Hepatology Costs and cost-effectiveness of different follow-up schedules for detection of occupational hepatitis C virus infection S Deuffic-Burban,1,2 D Abiteboul,3,4 F Lot,5 M Branger,4 E Bouvet,3,4 Y Yazdanpanah2,3,6,7 c An additional figure is published online only at http:// gut.bmj.com/content/vol58/ issue1 1 CTRS INSERM U795, Lille, France; 2 LEM-CNRS, Lille, France; 3 Groupe d’Etude sur le Risque d’Exposition au Sang (GERES), Paris, France; 4 Hˆopital Bichat-Claude Bernard, Paris, France; 5 Institut de Veille Sanitaire (InVS), Saint Maurice, France; 6 Service des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France; 7 EA 2694, Facult´e de M´edecine de Lille, Lille, France Correspondence to: Mrs Sylvie Deuffic-Burban, LEM- CNRS, Universit´e Catholique de Lille, 41 rue du Port, 59046 Lille Cedex, France; sylvie.burban@ neuf.fr Revised 22 August 2008 Accepted 27 August 2008 Accept for Online First 29 September 2008 This paper is freely available online under the BMJ Journals unlocked scheme, see http:// gut.bmj.com/info/unlocked.dtl Gut 2009;58:105–110. doi:10.1136/gut.2007.145516 ABSTRACT Objective: The purpose of this study was to compare the costs and cost-effectiveness (C/E) of early hepatitis C virus (HCV) RNA testing (alternative-US recommenda- tions) after occupational exposure to HCV with existing follow-up strategies: (1) French, anti-HCV antibodies and alanine transaminase (ALT) activity at months 1, 3 and 6; (2) European, monthly ALT activity for 4 months and anti- HCV antibodies at month 6; (3) and baseline-US, anti-HCV antibodies and ALT activity at month 6. Methods: A decision tree simulated each strategy for 7300 healthcare workers (HCWs) exposed to HCV each year in France, taking into account the impact of early diagnosis on the response to antiviral treatment and the deterioration of HCW quality of life after exposure. Results: For a HCV transmission risk of 0.5% after exposure, the French strategy led to the highest costs/ person (J181.40) and the baseline-US strategy to the lowest (J126.60) (J178.50) for alternative-US). The shortest mean time to HCV infection diagnosis (1 month) and the lowest number of chronic hepatitis C (CHC) patients (1.9/7300 HCWs exposed) was obtained with the alternative-US strategy (vs 6 months and 7.9 CHC, respectively with baseline-US). Compared with the alternative-US, the French strategy was associated with higher costs and lower utilities, and the European with a higher incremental C/E ratio. Compared with the baseline- US strategy, the alternative-US strategy C/E ratio was J2020 per quality-adjusted life year saved. Conclusion: In HCWs exposed to HCV, a strategy based on early HCV RNA testing shortens the period during which the HCW’s wait for his HCV status, leads to lower risk of progression to CHC and is reasonably cost- effective. Infection by hepatitis C virus (HCV) is an important occupational hazard for healthcare workers (HCWs). In France, in 2004, 41 276 accidental blood exposures occurred in hospitals, 58.7% of which were percutaneous injuries.1 Of these cases, 6.2% occurred to anti-HCV antibody- positive source patients and 24.1% to source patients whose status was not known but who were considered as potentially anti-HCV antibody positive. In the USA, 1 385 280 sharp injuries were estimated to occur annually, and 22 000 HCWs were exposed to at least one percutaneous injury with a sharp object contaminated with HCV2 (http://www.who.int/quantifying_ehimpacts/ publications/en/sharps.pdf). Different follow-up schedules for occupational HCV detection have been recommended in different countries. Whereas European guidelines recommend alanine transaminase (ALT) monitor- ing alone,3 French and baseline-US guidelines are based on anti-HCV antibody and ALT monitor- ing,4 5 but alternative-US guidelines propose HCV RNA testing at 4–6 weeks if earlier diagnosis of HCV infection is desired. The risk of transmission is first determined by the status of the source patient: when the occupational exposure involves an HCV RNA-negative source patient, the risk is considered to be zero; when the source patient is HCV RNA-positive, it is estimated at 0–10.3%,6–16 with an average rate of 0.5%.11 17 The results of a recent case–control study conducted in five European countries suggested that after occupa- tional exposure to HCV, assessment of the risk of transmission should take into account the severity of the injury and the device involved.18 Our hypothesis is that follow-up schedules should be tailored to the HCW’s risk of HCV seroconversion after percutaneous exposure. In this study, using a cost-effectiveness (C/E) analysis, we compared the three existing follow-up strategies recommended in France, Europe and the USA after occupational exposure to HCV, with a strategy based on early HCV RNA testing, accord- ing to the risk of HCV transmission. MATERIALS AND METHODS Study design We designed a decision analysis model to compare in HCWs exposed to an HCV-positive source the three existing strategies of follow-up and a strategy based on early HCV RNA testing: c Strategy 1: monitoring of anti-HCV antibodies and ALT activity at months 1, 3 and 6 after HCV exposure, and HCV RNA testing to confirm positive anti-HCV antibody results and/or ALT elevation (French recommenda- tions).4 c c c Strategy 2: monthly monitoring of ALT activ- ity for 4 months after HCV exposure, and of anti-HCV antibodies at month 6, and HCV RNA testing to confirm ALT elevation or positive anti-HCV antibody results (European recommendations).3 Strategy 3: anti-HCV antibody and ALT activity monitoring at month 6 after HCV exposure, and HCV RNA testing to confirm positive anti-HCV antibody results (baseline- US recommendations).5 Strategy 4: HCV RNA testing 1 month after HCV exposure (alternative-US recommenda- tions), as proposed by US recommendations if earlier diagnosis of HCV is desired.5 105