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Otimização do emprego de recursos econômicos para vacinação contra hepatite B em profissionais da área de saúde

Resumos

Com o objetivo de racionalizar o emprego de recursos econômicos em programas de vacinação contra hepatite B, em profissionais da área de saúde, foram estudados dois aspectos distintos: necessidade ou não de triagem sorológica pré-vacinação e viabilidade da utilização de doses reduzidas de vacina por via intradérmica (ID). A análise econômica de custo-minimização demonstrou que com prevalência de imunes na população a ser vacinada superior a 11% (o que ocorreu em nosso estudo apenas no grupo de funcionários) passou a ser economicamente viável a triagem sorológica, diferentemente do grupo de alunos e médicos, nos quais a vacina sem triagem foi a melhor opção estratégica. Quanto ao esquema a ser utilizado, o emprego de três doses por via intramuscular (IM) (esquema A) foi comparado com dois esquemas alternativos: 1) esquema B, utilizando primeira dose via ID e duas via IM e 2) esquema C, empregando as duas primeiras doses via ID e a terceira via IM. Após a terceira dose, as taxas de soroconversão nos esquemas Ae B (92% e 93%, respectivamente) e os títulos médios geométricos de antiHBs (1278 Ul/L e 789,6UI/L) foram semelhantes entre os dois grupos, e apresentaram diferença significante em relação ao esquema C, demonstrando que esquemas alternativos podem ser custo-efetivos.

Hepatite B; Imunização; Vacina contra HBV; Profissionais da área de saúde; Economia em saúde


In order to optimize the employment of financial resources to be allocated for hepatitis B vaccination programs involving health care workers', two different aspects were studied: the need of a prevaccination screening and the efficacy of low-doses schedules of HBV vaccine by the intradermal (ID) route. The economical analysis (a cost- minimization study) showed that when the prevalence of immune individuals is higher than 11% it is more cost-effective to perform prevaccination screening. This situation was obsemed in the employees group. For students and doctors vaccination without screening was the best approach. Regarding the schedules, 3 doses of HBV vaccine by the intramuscular (IM) route (group A) were compared to first dose by the ID route and second and third doses by the IM route (group B) and to first and second doses by the ID route and the last dose by the IM route (group C). After the third dose, soroconversion rates in groups A and B (92% and 93%, respectively) and geometric mean titers of antiHBs (1278 UI/I and 789.6 UI/l) were similar, and both were different from group A (p< 0.05), showing that alternative vaccination schedules may be cost-effective.

Hepatitis B; Immunization; Hepatitis B vaccine; Health care workers; Health economics


ARTIGOS

Otimização do emprego de recursos econômicos para vacinação contra hepatite B em profissionais da área de saúde

Maria Lucia Gomes Ferraz; Patrícia Marinho de Oliveira; Virgínia Maria Figueiredo; Vitorio Luis Kemp; Adauto Castelo Filho; Antonio Eduardo Benedito Silva

Endereço para correspondência Endereço para correspondência: Prof a Maria Lucia Gomes Ferraz. R. Machado Bittencourt 413/81, Vl. Clementino, 04044-001 São Paulo, SE Tel: (011) 549-1711; Fax: (011) 572-5945.

RESUMO

Com o objetivo de racionalizar o emprego de recursos econômicos em programas de vacinação contra hepatite B, em profissionais da área de saúde, foram estudados dois aspectos distintos: necessidade ou não de triagem sorológica pré-vacinação e viabilidade da utilização de doses reduzidas de vacina por via intradérmica (ID). A análise econômica de custo-minimização demonstrou que com prevalência de imunes na população a ser vacinada superior a 11% (o que ocorreu em nosso estudo apenas no grupo de funcionários) passou a ser economicamente viável a triagem sorológica, diferentemente do grupo de alunos e médicos, nos quais a vacina sem triagem foi a melhor opção estratégica. Quanto ao esquema a ser utilizado, o emprego de três doses por via intramuscular (IM) (esquema A) foi comparado com dois esquemas alternativos: 1) esquema B, utilizando primeira dose via ID e duas via IM e 2) esquema C, empregando as duas primeiras doses via ID e a terceira via IM. Após a terceira dose, as taxas de soroconversão nos esquemas Ae B (92% e 93%, respectivamente) e os títulos médios geométricos de antiHBs (1278 Ul/L e 789,6UI/L) foram semelhantes entre os dois grupos, e apresentaram diferença significante em relação ao esquema C, demonstrando que esquemas alternativos podem ser custo-efetivos.

