Disease burden of chronic hepatitis B among immigrants in Canada

Characterising the effectiveness of social determinants of health-focused hepatitis B interventions: a systematic review

Social determinants of health are important in designing effective interventions for hepatitis B virus (HBV) infection. This systematic review characterises equity-oriented, social determinants of health-focused HBV interventions, and describes their effectiveness in terms of the prevention, care, or treatment of HBV in high-income countries. We searched electronic databases for central concepts of 'HBV', 'equity', 'social determinants of health', 'intervention', and 'Organization for Economic Co-operation and Development (OECD) countries'. Screening and data abstraction were conducted independently by two reviewers. Data were abstracted from 66 studies; articles with a comparative study design (n=36) were included in the narrative synthesis, highlighting social determinants of health domains of interventions, HBV-relevant health outcomes, and extra-health social determinants of health effects (ie, those effects that extend beyond health outcomes). Synthesis aligned with six emergent themes corresponding to HBV prevention and care: knowledge and education, diagnosis and screening, immunisation, care initiation, engagement with clinical care and treatment, and upstream prevention. Studies presented a heterogeneous array of HBV-relevant health outcomes. Most interventions were tailored for social determinants of health domains of race, ethnicity, culture, and language; drug use; and socioeconomic status. Across the themes, at least two-thirds of interventions showed comparative effectiveness for addressing HBV. Extra-health social determinants of health outcomes were observed for two studies. Considerable diversity in population-level approaches was observed regarding intervention goals and effectiveness; most interventions were effective at enhancing the prevention, care, or treatment of HBV.

Hepatitis B virus genotype surveillance in Canadian blood donors and a referred patient population, 2016-2021

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) genotypes (A-H) have a distinct geographic distribution and are highly associated with the country of birth. Canada has experienced increased immigration over the past decade, primarily from regions where HBV is endemic. This study investigated the proportions and trends of HBV genotypes within blood donor and clinical populations of Canada over the period 2016-2021.

MATERIALS AND METHODS

Study samples involved two cohorts: (1) Canadian blood donors (n = 246) deferred from donation due to HBV test positivity and (2) chronic HBV patients from across Canada (clinically referred population, n = 3539). Plasma or serum was extracted, and the surface antigen and/or polymerase-coding region was amplified and sequenced to determine genotype by phylogenetic analysis.

RESULTS

Six (A-E, G) and eight (A-H) HBV genotypes were detected among deferred blood donors and the clinically referred population, respectively. Differences in HBV genotype proportions between the two cohorts were observed across Canada. Males comprised most of the referred population among genotypes A-E (p < 0.0001), except for genotypes B and C. The median age was younger among blood donors (36 years [range 17-72]) compared with the referred population (41 years [range 0-99]). Distinct trends of increasing (E, referred; B, blood donor) and decreasing genotype prevalence were observed over the study period.

CONCLUSION

HBV genotypes in Canada are highly diverse, suggesting a large immigrant population. Observed trends in genotype prevalence and proportional differences among cohorts imply shifts among the HBV-infected population of Canada, which warrants continued surveillance.

Factors associated with knowledge and awareness of Hepatitis B in individuals of Chinese descent: Results from a mass point of care testing and outreach campaign in Toronto, Canada

Background

Migrants from hepatitis B virus (HBV) endemic regions are at high risk of having chronic infection. Despite this, HBV knowledge and awareness programming, and low-barrier screening methods such as point of care (POC) testing, among this group have yet to become routine.

Methods

We conducted a mass HBV POC screening and knowledge and awareness campaign for individuals of Chinese descent in Toronto, Canada. POC screening was administered, then participants completed a knowledge questionnaire. Logistic regression identified associations between demographic factors and participants' level of HBV knowledge.

