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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., Competing Interests: Competing interests: Harry Janssen has received consultant fees and honoraria from Aligos, Antios, Arbutus, Eiger, Gilead Sciences, GSK, Janssen, Merck, Roche, VBI Vaccines, Vir Biotechnology and Viroclinics. Jordan Feld has received consultant fees from AbbVie, Antios, Arbutus, Eiger, Enanta, BlueJay, GSK, Janssen and Roche. Mia Biondi has received honoraria from Gilead and AbbVie. Hemant Shah has received consultant fees and honoraria from AbbVie, Gilead, Intercept and Lupin SCOPE. He has also received travel support and is a member of the advisory boards of AbbVie, Gilead, Intercept and Lupin. Homie Razavi was a member of the advisory boards of Gilead, AbbVie, Abbott, Merck, Janssen, Roche and VBI Vaccines. He is also a member of the board of directors of the Center for Disease Analysis Foundation. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Ontario is 1 of 5 provinces that immunize adolescents for hepatitis B virus (HBV), despite the World Health Organization recommendation for universal birth dose vaccination. One rationale for not vaccinating at birth is that universal prenatal screening and related interventions prevent vertical transmission. The aims of our study were to evaluate the uptake and epidemiology of prenatal HBV screening, and to determine the number of children in Ontario with a diagnosis of HBV before adolescent vaccination., Methods: We extracted data from ICES, Public Health Ontario and Better Outcomes & Registry Network (BORN) Ontario databases. We assessed prenatal screening uptake and prevalence of prenatal hepatitis B surface antigen (HBsAg) from 2012 to 2016, as well as subsequent hepatitis B e-antigen (HBeAg) and HBV DNA testing and percent positivity. We used age and region to subcategorize the results. In a separate unlinked analysis, we evaluated the number of children positive for HBV aged 0-11 years who were born in Ontario from 2003 to 2013., Results: From 2012 to 2016, 93% of pregnant women were screened for HBV, with an HBsAg prevalence of 0.6%. Prevalence of HBsAg increased with age, peaking at older than 45 years at 3%. North Toronto had the highest overall prevalence of 1.5%, whereas northern Ontario had the lowest. Of women who were HBsAg positive, HBeAg and HBV DNA tests were subsequently ordered in 13% and 38%, respectively. Of children born in Ontario between 2003 and 2013, 139 of 23 759 tested positive for HBV., Interpretation: Prenatal HBV screening is not universal and subsequent evaluation is poor, limiting optimal intervention and possibly contributing to some Ontario-born children being given a diagnosis of HBV before age 12 years. These findings underscore the limitations of the province's adolescent vaccination strategy., Competing Interests: Competing interests: Tony Mazzulli reports serving as a speaker, consultant or advisory board member for Merck, Pfizer, Qvella, Microbix, Roche, Verity Pharmaceuticals and Cipher Pharmaceuticals, and receiving research funding from Qvella and bioMérieux. Harry Janssen reports serving as a speaker, consultant or advisory board member for AbbVie, Arbutus, Benitec, Bristol Myers Squibb, Gilead Sciences, Glaxo, Janssen, Medimmune, Merck, Roche and Vir Biotechnology, and receiving research funding from AbbVie, Bristol Myers Squibb, Gilead Sciences, Janssen, Medimmune, Merck and Roche. Jordan Feld reports receiving research support or consulting fees from Abbott, AbbVie, Enanta, Gilead, Janssen, Roche, Arbutus and GlaxoSmithKline. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)