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Serologic testing, guideline adherence low among veterans with HBV in VA care
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BOSTON — Hepatitis B virus is common among US veterans, but new data indicate that rates of serologic testing and adherence to treatment guidelines in this patient population are low.
“While other chronic viral infections such as hepatitis C virus and HIV have received tremendous educational efforts, hepatitis B virus has received far less attention, particularly outside communities with high numbers from endemic regions,” David E. Kaplan, MD, MSc, a gastroenterologist at University of Pennsylvania and Philadelphia VA Medical Center, said in a press release.
Kaplan and colleagues identified 50,109 veterans (1.9%) in the VA Corporate Data Warehouse who tested positive for HBV surface antigen (HBsAg) between 2002 and 2014. The researchers analyzed whether a variety of tests were performed at any time following the positive HBsAg result.
Seventeen percent of veterans with a positive HBsAg result received testing for hepatitis B core IgM antibody (HBclgM), 23.7% hepatitis B e antigen (HBeAg), 20.7% hepatitis B e antibody (HBeAb), 78.2% hepatitis C virus antibody (HCV Ab), 33.2% HIV antibody (HIV Ab), 4.1% hepatitis D virus antibody (HDV Ab) or HDV RNA, and 14.2% HBV DNA polymerase chain reaction.
“Overall, 25% of individuals received antiviral therapy,” Kaplan said. “Of those individuals [who] we can determine ought to be treated based on HBeAg, alanine aminotransferase and HBV DNA criteria, only about 60% of individuals for whom treatment would likely be appropriate actually received treatment. Individuals referred to a specialist were significantly more likely to receive treatment … given [the] low referral rate, these data are not surprising.”
Among all veterans, 13,144 had ALT levels two times greater than 62 IU/mL; 21.3% received antiviral treatment. Among those with positive HBeAg with HBV DNA greater than 20,000 IU/mL, 72.2% received antiviral therapy. Among those with HBeAg hepatitis and HBV DNA greater than 2,000 IU/mL, 34.7% received antiviral therapy, according to the study abstract.
“Appropriate serological testing is critical for determining whether or not an individual patient meets AASLD treatment criteria for HBV,” Kaplan said. “Our … data definitively demonstrate that antiviral therapy in appropriate individuals has a significant impact on mortality, hepatic decompensation and hepatocellular carcinoma development. Improving adherence with guidelines is likely therefore to reduce death and health care costs.” – by Melinda Stevens
For more information:
Serper M. Abstract 68. Presented at: The Liver Meeting; Nov. 7-11, 2014; Boston.
Disclosure: Kaplan reports receiving grant and research support from Bayer Pharmaceuticals.
Perspective
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Adrian M. Di Bisceglie, MD, FACP
We need to have a continued focus on HBV because it remains a problem here in the United States and abroad. HBV infection rates are four times higher than the general population in our veteran population here in the United States.
This is a retrospective study of care quality and outcomes among a national sample of US veterans. The first thing was that they found out the rates of recommended laboratory testing for HBV range from 26% to 73%, so [that’s] lower than expected. We have standard recommendations for who should be tested for HBV, and these findings show these recommendations are not followed. Then, among patients with HBV, the rates of screening for liver cancer and treatment of antiviral therapy were low as well, and only 38% received antiviral treatment.
I believe based on my own experience that what is described here within the VA system is mirrored in the rest of the country. Individuals who should be tested for HBV are not being tested.
Those recommendations were updated by the CDC in 2008 to call for screening of all persons born in countries where HBV is endemic, wherever the rate of HBV is more than 2%, those individuals who immigrate to the United States need to be tested. If you look at the map provided by the CDC, that’s everywhere except Northern Europe, Australia and a little bit of Argentina. If someone comes from anywhere in Africa, anywhere in East Asia, anywhere in Eastern Europe, Southern Europe, the recommendation is that they be tested because they may have a high frequency [of HBV].
Among Asians, we have screening programs in St. Louis where we’ve been working with a community for 8 to 10 years. The frequency for HBV ranges from 8% to 9%. That’s nearly one in 12 individuals in these Asian communities [who] have HBV. The only way we’ll find out is by testing them, and what this VA experience tells us is that is not going to happen. We need to raise awareness about this.
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