All Americans ages 18 and older should be screened for hepatitis B virus (HBV) at least once, according to updated guidelines from the Centers for Disease Control and Prevention (CDC). The change brings the recommendation for hepatitis B in line with universal screening guidelines for hepatitis C and HIV. People at increased risk should be tested more often, and testing should be repeated during each pregnancy.
“Universal screening of adults for HBV infection is cost-effective compared with risk-based screening and averts liver disease and death,” the recommendation authors wrote. “Although a curative treatment is not yet available, early diagnosis and treatment of chronic HBV infections reduces the risk for cirrhosis, liver cancer and death.”
As described in the March 10 edition of Morbidity and Mortality Weekly Report, CDC researchers performed a systematic review of recent research to develop the new recommendations. For example, they looked at studies of HBV prevalence, testing yield (how many people are diagnosed relative to the number tested), how many more people could be linked to treatment and how many new infections could be averted if more people knew their status. They also considered cost-effectiveness and the potential harms of expanded screening.
HBV is a blood-borne virus that can be transmitted via shared needles and personal care tools such as razors, during sex and from mother to child during pregnancy or delivery. But many people with hepatitis B have no obvious risk factors and do not know how they acquired the virus. Vaccination can prevent hepatitis B, and the vaccine is now recommended for all infants, children and adults up to age 60.
Most people who acquire HBV as adults naturally clear the virus, but about 10% develop chronic infection; for those infected as young children, these proportions are reversed. Many people with chronic hepatitis B have no symptoms during its early stages. But over years or decades, chronic HBV infection can lead to serious liver complications, including cirrhosis, liver cancer and liver failure that necessitates a transplant. Hepatitis B can be treated with antiviral medications—including Viread (tenofovir disoproxil fumarate), Vemlidy (tenofovir alafenamide) and Baraclude (entecavir)—and sometimes interferon, but treatment usually does not lead to a cure.
Estimates of the number of people living with hepatitis B in the United States vary widely, ranging up to 2.4 million, and a majority of them do not know they carry the virus, according to the CDC. More than two thirds of people with chronic hepatitis B were born outside the United States.
Prior to the latest update, the CDC recommended HBV testing for a long list of people at increased risk, including those with a history of injection drug use, men who have sex with men, people living with HIV, people born to a mother with hepatitis B, those born in regions where HBV is common, people who have had household or sexual contact with someone known to have hepatitis B and people with elevated liver enzymes.
As part of the new recommendations, the CDC expanded the list to include people with multiple sexual partners or a history of sexually transmitted infections, people who have had hepatitis C and incarcerated individuals. To increase access to testing, the guidance emphasizes that “anyone who requests HBV testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks.”
Irrespective of one-time universal screening, repeat testing is still recommended for those with ongoing risk. The frequency of periodic testing “should be a shared decision between the patient and provider and based on individual risk factors, including age and immune status,” the authors wrote.
In addition, the guidance states that all pregnant people should be tested during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of prior testing, as this can prevent perinatal HBV transmission.
Children and adolescents were not included in the universal screening recommendation because of the low prevalence of hepatitis B and the high level of HBV vaccination in this age group. However, those who have risk factors and are not fully vaccinated should be tested.
In addition to recommending one-time universal screening and expanding the list of groups that could benefit from periodic risk-based testing, the authors recommend that initial screening should use a triple panel test, which can identify people who have active infection and might be eligible for treatment, those with inactive infection that could be reactivated and those who could benefit from vaccination.
Hepatitis B tests are not as straightforward as tests for hepatitis C and HIV. Triple panel tests look for three main markers: hepatitis B surface antigen (HBsAg), hepatitis B surface antibodies (anti-HBs) and hepatitis B core antibodies (anti-HBc). Different combinations show whether a person has acute infection, chronic infection, natural immunity after a prior infection or immunity due to vaccination. In addition, people who test positive for active infection may receive HBV DNA viral load tests to predict disease progression and monitor response to treatment.
Unlike the CDC, the United States Preventive Services Task Force (USPSTF) continues to recommend risk-based hepatitis B testing for adults and adolescents along with screening during each pregnancy. This matters because the Affordable Care Act requires insurers to cover preventive services recommended by USPSTF with no cost sharing. The American Association for the Study of Liver Diseases also recommends risk-based hepatitis B testing. In addition to the CDC’s list, it includes people with diabetes, people who live or work in residential care facilities and those who have traveled to countries with intermediate or high HBV prevalence.
The CDC’s new recommendation for one-time universal screening simplifies decisions about who should get tested and reduces the likelihood that people living with hepatitis B will fall through the cracks.
“Risk-based testing alone has not identified most persons living with chronic HBV infection and is inefficient for providers to implement,” the authors wrote. “Along with vaccination strategies, universal screening of adults and appropriate testing of persons at increased risk for HBV infection will improve health outcomes, reduce the prevalence of HBV infection in the United States and advance viral hepatitis elimination goals.”