Results

From 2015 to 2018, 33 outreach events resulted in 891 individuals completing testing and the knowledge questionnaire. Individuals averaged 64.4 years old. Most, 62% (N = 552), were female, and 73.6% (N = 656) have been in Canada for <30 years. The average questionnaire score was 70.7% correct, with 65.2% (N = 581) demonstrating a high level of HBV knowledge. Post-secondary education (OR: 2.19, 95% CI: 1.41, 3.39), income of $50,000 to <$75,000 (OR: 2.74, 95% CI: 1.39, 5.43), and having familial history of HBV (OR: 1.72, 95% CI: 1.06, 2.78) were associated with high knowledge. The observed prevalence of HBV was 1.5%, with 13 individuals testing positive on the POC test and confirmatory laboratory testing.

Conclusions

Improving knowledge and awareness of HBV is critical to empowering people, especially migrants who experience barriers to care, to pursue vaccination, testing, and treatment. Combining knowledge outreach and POC test campaigns, enabled discussion and screening for HBV with large numbers of people, and can be tailored for optimal effectiveness for specific groups.

Priority actions for elevating liver health in Canada: A call to action

Chronic liver disease (CLD) has become a silent epidemic in our country and has resulted in significant physical, psychosocial, and financial burden. Although other international liver associations have published frameworks for the principal actions required to improve liver health across health systems, Canada does not have a strategy to address the growing concerns of CLD. Thus, a multidisciplinary group of care providers involved in CLD management in Canada gathered to review the current burden of disease, gaps in management, and key opportunities for improving the identification and management of people at risk of developing progressive CLD.

Cost-effectiveness modelling of birth and infant dose vaccination against hepatitis B virus in Ontario from 2020 to 2050

BACKGROUND

The World Health Organization recommends universal birth dose vaccination for hepatitis B virus (HBV), yet only 3 provinces and territories in Canada provide birth dose vaccination, and Canadian-born children in Ontario are acquiring HBV before adolescent vaccination. We sought to determine whether birth and/or infant HBV vaccination is cost-effective.

METHODS

We used a dynamic HBV model that incorporates population by year, disease stage, sex and the influence of immigration to quantify the disease and economic burden of chronic HBV infection in Ontario from 2020 to 2050. We compared 4 vaccination scenarios, which included a birth dose vaccine and variations of the 2 subsequent doses (either alone or as a part of the hexavalent vaccine) and a hexavalent-only strategy in infancy with the current adolescent vaccination strategy. Our costing estimates were based on values from 2020.

RESULTS

All 4 infant vaccination approaches prevented an additional 550-560 acute and 160 chronic pediatric HBV infections from 2020 to 2050 compared with adolescent vaccination. Whereas birth dose could be cost-effective, incorporating vaccination into a hexavalent vaccine was cost saving. By 2050, the hexavalent approach led to $428 000 in cost savings per disability-adjusted life years averted.

INTERPRETATION

At the current prevalence in Ontario, a switch to birth dose or infant dose will be cost-effective or even cost saving. Introducing any form of infant HBV immunization in Ontario will prevent acute and chronic pediatric HBV infections.

Hepatitis B and C in Pregnancy and Children: A Canadian Perspective

In 2016, the World Health Organization released a plan to eliminate viral hepatitis as a public health threat by 2030. For Canada to achieve the recommended decreases in HBV- and HCV-related new diagnoses and deaths, an increase in services is urgently required. Identifying those at risk of, or who have acquired HBV and HCV, remains a challenge, especially with the emergence of new priority populations such as pregnant persons and children. Importantly, prenatal, and pediatric care are times when individuals are often already engaged with the healthcare system, leading to the potential for opportunistic or co-localized care and interventions. At present, Canada may not be maximizing all available virologic tools that could lead to increases in prevention, identification, improved management, or even cure. Here, we describe the continuum of care that includes preconception, prenatal, postpartum, and pediatric stages; and identify current global and Canadian recommendations, findings, and opportunities for improvement.

