Margolis HS, Coleman PJ, Brown RE, et al.Prevention of hepatitis B virus transmission by immunization: An economic analysis of current recommendations. JAMA1995; 274:1,201-1,208.

Routine infant vaccination -- rather than adolescent vaccination -- should be the primary means of preventing hepatitis B transmission in the United States, the authors of this cost-benefit analysis report.

"However, since the cost per life-year saved of adolescent vaccination compares favorably with other vaccination and medical practices, vaccination of 11-12-year-old children should be considered part of the comprehensive strategy to eliminate HBV transmission in the United States," the authors note.

According to their analysis, prevention of perinatal infection and routine infant vaccination would lower the 4.8% lifetime risk of HBV infection by at least 68%, compared with a 45 percent reduction for adolescent vaccination. From a societal perspective, prevention of perinatal HBV infections would save $41.8 million in medical and work-loss costs, although an estimated 1,317 children would still become chronically infected despite the program. Routine infant immunization would provide an additional savings of $19.7 million. An estimated 2,226 children, adolescents, and adults would acquire chronic HBV infection annually, however because of incomplete vaccination or vaccine failure. Adolescent immunization would provide a $3.5 million savings, because this strategy does not prevent an estimated 4,683 chronic infections in young children, adolescents, or adults because of the expected lower rate of vaccination, the authors found.

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Scharschmidt BF. Hepatitis E: A virus in waiting. Lancet 1995; 346:519-520.

Though few cases of hepatitis E virus (HEV) infection have been documented in developed nations, HEV is emerging on a global level as a serious health menace whose modus operandi is not fully understood, the author warns.

The first extensively studied outbreak of HEV infection occurred in Delhi, India, in the winter of 1955-56 when raw sewage carried by the flooding Yamuna River caused 30,000 cases of jaundice. The characteristics of the epidemic -- particularly its fecal-oral spread and lack of chronic disease -- initially suggested hepatitis A virus infection. But later testing of stored blood implicated a new agent -- HEV. The pathogen is now been identified as a non-enveloped, single-stranded RNA virus unrelated to other hepatitis viruses.

"We need to establish whether HEV shows sufficient strain variation to escape detection by current serological assays, and whether such variation might account for our inability to detect HEV antibodies in patients with otherwise unexplained fulminant hepatic failure," the author concludes. ". . . It remains uncertain whether subclinical or unrecognized infection accounts for the 2% or more of blood donors in developed countries with HEV antibodies. If so, [developed countries] may be encountering more HEV than they realize."