Palavras-chave: Hepatite B. Imunização. Vacina contra HBV. Profissionais da área de saúde. Economia em saúde.

ABSTRACT

In order to optimize the employment of financial resources to be allocated for hepatitis B vaccination programs involving health care workers', two different aspects were studied: the need of a prevaccination screening and the efficacy of low-doses schedules of HBV vaccine by the intradermal (ID) route. The economical analysis (a cost- minimization study) showed that when the prevalence of immune individuals is higher than 11% it is more cost-effective to perform prevaccination screening. This situation was obsemed in the employees group. For students and doctors vaccination without screening was the best approach. Regarding the schedules, 3 doses of HBV vaccine by the intramuscular (IM) route (group A) were compared to first dose by the ID route and second and third doses by the IM route (group B) and to first and second doses by the ID route and the last dose by the IM route (group C). After the third dose, soroconversion rates in groups A and B (92% and 93%, respectively) and geometric mean titers of antiHBs (1278 UI/I and 789.6 UI/l) were similar, and both were different from group A (p< 0.05), showing that alternative vaccination schedules may be cost-effective.

Keyworks: Hepatitis B. Immunization. Hepatitis B vaccine. Health care workers. Health economics.

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REFERÊNCIAS BIBLIOGRÁFICAS

1. Alwood GK, Pearce NE, Fracp CRL, Milne A, Lucas CR, Krugman S. Low dose hepatitis B vaccination in children. New Zeland Medical Journal 99:47- 49,1986.

2. Bergamini F, Zanetti A. Immunogenicity of yeast- derived hepatitis B vaccines in young adults. Postgraduate Medical Journal 63-137-138,1987.

3. Brink NS, Murray AB. Intradermal vaccination against hepatitis B in a group of medical students. South African Medical Journal 79.653-654,1991.

4. Centers for Disease Control. Inadequate immune response among public safety workers receiving intradermal vaccination against hepatitis B - United States, 1990-1991. MMWR Morbidity and Mortality Weekly Report 40:569-572,1991.

5. Clarke JA, Hollinger FB, Lewis E, Russell LA, Miller CH, Huntley A, Flynn NM. Intradermal inoculation with Heptavax B - immune response and histologic evaluation of injection sites. Journal of the American Medical Association 262:2567- 2571,1989.

6. Dienstag JL, Stevens CE, Bhan AK, Szmuness W. Hepatitis B vaccine administered to chronic carriers of hepatitis B surface antigen. Annals of Internal Medicine 96:575-579,1982.

7. Eisenberg JM.A guide to the economic analysis of clinical practices. Journal of the American Medical Association 262: 2879-2885,1989.

8. Expanded Programme on Immunization (EPI). Global advisory group, 13th meeting. Cairo, Egypt 1-26,1990.

9. Ferraz MLG, Silva AEB, Kemp VL, Cruz CN, Guimarães RX. Assessment of the immunological response to hepatitis B vaccine in health care professionals. Revista da Associação Médica Brasileira 38:5-8,1992.

10. Foutch PG, Carey WD. Diagnostic limitations of antibody to hepatitis B surface antigen. New England Journal of Medicine 310:1671,1984.

11. Frazer IH, Jones B, Dimitrakakis M, Mackay IR. Intramuscular versus low dose intradermal hepatitis B vaccine - Assessment by humoral and cellular immune response to hepatitis B surface antigen.The Medical Journal of Australia 146:242- 245,1987.

12. Goudeau A, Dubois F, Dubois MC, Louq C, Mazert MC. Immunogenicity of low dose (1.25 and 0. 31 Mg) hepatitis B vaccine. Lancet 2:1091-1092, 1984.

13. Hadler SC. Hepatitis B virus infection and health care workers. Vaccine 8 (suppl 1): s24-s28,1990.

14. Hadler SC, Francis DI! Maynard JE, Thompson SE, Judson FN, Echenberg DF, Ostrow DG, Penley KA, Altman NL. Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. New England Journal of Medicine 315:209- 214,1986.

15. Hankins DG, Ebert KD, Siebold CM, Fuller TK, Frascone RJ, Campion BC. Hepatitis B vaccine and hepatitis B markers: cost effectiveness of screening prehospital personnel. American Journal of Emergency Medicine 5:205-206,1987.

