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Adults at increased risk for hepatitis B virus (HBV) infection are recommended to receive vaccination. We conducted a cost utility analysis to evaluate approaches for implementing that recommendation in selected high-risk settings: community outreach events with a large proportion of immigrants, syringe service programs, substance use treatment centres, sexually transmitted infection (STI) clinics, tuberculosis (TB) clinics and jails. We utilized a decision tree framework with a Markov disease progression model to compare quality adjusted life-years and cost in 2021 United States dollars from four strategies: a 3-dose vaccination regimen with prevaccination screening and testing (PVST; baseline comparison); PVST at the initial encounter followed by a 2-dose series (Intervention 1); PVST with the first dose of a 2-dose vaccination series at the initial encounter (Intervention 2); and a 2-dose vaccination series without PVST (Intervention 3). In all settings, Intervention 1 resulted in worse health outcomes compared with the baseline strategy. Intervention 2 averted incident chronic HBV infections in all settings (range -9.4% in TB clinics, -14.8% in syringe service programs) and was a cost-saving approach in settings with higher risk of infection (i.e. jails, -$266 per person; syringe service programs, -$597; substance use treatment centres, -$130). Providing a 2-dose vaccination series without any screening (Intervention 3) averted incident HBV infections and was cost-saving in all settings but resulted in more HBV-related deaths in settings with higher HBV prevalence. These results demonstrate a 2-dose vaccine series is a cost-effective approach in these high-impact settings, even if prevaccination testing is not possible.

Objective To describe the management and resolution of acute liver failure (ALF) in two dogs following ingestion of cheese tree (Glochidion ferdinandi) roots. Case summaries A 2-year-old male entire Bullmastiff and a 5-year-old female neutered German Shepherd dog were presented for acute-onset lethargy and vomiting after chewing on tree roots of a cheese tree. Both dogs developed clinical abnormalities consistent with ALF, including hepatic encephalopathy, marked increase in alanine aminotransferase activity and bilirubin concentration, and prolonged coagulation times. Treatment included administration of intravenous fluids, hepatoprotectants, vitamin K1 , antibiotics, lactulose, antacids, antiemetics, and multiple fresh frozen plasma transfusions. Follow-up examinations performed 30 days after initial presentation revealed the dogs to be clinically healthy with serum biochemical and coagulation profiles within reference intervals. New or unique information This is the first report describing ALF in two dogs following ingestion of cheese tree (G. ferdinandi) roots. In this clinical setting, despite a poor prognosis, survival and recovery of adequate liver function were possible with medical management.