fewer endorsed noninterference as 1 of their reasons. Neither group cited greater enjoyment of sex as a major incentive for vasectomy. The study findings suggest that Latinos in the US have insufficient knowledge about vasectomy to consider it as a birth control method. White respondents were more knowledgeable about vasectomy and more aware of its positive aspects than the Latinos.