16. Heijtink RA, Knol RM, Schalm SW. Low dose (2μg) hepatitis B vaccination in medical students: comparable immunogenicity for intramuscular and intradermal routes. Journal of Medical Virology 27:151-154,1989.

17. Hoofnagle JH, Sheretz RJ. Diagnostic limitations of antibody to hepatitis B surface antigen. New England Journal of Medicine 310:1672,1984.

18. Jacobson JJ,Turno DE, Johnston FK, Schipman Jr C. Cost effectiveness of prevaccination screening for hepatitis B antibody. Journal of Dental Education 51:94-97,1987.

19. Jonsson B. Cost benefit analysis of hepatitis B vaccination. Postgraduate Medical Journal 63(suppl 2):27-32,1987.

20. Kane MA. Progress on the control of hepatitis B infection through immunization. Gut (suppl 1): sl0-sl2,1993. 21. Lansang MA, Domingo E, Lingao A, West S - A cost effectiveness analysis of a simple micromethod for hepatitis B screening in hepatitis B virus Control programmes. International Journal of Epidemiology 18(suppl 2):38-42,1989.

22. Lee CY, Hwang LY, Beasley RP. Low-dose hepatitis B vaccine. Lancet 2:860-861,1989.

23. Lewis TL, Alter IIJ, Chalmers TC, Holland PV, Purcell RH, Ailing I)W, Young D, Frenkel LD, Lee SL, Lamson ME. A comparison of the frequency of hepatitis-B antigen and antibody in hospital and nonhospital personnel. New England Journal of Medicine 289:647-651,1973.

24. Lok ASF, Lai C-L, Wu P-C. Prevalence of isolated antibody to hepatitis B core antigen in an area endemic for hepatitis B virus infection: Implications in hepatitis B vaccination programs. Hepatology 8:766-770,1988.

25. Margolis HS, alter MJ, hadler SC. Hepatitis B: evolving epidemiology and implications for control. Seminars in Liver Disease 11:84-92,1991.

26. Maruna H, Westphal G. Epidemiology and risk calculation of hepatitis-B as an occupational disease in the Austrian Health Service. Internal Archives of Occupational and Environmental Health 57:259-265,1986.

27. Maynard JE. Nosocomial viral hepatitis. American Journal of Medicine 70:439-444,1981.

28. Mok Q, Underhill G, Wonke B, Aldouri M, Kelsey M, Jefferies D. Intradermal hepatitis B yaccine in thalassemia and sickle cell disease. Archives of Diseases in Childhood 64:535-540,1989.

29. Morris CA, Oliver PR, Reynolds F, Selkon JB. Intradermal hepatitis B immunization with yeast- derived vaccine: serological response by sex and age. Epidemioloy and Infection 103:387-394, 1989.

30. Muller J, Hainsworth M, Terry T. Screening before immunisation against hepatitis B - is it cost effective? South African Medical Journal 75:504- 505,1989.

31. Oxman MN. Hepatitis B vaccination of high-risk hospital personnel. Anesthesiology 60:1-3,1984.

32. Redfield RR, Innis BL, Scott RM, Cannon HG, Bancroft WH. Clinical evaluation of low-dose intradermally administered hepatitis B virus vaccine. Journal of the American Medical Association 254:3203-3206,1985.

33. Stingl G, Katz SI, Clement L, Green I, Shevach EM. Immunologic functions of la-bearing epidermal Langherhans cells. Journal of Immunology 121:2005-2013,1978.

34. Weissberg JI, Andres LL, Smith CI,Weik S, Nichols JE, Garcia G, Robinson WS, Merigan TC, Gregory PB. Survival in chronic hepatitis B. An analysis of 379 patients. Annals of Internal Medicine 101: 613-636,1984.

35. Whittle HC, Lamb WH, Eccles MJ - Failure of intradermal hepatitis B vaccine in Gambian children. In: Coursaget P Tong MJ (eds). Progress in Hepatitis B vaccination. Colloques INSERM, Paris, vol. 194, p 301-309,1990.

36. Wilkins TD, Cossart Y. Low-dose intradermal vaccination of medical and dental students. The Medical Journal of Australia 152:141-143,1990.

37. Zajak BA, West DJ, McAlleer WJ, Scolnick EM. Overview of clinical studies with hepatitis B vaccine made by recombinant DNA. Journal of Infection 13(supl A):39-45,1986.

