Community-based screening and treatment for chronic hepatitis B in sub-Saharan Africa
Authors: Gang Qin, Jian-Guo Shao
Journal: The Lancet Global Health (2016)

Shevanthi Nayagam and colleagues (August, 2016)1Nayagam S Conteh L Sicuri E et al.Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysis.Lancet Glob Health. 2016; 4: e568-e578Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar estimate the cost-effectiveness of a community-based screen-and-treat programme for chronic hepatitis B in The Gambia. We have some comments on several aspects of the economic modelling. First, Nayagam and colleagues construct a Markov model including health states such as immune tolerant, immune reactive, inactive carrier, HBeAg-negative chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma. Unfortunately, the baseline proportion of each health state is presented neither in their Article1Nayagam S Conteh L Sicuri E et al.Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysis.Lancet Glob Health. 2016; 4: e568-e578Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar nor in the original PROLIFICA study.2Lemoine M Shimakawa Y Njie R et al.Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study.Lancet Glob Health. 2016; 4: e559-e567Summary Full Text Full Text PDF PubMed Scopus (105) Google Scholar Moreover, the assumption that transitions between the stages are unidirectional might be misleading, because bidirectional transitions have been well accepted.3Fan L Owusu-Edusei Jr, K Schillie SF Murphy TV Cost-effectiveness of active-passive prophylaxis and antiviral prophylaxis during pregnancy to prevent perinatal hepatitis B virus infection.Hepatology. 2016; 63: 1471-1480Crossref PubMed Scopus (36) Google Scholar Second, for the transition rates from cirrhosis to hepatocellular carcinoma, Nayagam and colleagues provide estimates for antiviral-treated patients versus untreated patients separately in table 1. However, the estimates for transition rates from chronic hepatitis B to cirrhosis or hepatocellular carcinoma in antiviral-treated patients are absent. Long-term antiviral therapy can lead to regression of fibrosis4Marcellin P Gane E Buti M et al.Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year open-label follow-up study.Lancet. 2013; 381: 468-475Summary Full Text Full Text PDF PubMed Scopus (1230) Google Scholar and reduction of cirrhosis and hepatocellular carcinoma. Last, using one-way sensitivity analyses, Nayagam and colleagues show that the screen-and-treat programme remains cost-effective over wide ranges of time-varying and district-specific factors. However, the results in their tornado diagram might be misleading because the ranges of output incremental cost-effectiveness ratios (ICERs) are not consistent with those of input variables. For example, poorer treatment adherence (95–77% rather than 77–95%) makes this programme less cost-effective (ICER US$515–547 per quality-adjusted life-year averted). Similarly, the ranges of 0·010–0·052, 0·0155–0·0471, 0·039–0·507, and 0·008–0·080 should be reversed, as done elsewhere.5Wu B Li T Chen H Shen J Cost-effectiveness of nucleoside analog therapy for hepatitis B in China: a Markov analysis.Value Health. 2010; 13: 592-600Summary Full Text PDF PubMed Scopus (50) Google Scholar We declare no competing interests. This study was supported in part by grants from Jiangsu Provincial Department of Science and Technology (BE2015655), China, National Natural Science Foundation of China (81370520), and Jiangsu Provincial 333 Talent Project Foundation. Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysisAdult community-based screening and treatment for HBV in The Gambia is likely to be a cost-effective intervention. Higher cost-effectiveness might be achievable with targeted facility-based screening, price reductions of drugs and diagnostics, and integration of HBV screening with other public health interventions. Full-Text PDF Open AccessCommunity-based screening and treatment for chronic hepatitis B in sub-Saharan Africa – Authors' replyWe thank Gang Qin and Jian-Guo Shao for their interest in our study1 and their observations. First, in response to their point about the baseline proportion of people in each health state, we would like to draw their attention to the table in the supplementary appendix, where these values are presented. Full-Text PDF Open Access