Selected and summarized by Ronald O. Valdiserri, MD, MPH, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, and Co-Chair of HepVu.
Dr. Valdiserri reviews significant articles on prevention, public health, and policy advances in viral hepatitis. This month, he highlights “Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations – United States, 2023.” Conners E, Panagiotakopoulos L, Hofmeister MG, Spralding PR, Hagan LM, et al. MMWR Recommendations and Reports. 2023.
What question(s) does this study address?
Persons with chronic hepatitis B virus infection are more likely to die prematurely, compared to the general population, from liver cancer, cirrhosis, and other conditions. The Centers for Disease Control and Prevention (CDC) estimates that 580,000 to 2.4 million people in the U.S. are living with chronic hepatitis B infection and that two-thirds of these individuals are unaware of their infection. Although there is currently no cure for hepatitis B, antiviral treatment and medical monitoring can reduce the morbidity and mortality associated with chronic infection.
Hepatitis B infection status can be determined by three reliable and relatively inexpensive blood tests: hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and antibody to hepatitis B core antigen (anti-HBc). The presence of HBsAg for at least 6 months indicates chronic infection. The presence of anti-HBs after a decline of HBsAg indicates recovery from hepatitis B infection and total anti-HBc is present in those with a current or resolved hepatitis B infection–but it is not present in those who have received a hepatitis B vaccine.
Prior to the current report, recommendations for hepatitis B screening were risk-based, as determined by a history of certain behaviors (e.g., injection drug use or male-to-male sex), or an individual’s country of birth (e.g. high prevalence regions like Asia and Africa). This report updates the 2008 recommendations by providing evidence to support universal hepatitis B screening for all adults 18 years of age or older.
What are the major findings of this report/article?
- Relying solely on risk-based testing has failed to identify most persons living with chronic hepatitis B infection in the United States and is “inefficient” for providers to implement.
- Universal screening for hepatitis B is cost-effective. A recent model predicted that compared with risk-based screening, one-time, universal HBV screening among adults would avert additional cases of cirrhosis, liver cancer, and hepatitis B-related deaths at an estimated savings of $263,000/100,000 adults screened.
- A triple panel is recommended for initial screening (i.e., HBsAg, anti-HBs, and total anti-HBc) as the results will indicate who has active hepatitis B infection and requires care, those with resolved infection, those who are susceptible to infection (and require vaccination), and those who’ve been previously vaccinated.
- Evidence provided in the report indicates that the potential harms of universal screening for hepatitis B do not outweigh its potential benefits.
- The report reiterates previous recommendations that all pregnant persons should be screened for hepatitis B during each pregnancy, regardless of vaccination status or history of past hepatitis B testing.
- The report continues to recommend hepatitis B testing for persons with known risk factors and expands risk-based testing to include incarcerated or formerly incarcerated persons, persons with a history of sexually transmitted infections or multiple sex partners, and persons with a history of hepatitis C.
What are the implications for the prevention and control of viral hepatitis?
- Based on a systematic review and analysis of existing information, the CDC now recommends that all adults 18 years and older should be screened for hepatitis B at least once during their lifetime.
- Implementation of these new screening recommendations should be simpler and less stigmatizing than having to question individuals about past risk behaviors or practices.
- These recommendations complement the 2022 Advisory Committee on Immunization Practices (ACIP) recommendation to vaccinate all adults aged 19-59 years for hepatitis B, because universal screening will identify susceptible individuals in need of vaccination.
- Increasing the diagnosis of chronic hepatitis B infection through universal screening will help to promote entry into hepatitis B care and may help to reduce viral transmission to close contacts.
- Widespread implementation of these recommendations will help to advance viral hepatitis elimination goals by reducing hepatitis B-related morbidity and mortality and, along with vaccination strategies, decrease the prevalence of hepatitis B infections.