38. Zoulek G, Lorbeer B, Jilg W, Deinhardt D. Evaluation of a reduced dose of hepatitis B vaccine administered intradermally. Journal of Medical Virology 14:27-32,1984.

Recebido para publicação em 10/02/95.

Disciplinas dc Gastroenterologia e de Doenças Infecciosas e Parasitárias da Escola Paulista de Medicina - Universidade Federal de São Paulo (UNIFESP), São Paulo, SP.

  • 1. Alwood GK, Pearce NE, Fracp CRL, Milne A, Lucas CR, Krugman S. Low dose hepatitis B vaccination in children. New Zeland Medical Journal 99:47- 49,1986.
  • 2. Bergamini F, Zanetti A. Immunogenicity of yeast- derived hepatitis B vaccines in young adults. Postgraduate Medical Journal 63-137-138,1987.
  • 3. Brink NS, Murray AB. Intradermal vaccination against hepatitis B in a group of medical students. South African Medical Journal 79.653-654,1991.
  • 4. Centers for Disease Control. Inadequate immune response among public safety workers receiving intradermal vaccination against hepatitis B - United States, 1990-1991. MMWR Morbidity and Mortality Weekly Report 40:569-572,1991.
  • 5. Clarke JA, Hollinger FB, Lewis E, Russell LA, Miller CH, Huntley A, Flynn NM. Intradermal inoculation with Heptavax B - immune response and histologic evaluation of injection sites. Journal of the American Medical Association 262:2567- 2571,1989.
  • 6. Dienstag JL, Stevens CE, Bhan AK, Szmuness W. Hepatitis B vaccine administered to chronic carriers of hepatitis B surface antigen. Annals of Internal Medicine 96:575-579,1982.
  • 7. Eisenberg JM.A guide to the economic analysis of clinical practices. Journal of the American Medical Association 262: 2879-2885,1989.
  • 8. Expanded Programme on Immunization (EPI). Global advisory group, 13th meeting. Cairo, Egypt 1-26,1990.
  • 9. Ferraz MLG, Silva AEB, Kemp VL, Cruz CN, Guimarães RX. Assessment of the immunological response to hepatitis B vaccine in health care professionals. Revista da Associação Médica Brasileira 38:5-8,1992.
  • 10. Foutch PG, Carey WD. Diagnostic limitations of antibody to hepatitis B surface antigen. New England Journal of Medicine 310:1671,1984.
  • 11. Frazer IH, Jones B, Dimitrakakis M, Mackay IR. Intramuscular versus low dose intradermal hepatitis B vaccine - Assessment by humoral and cellular immune response to hepatitis B surface antigen.The Medical Journal of Australia 146:242- 245,1987.
  • 12. Goudeau A, Dubois F, Dubois MC, Louq C, Mazert MC. Immunogenicity of low dose (1.25 and 0. 31 Mg) hepatitis B vaccine. Lancet 2:1091-1092, 1984.
  • 13. Hadler SC. Hepatitis B virus infection and health care workers. Vaccine 8 (suppl 1): s24-s28,1990.
  • 14. Hadler SC, Francis DI! Maynard JE, Thompson SE, Judson FN, Echenberg DF, Ostrow DG, Penley KA, Altman NL. Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. New England Journal of Medicine 315:209- 214,1986.
  • 15. Hankins DG, Ebert KD, Siebold CM, Fuller TK, Frascone RJ, Campion BC. Hepatitis B vaccine and hepatitis B markers: cost effectiveness of screening prehospital personnel. American Journal of Emergency Medicine 5:205-206,1987.
  • 16. Heijtink RA, Knol RM, Schalm SW. Low dose (2μg) hepatitis B vaccination in medical students: comparable immunogenicity for intramuscular and intradermal routes. Journal of Medical Virology 27:151-154,1989.
  • 17. Hoofnagle JH, Sheretz RJ. Diagnostic limitations of antibody to hepatitis B surface antigen. New England Journal of Medicine 310:1672,1984.
  • 18. Jacobson JJ,Turno DE, Johnston FK, Schipman Jr C. Cost effectiveness of prevaccination screening for hepatitis B antibody. Journal of Dental Education 51:94-97,1987.
  • 19. Jonsson B. Cost benefit analysis of hepatitis B vaccination. Postgraduate Medical Journal 63(suppl 2):27-32,1987.