The mean attributable health care costs associated with hepatitis B virus in Ontario, Canada: A matched cohort study

BACKGROUND: No Canadian studies examined the economic impact of hepatitis B virus (HBV) using population-based, patient-level data. We determined attributable costs associated with HBV from a health care payer perspective. METHODS: We conducted an incidence-based, matched cohort, cost-of-illness study. We identified infected subjects (positive HBV surface antigen, DNA, or e-antigen) between 2004 and 2014, using health administrative data. The index date was the first positive specimen. The cohort was organized into three groups: no HBV-related complications, HBV-related complications before index date, and HBV-related complications post-index date. To evaluate costs (2017 Canadian dollars), we adopted the phase-of-care approach defining six phases. Mean attributable costs were determined by evaluating mean differences between matched pairs. Hard match variables were sex, age group, index year, rurality, neighbourhood income quintile, comorbidities, and immigrant status. Costs were combined with crude survival data to calculate 1-, 5-, and 10-year costs. RESULTS: We identified 41,469 infected subjects with a mean age of 44.2 years. The majority were males (54.7%), immigrants (58.4%), and residents of major urban centres (96.8%). Eight percent had HBV-related complications before index date and 11.5% had them post index date. Across groups, mean attributable costs ranged from CAD-$27–$19 for pre-diagnosis, CAD$167–$1,062 for initial care, CAD$53–$407 for continuing care, CAD$1,033 for HBV-related complications, $304 for continuing care for complications, and CAD$2,552–$4,281 for final care. Mean cumulative 1-, 5-, and 10-year costs ranged between CAD$253–$3,067, $3,067–$20,349, and CAD$6,128–$38,968, respectively. CONCLUSIONS: HBV is associated with long-term economic burden. These results support decision-making on HBV prevention and monitoring strategies.

Cost-effectiveness of couple-based immunization strategy to prevent mother-to-child transmission of hepatitis B virus in China: A decision-analytic Markov model

BACKGROUND

Mother-to-child transmission (MTCT) is the major route of HBV transmission in many parts of the world. We designed couple-based immunization strategy and aimed to assess the cost-effectiveness of this strategy in China.

METHODS

We constructed a decision-analytic Markov model to compared current immunization strategy consisting of hepatitis B vaccination (HepB) for all infants and extra hepatitis B immunoglobulin for infants with HBsAg-positive mothers versus couple-based immunization strategy including additional HBV screening for pre-pregnant couples and HepB for high-risk wives. Costs were assessed from a healthcare system perspective. Number of infants with perinatal HBV infection, life-years (LYs), quality-adjusted life-years (QALYs), and disability-adjusted life-years (DALYs) were used to access effects. We calculated incremental cost-effectiveness ratios (ICERs) and performed sensitivity analysis.

FINDINGS

Based on the birth cohort of 17,578,815 livebirths in China in 2017, couple-based immunization strategy reduced perinatal HBV infection by 18% (9194/51,365) with cost increase of ¥ 41 million, saved 49,986 LYs (ICER: ¥819 per LY saved), gained 48,879 QALYs (ICER: ¥837 per QALY gained) and averted 63,362 DALYs (¥646 per DALY averted) compared with current immunization strategy. These ICERs were below willingness-to-pay levels of China's once GDP per capita (¥59,660), remaining robust in sensitivity analysis.

INTERPRETATION

Under the intermediate endemic of HBV infection in China, implementation of couple-based immunization strategy can improve the efficiency of preventing MTCT of HBV, and is highly cost-effective. This strategy can be a new immunization strategy choice to achieve the target of eliminating hepatitis B by 2030.

FUNDING

National Natural Science Foundation of China.

