title: Empiric immunization versus serologic screening: developing a cost-effective strategy for the use of hepatitis A immunization in travelers.
abstract: BACKGROUND
  Older individuals and those born overseas are thought at increased risk of prior exposure and thus have naturally acquired immunity to hepatitis A. Whether these individuals or other groups of international travelers should be screened for acquired immunity or empirically immunized is not clear. Hepatitis A serology and risk factor data was obtained prospectively in patients presenting for hepatitis A immunization and used to develop a cost-effective strategy for the use of serologic screening and empiric immunization in our traveler population.
  
  
  METHODS
  Candidates for hepatitis A immunization were routinely screened for total hepatitis A serum antibody. Risk factor data including country of birth, travel history, and history of jaundice was collected. Cost-effectiveness was assessed by comparing the cost of serology to screen all patients plus cost to immunize those found to be seronegative with, the cost of empirically immunizing all patients.
  
  
  RESULTS
  Analyses were conducted comparing age, travel history, country of birth, and history of jaundice for significance in predicting seropositivity in a group of 115 subjects. Country of birth was statistically a significant predictor of positive results with 80.0% of foreign-born patients positive for total antibody against hepatitis A compared with 35.6% of patients born in the United States. Living outside of the United States (defined as greater than 30 days) was also correlated with a higher prevalence of hepatitis A positive serology. Age was not predictive for the group as a whole. A lower prevalence (24.3%) was noted in the group of US born individuals aged 30 to 60. Travel and prior history of jaundice failed to demonstrate significance.
  
  
  CONCLUSIONS
  Employing a simple cost-effectiveness equation using cost of serological testing, cost of vaccine, and prevalence of acquired immunity in the community, a strategy was developed. In our population it was cost-effective to screen all foreign-born individuals and those who had lived outside the United States.
authors.affiliation: Department of Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: Joel T
authors.initials: JT
authors.lastname: Fishbain
authors.forename: Robert E
authors.initials: RE
authors.lastname: Eckart
authors.forename: Kyle C
authors.initials: KC
authors.lastname: Harner
authors.forename: Duane R
authors.initials: DR
authors.lastname: Hospenthal
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D005260:Female; D006506:Hepatitis A / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control*; D022362:Hepatitis A Vaccines / Q000627:therapeutic use*; D006508:Hepatitis Antibodies / Q000097:blood; D006801:Humans; D017589:Immunization Programs / Q000191:economics*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012698:Serologic Tests / Q000191:economics*; D014195:Travel; D014481:United States / Q000453:epidemiology
chemical_list: D022362:Hepatitis A Vaccines; D006508:Hepatitis Antibodies