Control of hepatitis B in the United Kingdom Mary Ramsay *, Nigel Gay, Koye Balogun, Marian Collins Immunization Division, PHLS Communicable Disease Surveillance Centre, London, UK Abstract Control of hepatitis B in the UK is based upon selective vaccination of persons in high-risk groups. To assess the likely cost- eectiveness of changes to this policy, information on the current burden of HBV infection in the UK is required. Laboratory reports of acute hepatitis B suggest that the vast majority of new hepatitis B infections acquired in the UK occur in adults, even after adjustment for unapparent infection. In childhood, perinatal transmission remains the most signi®cant known risk factor. Universal antenatal screening has the potential to prevent perinatal infections in UK births and a substantial proportion of those UK acquired infections which lead to carriage. In addition to antenatal screening, universal infant vaccination (at 2, 3 and 4 months) can, in the short term, only prevent the small number of infections acquired in childhood. Economic analysis using current surveillance data is required to assess the possible cost-bene®t of universal vaccination. Regardless of this, there is an urgent need to improve selective vaccination and to ensure that a high proportion of antenatal carriers is identi®ed. # 1998 Published by Elsevier Science Ltd. All rights reserved. Keywords: Hepatitis B; Vaccination; Surveillance; Economic evaluation 1. Introduction Currently, the UK policy for the control of hepatitis B is based upon selective vaccination of persons in high-risk groups [1]. Infants at risk of perinatal infec- tion can be identi®ed by antenatal screening for hepa- titis B carriage and are one of the groups targeted for vaccination. Universal screening has been rec- ommended for some time, but implementation of the policy is patchy (Newell, personal communication). Selective screening of mothers based on ethnicity or knowledge of high-risk behaviour is known to miss some infants of carrier mothers [2]. The World Health Organization has recommended that all countries integrate HBV vaccination into their national immunization programme by 1997 [3]. This would require adoption of universal vaccination of either infants or adolescents, or of both age groups. However, it is not clear that the burden of disease in the UK justi®es the high cost that this programme would entail. Other options for improving the control of hepatitis B include the implementation of universal antenatal screening and eorts to improve the delivery of selective vaccination. To decide which policy, or combination of policies is required, a review of data on hepatitis B in England and Wales was performed. 2. Methods Cases of acute hepatitis B infection are reported to PHLS Communicable Disease Surveillance Centre from laboratories in England and Wales. Laboratory reports of acute hepatitis B to CDSC underestimate the true incidence of infection because of the occur- rence of asymptomatic infections and under-reporting by laboratories. A study involving active case search- ing in the London area suggested, however, that lab- oratory reports give a fairly accurate estimate of the incidence of symptomatic disease and can therefore be used to infer trends over time [4]. Estimation of the true incidence of acute hepatitis B requires quanti®cation of the proportion of asymptomatic disease and the level of under-reporting. The proportion of infections that are symptomatic is age dependent (Table 1) [3]. To estimate the level of under-reporting an audit was conducted in 1997 in Vaccine 16 (1998) S52±S55 0264-410X/98/$19.00 # 1998 Published by Elsevier Science Ltd. All rights reserved. PII: S0264-410X(98)00295-3 PERGAMON * Corresponding author.