Cost-effectiveness of augmenting universal hepatitis B vaccination with immunoglobulin treatment: a case study in Zhejiang Province, East China

Objective: To evaluate the cost-effectiveness of the current strategy combining universal vaccination with hepatitis B immunoglobulin (HBIG) treatment for infants of hepatitis B surface antigen (HBsAg) positive mothers compared with universal vaccination with hepatitis B vaccine only.Methods: A decision tree model with a Markov process was constructed and used to simulate the lifetime of the birth cohort in Zhejiang Province during 2016. The current strategy was compared against universal vaccination with respect to costs and health effects. Costs were assessed from the health care system perspective. Health effects were measured by the number of hepatitis B virus (HBV) related diseases and deaths avoided and quality-adjusted life-years (QALYs) gained. The incremental cost‑effectiveness ratio (ICER) is calculated and compared to standard willingness-to-pay thresholds. A one-way sensitivity analysis and a probabilistic sensitivity analysis (PSA) were performed to assess parameter uncertainties.Results: Over the cohort's lifetime, 182 acute symptomatic infections, 2215 chronic infections, 872 cases of cirrhosis, 595 cases of hepatocellular carcinoma (HCC) and 1,350 HBV-related deaths among the cohort of 624,000 infants would be further avoided by the current strategy compared to universal vaccination. Universal vaccination was dominated by the current strategy that produced not only higher total QALYs, but also had lower costs. The results remained robust over a wide range of assumptions.Conclusions: The current strategy was cost saving compared to universal vaccination, and continuing the current strategy is recommended to further decrease the burden of hepatitis B.

Epidemiologic and clinical features of chronic hepatitis B virus infection in 8 Canadian provinces: a descriptive study by the Canadian HBV Network

BACKGROUND

Published Canadian epidemiologic data on hepatitis B virus (HBV) infection include single-centre studies or are focused on Indigenous populations. We performed a study to characterize the demographic and clinical features, liver disease status and treatment of people with chronic hepatitis B in Canada.

METHODS

In this descriptive, opportunistic, cross-sectional study, available data for people known to be monoinfected with HBV were collected by the Canadian HBV Network from existing clinical databases, with support from the National Microbiology Laboratory, Public Health Agency of Canada. Data were collected in all provinces with the exception of New Brunswick and Newfoundland and Labrador. We analyzed the data using parametric and nonparametric statistical methods, with a significance level of p < 0.05.

RESULTS

In the 9380 unique patient records reviewed, the median age was 48 years, and 5193 patients (55.4%) were male. Ethnicity information was available for 7858 patients, of whom 5803 (73.8%) were Asian, 916 (11.6%) were black and 914 (11.6%) were white. Most of those tested (5556/6796 [81.8%]) were negative for HBV e-antigen, and most of those with fibrosis data (3481/4260 [81.7%]) had minimal liver fibrosis, with more advanced fibrosis noted in older people (> 40 yr). Of the 980 patients with genotype data, 521 (53.2%) had genotype B or C infection. Most of the 9241 patients with known confirmed treatment status received tenofovir disoproxil fumarate (1655 [17.9%]), lamivudine (1434 [15.5%]) or entecavir (548 [5.9%]).

INTERPRETATION

Based on available data, Canadian patients with chronic hepatitis B are predominantly Asian and negative for HBV e-antigen, and have genotype B or C infection. Interprovincial variations were noted in antiviral treatment regimen. This multicentre nationwide study provides data regarding patients with chronic hepatitis B and may inform future studies on the epidemiologic features of HBV infection in Canada.

Management of Hepatitis B Virus Infection: 2018 Guidelines from the Canadian Association for the Study of Liver Disease and Association of Medical Microbiology and Infectious Disease Canada

Hepatitis B virus (HBV) infection is an important public health problem in Canada. In keeping with evolving evidence and understanding of HBV pathogenesis, the Canadian Association for the Study of Liver Disease periodically publishes HBV management guidelines. The goals of the 2018 guidelines are to (1) highlight the public health impact of HBV infection in Canada and the need to improve diagnosis and linkage to care, (2) recommend current best-practice guidelines for treatment of HBV, (3) summarize the key HBV laboratory diagnostic tests, and (4) review evidence on HBV management in special patient populations and include more detail on management of HBV in pediatric populations. An overview of novel HBV tests and therapies for HBV in development is provided to highlight the recent advances in HBV clinical research. The aim and scope of these guidelines are to serve as an up-to-date, comprehensive resource for Canadian health care providers in the management of HBV infection.

