title: Hepatitis A virus vaccination in persons with hepatitis C virus infection: consequences of quality measure implementation.
abstract: Hepatitis A virus (HAV) superinfection in persons with hepatitis C virus (HCV) infection has been associated with a high mortality rate, and vaccination is recommended. The incidence of HAV is low, and the aim of this study was to determine the mortality risk of HAV superinfection and the consequences of routine vaccination in persons with HCV infection. To determine the mortality risk of HAV superinfection, a meta-analysis including studies reporting mortality in HCV-infected persons was performed. Data were extracted independently by two investigators and recorded on a standardized spreadsheet. The pooled mortality estimate was used to determine the number needed to vaccinate (NNV) to prevent mortality from HAV superinfection. The total vaccine cost was also calculated. A total of 239 studies were identified using a defined search strategy. Of these, 11 appeared to be relevant, and of these, 10 were suitable for inclusion in the meta-analysis. The pooled odds ratio (OR) for mortality risk in HAV superinfection of HCV-infected persons was 7.23 (95% confidence interval: 1.24-42.12) with significant heterogeneity (I(2) = 56%; P = 0.03) between studies. Using the pooled OR for mortality, this translates to 1.4 deaths per 1,000,000 susceptible persons with HCV per year. The NNV to prevent one death per year is therefore 814,849, assuming 90% vaccine uptake and 94.3% vaccine efficiency. The vaccine cost for this totals $162 million, or $80.1 million per death prevented per year.
  
  
  CONCLUSIONS
  These data challenge the use of routine HAV vaccination in HCV-infected persons and its incorporation into clinical practice guidelines. HAV vaccination of all HCV-infected persons is costly and likely to expose many individuals to an intervention that is of no direct benefit.
authors.affiliation: Hepatitis C Virus Research Group, University of Birmingham, Birmingham, United Kingdom. i.a.c.rowe@bham.ac.uk
authors.forename: Ian A
authors.initials: IA
authors.lastname: Rowe
authors.forename: Richard
authors.initials: R
authors.lastname: Parker
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Armstrong
authors.forename: Diarmaid D
authors.initials: DD
authors.lastname: Houlihan
authors.forename: David J
authors.initials: DJ
authors.lastname: Mutimer
mesh_terms: D017048:Health Care Costs / Q000706:statistics & numerical data; D006506:Hepatitis A / Q000191:economics / Q000401:mortality* / Q000517:prevention & control; D022362:Hepatitis A Vaccines / Q000191:economics / Q000627:therapeutic use*; D019698:Hepatitis C, Chronic / Q000191:economics / Q000401:mortality*; D006801:Humans; D015994:Incidence; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012307:Risk Factors; D015163:Superinfection / Q000191:economics / Q000401:mortality* / Q000517:prevention & control
chemical_list: D022362:Hepatitis A Vaccines