  • 20. Kane MA. Progress on the control of hepatitis B infection through immunization. Gut (suppl 1): sl0-sl2,1993.
  • 21. Lansang MA, Domingo E, Lingao A, West S - A cost effectiveness analysis of a simple micromethod for hepatitis B screening in hepatitis B virus Control programmes. International Journal of Epidemiology 18(suppl 2):38-42,1989.
  • 22. Lee CY, Hwang LY, Beasley RP. Low-dose hepatitis B vaccine. Lancet 2:860-861,1989.
  • 23. Lewis TL, Alter IIJ, Chalmers TC, Holland PV, Purcell RH, Ailing I)W, Young D, Frenkel LD, Lee SL, Lamson ME. A comparison of the frequency of hepatitis-B antigen and antibody in hospital and nonhospital personnel. New England Journal of Medicine 289:647-651,1973.
  • 24. Lok ASF, Lai C-L, Wu P-C. Prevalence of isolated antibody to hepatitis B core antigen in an area endemic for hepatitis B virus infection: Implications in hepatitis B vaccination programs. Hepatology 8:766-770,1988.
  • 25. Margolis HS, alter MJ, hadler SC. Hepatitis B: evolving epidemiology and implications for control. Seminars in Liver Disease 11:84-92,1991.
  • 26. Maruna H, Westphal G. Epidemiology and risk calculation of hepatitis-B as an occupational disease in the Austrian Health Service. Internal Archives of Occupational and Environmental Health 57:259-265,1986.
  • 27. Maynard JE. Nosocomial viral hepatitis. American Journal of Medicine 70:439-444,1981.
  • 28. Mok Q, Underhill G, Wonke B, Aldouri M, Kelsey M, Jefferies D. Intradermal hepatitis B yaccine in thalassemia and sickle cell disease. Archives of Diseases in Childhood 64:535-540,1989.
  • 29. Morris CA, Oliver PR, Reynolds F, Selkon JB. Intradermal hepatitis B immunization with yeast- derived vaccine: serological response by sex and age. Epidemioloy and Infection 103:387-394, 1989.
  • 30. Muller J, Hainsworth M, Terry T. Screening before immunisation against hepatitis B - is it cost effective? South African Medical Journal 75:504- 505,1989.
  • 31. Oxman MN. Hepatitis B vaccination of high-risk hospital personnel. Anesthesiology 60:1-3,1984.
  • 32. Redfield RR, Innis BL, Scott RM, Cannon HG, Bancroft WH. Clinical evaluation of low-dose intradermally administered hepatitis B virus vaccine. Journal of the American Medical Association 254:3203-3206,1985.
  • 33. Stingl G, Katz SI, Clement L, Green I, Shevach EM. Immunologic functions of la-bearing epidermal Langherhans cells. Journal of Immunology 121:2005-2013,1978.
  • 34. Weissberg JI, Andres LL, Smith CI,Weik S, Nichols JE, Garcia G, Robinson WS, Merigan TC, Gregory PB. Survival in chronic hepatitis B. An analysis of 379 patients. Annals of Internal Medicine 101: 613-636,1984.
  • 35. Whittle HC, Lamb WH, Eccles MJ - Failure of intradermal hepatitis B vaccine in Gambian children. In: Coursaget P Tong MJ (eds). Progress in Hepatitis B vaccination. Colloques INSERM, Paris, vol. 194, p 301-309,1990.
  • 36. Wilkins TD, Cossart Y. Low-dose intradermal vaccination of medical and dental students. The Medical Journal of Australia 152:141-143,1990.
  • 37. Zajak BA, West DJ, McAlleer WJ, Scolnick EM. Overview of clinical studies with hepatitis B vaccine made by recombinant DNA. Journal of Infection 13(supl A):39-45,1986.
  • 38. Zoulek G, Lorbeer B, Jilg W, Deinhardt D. Evaluation of a reduced dose of hepatitis B vaccine administered intradermally. Journal of Medical Virology 14:27-32,1984.
  • Endereço para correspondência:

    Prof
    a Maria Lucia Gomes Ferraz.
    R. Machado Bittencourt 413/81, Vl. Clementino,
    04044-001
    São Paulo, SE
    Tel: (011) 549-1711;
    Fax: (011) 572-5945.
  • Datas de Publicação

    • Publicação nesta coleção
      10 Abr 2013
    • Data do Fascículo
      Dez 1995

    Histórico

    • Recebido
      10 Fev 1995
    • Aceito
      10 Fev 1995
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