Cost-effectiveness analysis of hepatitis B vaccine booster in children born to HBsAg-positive mothers in rural China

OBJECTIVE

In rural areas of China with highly endemic for hepatitis B virus (HBV) infection, protective efficacy was observed in adulthood when a one-dose HBV vaccine booster was administered to high-risk children born to mothers who were positive for hepatitis B surface antigen (HBsAg). The aim of this study was to estimate the cost-effectiveness of an HBV vaccine booster in this specific group of children when given at 10 years of age.

METHODS

Two potential strategies were considered: strategy 1 was a one-dose booster given if the child was negative on HBsAg screening; strategy 2 was a one-dose booster given if the child was negative on both HBsAg plus anti-HBs screening. A decision tree combined with a Markov model was developed to simulate the booster intervention process and to simulate the natural history of HBV infection in a cohort of 10-year-old children who were born to HBsAg-positive mothers. The model was calibrated based on multiple selected outcomes. Costs and quality-adjusted life years (QALYs) were measured from a societal perspective. Cost-effectiveness ratios (CERs) of the different strategies were compared in both base-case and one-way sensitivity analyses.

RESULTS

Compared to the current practice of 'no screening and no booster', both strategy 1 and strategy 2 were cost-saving, with CERs estimated at US$ -6961 and US$ -6872 per QALY gained, respectively. In the one-way sensitivity analysis for strategy 1, all the CERs were found to be less than US$ -5000 per QALY gained after considering the uncertainty of all the variables, including vaccination protective efficacy, natural history, behavior, and various costs and utility weights. In a 'worst case' scenario (all parameter values simultaneously being at the worst), the CER of strategy 1 increased to US$ 3263 per QALY gained, which was still less than the GDP per capita of China in 2016 (US$ 8126).

CONCLUSIONS

A hepatitis B vaccine booster given to children born to HBsAg-positive mothers in rural China would be cost-effective and could be considered in HBV endemic areas.

Let's Talk About B: Barriers to Hepatitis B Screening and Vaccination Among Asian and South Asian Immigrants in British Columbia

INTRODUCTION

Chronic hepatitis B (HBV) is prevalent among Asian immigrants in Canada with high morbidity and mortality rates. While some studies have identified barriers to health care and information access, few have studied the impact of culturally relevant information and addressed challenges with recommendations for effective public education and outreach programs.

METHODS

Culturally tailored HBV education workshops were delivered over a 12-month period to Chinese, Filipino, Korean and Punjabi immigrants in Lower Mainland, British Columbia (BC). Data from pre- and post-workshop surveys and 2-week and 1-month follow-up interviews were collected and analyzed to evaluate knowledge gaps and challenges around HBV prevention and screening. Barriers, health care service gaps and facilitators identified in the interviews were coded and analyzed.

RESULTS

Data were collected from 827 workshop participants. Our results show that targeted immigrants in Lower Mainland, BC face many barriers to accessing HBV screening and vaccination. Limited knowledge and awareness of HBV vaccination/prevention/treatment, limited English proficiency and eLiteracy skills, system and provider level barriers to accessing HBV care, and immigration related barriers are among the reported challenges. More than half of participants who took part in the HBV education workshops engaged in actions related to HBV prevention or management.

CONCLUSION

Study findings support the need for culturally tailored HBV public education and outreach programs to further advance HBV immunization and awareness in BC. Addressing barriers and developing targeted programmatic strategies identified in this study will promote more effective HBV education programming and improve uptake of HBV screening and vaccination in BC's immigrant populations.

