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To streamline best practices on hepatitis B (HBV) screening and linkage to care, the American College of Physicians’ (ACP) High Value Care Task Force and the Centers for Disease Control and Prevention (CDC) are recommending sweeping procedures for vaccinating and screening high-risk individuals. The guidelines were published in the Annals of Internal Medicine. ACP and CDC made their recommendations after conducting a scientific literature review of studies and clinical guidelines for HPV published over the last 12 years, from 2005 to present.
“Hepatitis B vaccination is the most effective measure to prevent HBV infection and its complications,” said CDC medical epidemiologist Winston Abara, MD, PhD, in a statement. “Because of HBV transmission risk and low hepatitis B vaccination coverage, increasing hepatitis B vaccination coverage among unvaccinated adults is essential,” he said. The infection leads to approximately 14,000 deaths annually in the United States. About 847,000 people have chronic HBV infection in this country, yet many don’t even know they’re infected. This leads to continuous infection of the virus, according to the ACP-CDC guidelines.
“The majority of persons at risk for or infected with the hepatitis B virus do not get screened, vaccinated, or linked to care,” said ACP President Jack Ende, MD, MACP, in a statement. “Hepatitis B vaccination and screening are cost-effective interventions to reduce the burden of chronic hepatitis B infection. Utilization, however, remains low.”
In addition to recommending immunization for all unvaccinated adults at risk for infection, the guideline calls for HBV screening in high-risk individuals, such as those born in countries where HBV prevalence is at 2% or higher. Doctors should screen men who have sex with men, those who inject drugs or are HIV positive, as well as household and sexual contacts of HBV-infected individuals. Other populations that should get screened include blood and tissue donors, individuals who have been incarcerated, individuals with end-stage renal disease and on hemodialysis or those needing immunosuppressive therapy, those with hepatitis C virus, individuals with elevated alanine aminotransferase levels, and pregnant women and infants born to HBV-infected mothers.
All HBV-identified patients should be referred for post-test counseling and HBV-directed care. “Although not all patients with chronic HBV infection require treatment, they all should be routinely evaluated for hepatocellular carcinoma and treatment eligibility through history and physical examination,” advised ACP-CDC.
The recommendations list the various clinical states for HBV infection and what courses of action to take in light of test results. As an example, a patient with chronic HBV infection who tests positive for hepatitis B surface antigen (HBsAg) and for total antibody to hepatitis B core antigen (anti-HBc) but negative for total antibody to hepatitis B surface antigen (anti-HB) should receive HBV-directed care. The groups recommend the same course of action for someone with an acute infection with similar test results (a positive result for IgM anti-HBc).
However, for a patient with a resolved infection who tests negative for HBsAg but positive for total anti-HBc and anti-HB, counseling and reassurance is recommended. Someone who is susceptible to HBV but has never been infected or vaccinated should be immunized, according to the ACP-CDC guidelines.
For those with an isolated core antibody (which may result from a false-positive test result or other factors) who test positive for total anti-HBc, the course of action may vary depending on that individual’s circumstances.