Vaccine 28 (2010) 7723–7730 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Public vaccination programmes against hepatitis B in The Netherlands: Assessing whether a targeted or a universal approach is appropriate Hans Houweling a,* , Christiaan F.W. Wittevrongel a , Marcel Verweij a,b , E. Joost Ruitenberg a,c , on behalf of the National Immunisation Programme Review Committee of the Health Council of the Netherlands a Health Council of the Netherlands, The Hague, The Netherlands b Ethics Institute, Utrecht University, The Netherlands c Athena Institute, VU University Amsterdam, The Netherlands article info Article history: Received 19 April 2010 Received in revised form 15 September 2010 Accepted 21 September 2010 Available online 14 October 2010 Keywords: Hepatitis B Universal vaccination The Netherlands Targeted approach Risk group approach Assessment Selection criteria Public vaccination programme abstract To date, the policy to control hepatitis B in the Netherlands is to vaccinate specific risk groups, rather than all children. Low incidence of the disease has fueled debate whether such a targeted vaccination strategy or rather a universal strategy, as recommended by the World Health Organization, is appro- priate. The standard framework for assessing whether a particular vaccination should be included in a public programme, as recently proposed by the Health Council of the Netherlands (HCN), was applied to the various options for hepatitis B vaccination. This framework includes seven selection criteria, grouped under five thematic headings: seriousness and extent of the disease burden, effectiveness and safety of the vaccination, acceptability of the vaccination, efficiency of the vaccination, and priority of the vac- cination. From about 1990 the disease burden has stayed more or less the same over time and careful assessment has made it clear that the targeted approach has failed to reach a significant part of the risk groups. Models suggest that the public health benefits obtained through targeted programmes could be augmented considerably by universal vaccination. Based on the assessment that universal vaccination means better protection for high-risk groups as well as the whole population, the HCN calls for universal immunisation, even though hepatitis B to a large extent is limited to specific high-risk groups. Should the Netherlands adopt universal vaccination, several immunisation programmes targeted to high-risk groups will, however, remain of crucial importance for years to come. © 2010 Elsevier Ltd. All rights reserved. 1. Introduction Hepatitis B virus (HBV) infection causes a high burden of disease. Worldwide, an estimated 2 billion people were infected at some time in the past, and 4–5 million new infections occur every year. Over 350 million people are estimated to be chronically infected and every year about 600,000 people die from HBV-related liver disease or hepatocellular carcinoma (HCC) [1]. The burden of dis- ease is distributed unevenly across the globe, with relatively high prevalence in sub-Saharan Africa, south-east Asia and parts of South America, but low incidence in North America, Australia and north- west Europe. By 1992 the World Health Organization (WHO) had called for the worldwide introduction of universal vaccination of children against hepatitis B. However, the low incidence of the disease north-west Europe has fueled debate whether targeted or universal vaccina- * Corresponding author at: Health Council of the Netherlands, PO Box 16052, 2500 BB, The Hague, The Netherlands. Tel.: +31 70 3406625; fax: +31 70 3407520. E-mail address: hans.houweling@gr.nl (H. Houweling). tion strategies are the way to go [2,3]. To date, the policy in the Netherlands has been to vaccinate specific risk groups, rather than all children. So far, the controversy regarding universal vaccination has not been resolved. To further the discussion, the standard framework for assess- ing whether particular vaccinations should be included in a public programme, as recently proposed by the Health Council of the Netherlands (HCN), was applied to hepatitis B [4]. That frame- work includes seven selection criteria and provides a framework for the systematic examination of arguments for and against the inclusion and prioritisation of particular vaccinations within public programmes. 2. Hepatitis B in the Netherlands 2.1. Disease burden In the Netherlands each year between 200 and 300 cases of acute hepatitis B (1.4 and 2.0 per 100,000 persons) and about 1500 cases of chronic hepatitis B are reported, as are a number of deaths from acute disease and an average of 23 deaths from 0264-410X/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2010.09.068