Cost-effectiveness analysis of oral anti-viral drugs used for treatment of chronic hepatitis B in Turkey

BACKGROUND

All international guidelines suggested that Tenofovir and Entecavir are the primary drugs at the first line therapy for the treatment of chronic hepatitis B (CHB). However, in Turkey these medications reimbursed at the second line therapy according to the Healthcare Implementation Notification. The aim of this study is to compare the cost effectiveness of oral antiviral treatment strategies in CHB for Turkey using lamuvidine, telbuvidine, entecavir, and tenofovir as medications.

METHODS

The analysis was conducted using Markov models. The analysis scenarios based on first line treatment options with Lamuvidine, Telbuvidine, Entecavir, and Tenofovir as the medications. In the analysis, inadequate response or resistance after receiving 12 months of the treatment with Entecavir and Telbivudine were compared to the results found from switching from Entecavir to Tenofovir or from switching from Telbuvidine to Tenofovir. In additional, inadequate response or resistance after receiving 6 months of the treatment for Lamivudine was compared to the results found from switching from Lamivudine to Tenofovir. The study population included men and women, who were 40 years of age. The patients` compliance was estimated 100 % for all of the therapy options. The model duration was constructed to evaluate, treatment strategy duration of 40 years. The cost of medications, examinations/follow-ups and complications were included in the model. Years of Potential Life Lost was used as the health outcome. An incremental cost-effectiveness ratio analysis has been conducted.

RESULTS AND DISCUSSION

While the minimum years of life lost was found as 0.22 with tenofovir treatment in 5 years, treatment cost was calculated as 12,169 TL. These values were detected as 0.56 years and 7727 TL, 0.37 years and 12,770 TL, respectively for lamuvidine and telbuvidine treatments. The maximum years of life lost and treatment cost was with lamuvidine treatment were detected as 1.60 years and 18,813 TL and, secondly 0.89 years and 24,007 TL for lamuvidine-tenofovir treatment during 10 years. The minimum years of life lost and cost are 0.54 year and 35,821 TL for tenofovir treatment during 10 years. The minimum years of life lost and cost were determined as 1.21 years and 52,839 TL for tenofovir treatment strategy during 20 years. During 30 years period, tenofovir treatment was found to have the minimum years of life lost (1.73 years) and minimum cost (84,149 TL). When the results of 40 years period were analyzed, years of life lost and costs are 2.06 years and 119,604 TL, 2.13 years and 162,115 TL, 2.13 years and 161,642 TL, 6.52 years and 147,245 TL, 3.20 years and 132,157 TL, 4.10 years and 151,059 TL and 3.05 years and 138,182 TL for tenofovir, entecavir, entecavir-tenofovir, lamuvidine, lamuvidine-tenofovir, telbivudine and telbivudine-tenofovir.

CONCLUSIONS

In the model presented in this study, in cost effectiveness analysis about CHB treatments, Tenofovir was found to be one of the cost effective methods in comparison with other treatment strategies different time intervals. Beyond this achievement Tenofovir has shown to reduce cumulative treatment cost in first line CHB treatment when compared with regard to 40 year cumulative treatment cost.

Characterization of Acute and Chronic Hepatitis B Virus Genotypes in Canada

Objective

The prevalence and distribution of hepatitis B virus (HBV) genotypes in Canada is not known. Genotypic analysis may contribute to a better understanding of HBV strain distribution and transmission risk.

Methods

HBV surface antigen (HBsAg) positive samples of acute (n = 152) and chronic (n = 1533) HBV submitted for strain analysis or reference genotype testing between 2006 and 2012 were analyzed. The HBsAg coding region was amplified to determine the HBV genotype by INNO-LiPA assay or sequence analysis. Single and multivariate analyses were used to describe genotypes’ associations with known demographic and behavioral risk factors for 126 linked cases of acute HBV.

