CDC recommends hepatitis B testing for all adults
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The CDC has updated its guidance for hepatitis B testing for the first time since 2008 and now recommends that all adults in the U.S. be tested for HBV at least once in their lifetime.
“Chronic hepatitis B virus (HBV) infection can lead to substantial morbidity and mortality,” Erin E. Conners, PhD, epidemiologist at the CDC’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, and colleagues wrote, adding that an estimated 580,000 to 2.4 million people are living with HBV infection in the U.S., of whom two-thirds might be unaware of their infection.
“Although treatment is not considered curative, antiviral treatment, monitoring and liver cancer surveillance can reduce morbidity and mortality,” Conners and colleagues wrote.
The authors wrote that a more universal screening approach will enable identification of infections, as well as people at risk for potential infections, and lead to appropriate infection management.
It could also identify people who would benefit from HBV vaccination, which was recently recommended by the CDC’s Advisory Committee on Immunization Practices for all adults aged 19 to 59 years.
In an MMWR report, Conners and colleagues provided updates to the CDC’s guidance for HBV testing after they performed a systematic literature review of existing research and recommendations to assess how adult universal screening for HBV affects the number and composition of people who screen positive for HBV infection and what the harms of HBV screening could be.
Based on these efforts, the updated CDC guidance advises testing for:
- all adults aged 18 years and older at least once during a lifetime (new recommendation);
- all pregnant persons during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing;
- everyone with a history of risk for HBV infection, regardless of age, if they might have been susceptible during the period of risk, including those who have never been infected with HBV and either did not complete an HBV vaccine series per ACIP recommendations or who are known vaccine nonresponders;
- susceptible persons, regardless of age, with ongoing risk should be tested periodically, while risk persists;
- anyone who requests HBV testing, regardless of disclosure of risk, “because many persons might be reluctant to disclose stigmatizing risks” (new recommendation);
- people who have an increased risk for acquiring HBV infection, including infants born to HBsAg-positive pregnant women, people born in regions with HBV infection prevalence of 2% or more, U.S.-born people not vaccinated as infants whose parents were born in regions with HBV infection prevalence of 8% or higher, injection drug users or those with a history of it, people currently or formerly incarcerated, people with HIV, people with hepatitis C virus infection or a past HCV infection (new recommendation), and men who have sex with men.
The CDC plans to review these recommendations as new treatments, tests, epidemiology, hepatitis B vaccination rates and experience gained after implementation of these recommendations become available and will revise them as needed.
“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 U.S., and advance viral hepatitis elimination goals."
Perspective
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The CDC’s updated guidance to recommend universal HBV screening for adults provides us with the critical missing tool we need to eliminate HBV in the U.S. and ensure that every person with chronic HBV is aware of their diagnosis and appropriately linked to care. This new universal HBV screening recommendation, in coordination with the CDC’s ACIP’s decision to recommend universal HBV vaccination for adults aged 19 to 59 years and ongoing universal infant and childhood HBV vaccination enables every person to know their HBV status and receive the vaccine if they are susceptible to infection. Not only does this universal screening recommendation have the potential to reduce racial and ethnic health disparities and improve health outcomes, but it also allows us to proactively prevent HBV outbreaks in the setting of the opioid epidemic.
In order to achieve HBV elimination in the U.S., it is essential that primary care clinicians implement these new universal screening recommendations in clinical practice, including testing for HBV surface antigen (HBsAg), antibody to HBV surface antigen (anti-HBs) and antibody to HBV core antigen (total anti-HBc); ensure that individuals diagnosed with chronic HBV are linked to follow-up care; continue implementation of recommended universal childhood and adult HBV vaccine guidelines, including vaccinating all those found susceptible to HBV during screening; and consider implementing clinic protocols similar to those used for universal adult HIV and HCV screening to ensure all adults are screened for HBV.
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