Results

Nine genotypes were detected (A to I), including mixed infections. Genotype C (HBV/C) dominated within chronic infections while HBV/D and A prevailed among acute HBV cases. History of incarceration and residing with a chronic HBV carrier or injection drug user were the most frequently reported risks for acute HBV infection. Over time, HBV/A increased among both acute and chronic infections, and HBV/C and HBV/D decreased among chronic infections.

Conclusion

Chronic and acute HBV genotypes in Canada differ in the relative distribution and their associations with known risk factors, suggesting different routes of transmission and clinical progression of infection.

An economic analysis of adult hepatitis B vaccination in China

BACKGROUND AND OBJECTIVE

With the universal infant hepatitis B vaccination (HepB) program, China has made remarkable achievements to prevent and control hepatitis B. In order to further reduce hepatitis B virus (HBV) infection, the Chinese government is considering implementing a widespread adult HBV vaccination campaign. We performed an economic analysis of two different adult HepB vaccination strategies for 21-59-years-olds: vaccination without screening and screening-based vaccination.

METHODS

Cost-benefit analyses were conducted. All 21-59-year-olds were divided into two groups: young adults (ages 21-39) and middle-aged adults (ages 40-59). Costs and benefits were estimated using the direct cost and societal (direct and indirect costs) perspectives. All costs and benefits were adjusted to 2014 US dollars, where future values were discounted at a 3% annual rate. We calculated benefit-cost ratios (BCRs) of the two vaccination strategies for the two different age groups. Sensitivity analyses varied key parameters within plausible ranges.

RESULTS

Among young adults, the direct and societal BCRs for a vaccination campaign with no screening would be 1.06 and 1.42; with a screening-based vaccination campaign, the model estimated the direct and societal BCRs would be 1.19 and 1.73. Among middle-aged adults, the direct and societal BCRs for a vaccination campaign without screening would be 0.59 and 0.59; with a screening-based vaccination campaign, the model estimated the direct and societal BCRs would be 0.68 and 0.73.

CONCLUSION

The results of our study support a HepB vaccination campaign for young adults. Additionally, a vaccination campaign with screening appeared to provide greater value than a vaccination without screening.

Hepatitis B virus screening before adjuvant chemotherapy in patients with early-stage breast cancer: a cost-effectiveness analysis

Most patients with hepatitis B virus (HBV) have no symptoms, and many are unaware of the infection. However, HBV can reactivate with immunosuppression; chemotherapy causes reactivation in 22 % of hepatitis B surface antigen-positive patients. HBV reactivation can be fatal. HBV reactivation can be prevented, provided that HBV is recognized prior to chemotherapy. The objective of this study is to estimate the health and economic effects of HBV screening strategies in patients receiving adjuvant chemotherapy for breast cancer. We developed a state-transition microsimulation model to examine the cost-effectiveness of three HBV screening strategies: (1) "No screening"; (2) "Screen-and-Treat to prevent reactivation" (screen-all) with either lamivudine/tenofovir (LAM/TDF) or entecavir (ETV); and (3) "Screen-and-Treat high-risk only" (screen-HR) and treat with either LAM/TDF or ETV. Model data were obtained from the published literature. We used a payer's perspective, a lifetime horizon, and a 5 % discount rate for the analysis. "Screen-all" would prevent at least 38 severe reactivations per 100,000 persons screened over the lifetime of the cohort. "Screen-all" was associated with an increase of 0.0034-0.0035 QALYs and an additional cost of C$164-C$266 per person, which translated into an incremental cost-effectiveness ratio of C$47,808/QALY-C$76,527/QALY gained compared with "No screening" depending on the antiviral therapy received. "Screen-all" was the most cost-effective strategy, while "Screen-HR" was inferior in all scenarios tested. HBV screening before adjuvant chemotherapy for breast cancer patients would prevent a significant number of reactivations, would likely be moderately cost-effective, and may extend the lives of breast cancer patients.