Hepatitis B screening recommendations

​​The American College of Physicians and the CDC recently published their "best practice advice" for Hepatitis B vaccination, screening and linkage to care (see DOI: 10.7326/M17-1106​, or http://annals.org/aim/fullarticle/2664089/hepatitis-b-vaccination-screening-linkage-care-best-practice-advice-from ).

Details:

--Vaccination:

    --it works, with about 90% effectiveness in healthy adults <40 yo. Since implementation of universal vaccination of newborns, the number of acute hep B virus (HBV) infections in adults​ has decreased from 9.6 per 100,000 people in 1982 to 1.1 per 100,000 in 2015

    --Recommendations are to vaccinate all adults at risk: sexual and household contacts of HBsAg-positive persons, sexually active people not in mutually monogamous relationships [often hard to know for sure....], people seeking evaluation for STIs, MSM, recent or current injection drug users, residents and staff at facilities for developmentally-challenged persons; incarcerated persons; health care workers and public safety employees at risk for exposure to blood or blood-contaminated body fluids; adults 19-59 yo with diabetes; people with ESRD including those on any type of dialysis; people with chronic liver disease, including but not limited to hepatitis C, cirrhosis, NAFLD, alcoholic liver disease, autoimmune liver disease or ALT or AST levels >twice upper limit of normal; pregnant women who are at risk during pregnancy (>1 sex partner in past 6 months, previous eval or treatment for STI, recent or current injection drug use (IDU), or HBsAg-positive sex partner); HIVinfected people; international travelers to regions with high or intermediate levels of endemic infection (see below); and any adult seeking protection from HBV infection. [for many of these, i would screen first for those at high risk and vaccinate if negative. my concerns are that vaccination is unnecessary/costly/and occ has adverse effects; and that just vaccinating these high-risk people would not detect those who were positive in order to do the appropriate follow-up/treatment, as below. my guess is that this is what they meant, though not explicitly noted]

    ​--and, those in the following settings should be assumed to be at high risk: STI treatment facilities, HIV testing and treatment facilities, facilities for patients with drug abuse programs, health care settings targeting IDUs and MSM, correctional facilities, hemodialysis facilities and ESRD programs, institutions and nonresidential programs for developmentally disabled persons

    --immunocompromised persons (HIV, ESRD) often need higher doses of vaccine, and these people should be tested with HBsAb levels (should be >10) post-vaccination, and those with lower levels be revaccinated

--Screening:

    --screen with HBsAg, HBcAb and HBsAb

   -- high risk populations to screen:

        ​--all persons from intermediate (2-7% prevalence) or high HBV prevalence (>7%); overall high risk is defined as 2% prevalence or higher: all of Africa and Asia, Central America (Guatemala and Honduras), South America (Bolivia, Brazil, Colombia, Ecuador, Guyana, Suriname, Venezuela), Caribbean (Antigua and Barbuda, Dominica, Grenada, Haiti, Jamaica, St Kitts, St Lucia, Turks and Caicos), Eastern Europe (all but Hungary), Middle East (all but Cyprus and Israel), North America (indigenous peoples in northern Canada), South Pacific (all but Australia and New Zealand), Western Europe (Malta and indigenous peoples in Greenland)

        --MSM

        --persons who inject drugs

        --HIV-positive

        --household and sexual contacts of HBV infected persons

        --people on immunosuppressive therapy

        --people with ESRD (including hemodialysis)

        --people with hepatitis C (cases reported of HBV reactivation in those being treated with direct-acting antivirals for Hep C

        --people with hepatic inflammation with ALT> 19 IU/L for women and >30 IU/L for men

        --incarcerated people

        --pregnant women (can screen just with HBsAg)

        --infants born from HBV-positive women

--Linkage to care:

    ​--all patients who have chronic HBV infection should be linked to care and potential treatment, including regular monitoring HBV DNA levels, liver aminotransferases, and hepatocellular carcinoma (HCC) surveillance

--Harms of screening:

    ​--vaccination: soreness at injection site (3-29%), mild fever (1-6%).  Anaphylaxis rate of 1 per 1.1 million doses. vaccine contraindicated in people with yeast allergies

--Cost

    ​--incremental cost-effectiveness ratio with routine vaccination = $3500 per quality-adjusted life-year (QALY) gained. Screening and treatment of immigrants from HBV-endemic areas <$50,000 per QALY gained (considered to be cost-effective); more recent CDC estimates are <$18,009

    --cost of vaccine: $24-62 per dose; much lower than cost of treatment of HBV ($4000-$26000), decompensated cirrhosis ($38,932-$153,110), liver transplant ($343,241-$514,862) in the first year.

    --cost of screening those from countries with HBV prevalence >2%: $750-$3752 per case of chronic HBV identified

--Systems approaches to improving screening and vaccination include using EMR-based reminders, or other reminder/recall systems when vaccines are due as well as prompts for screening (these have shown large increases in appropriate vaccinations and screenings). Culturally-competent peer navigators can also help overcome system-level barriers to care

Commentary:​

--approx 847,000 people in the US are living with chronic HBV infections, with an attributable 14,000 deaths a year.

--60% of infected patients are unaware that they are, and therefore more likely to lead to ongoing transmission

--70% of infected people are foreign-born, with prevalence of 3-5% of foreign born people in the US (vs 0.3% in general population)

--15-40% of people with chronic HBV develop cirrhosis, HCC, or liver failure.  25% of these persons die prematurely as a result

--total direct and indirect costs in the US are around $1 billion

--and only 24.6% of US adults have received the complete vaccination series

    --20.7% of foreign-born adults in the US vs 25.5% of US-born adults have had vaccination coverage

    --25.3% of US adults with insurance coverage have had vaccination vs 19.4% of those without insurance

--and only 10-15% of appropriate chronic HBV infected patients receive treatment, 40-78% get ALT monitoring, <40% are monitored for HBV levels​

--linking HBV patients to treatment is a long-term endeavor: there needs to be repeated blood tests and HCC surveillance every 6-12 months

so, these recommendations are pretty similar to those from the past couple of decades. probably the most commonly missed populations are the foreign-born from the higher risk countries (certainly a large % of foreign-born in Boston and probably most larger cities) and those without insurance (which, of course, is a pretty awful situation in the wealthiest, resource-rich country in the world). as with most failures in implementing appropriate clinical practice, the issue is really developing systems to identify and test/vaccinate/treat patients.  it is quite difficult to focus on these types of issues as a busy clinician trying to help patients through their array of urgent medical/psychosocial issues in a quite limited visit time. but having seen many patients with chronic HBV and the sequelae, along with their dramatic effects on patient's/family's health and well-being, it is pretty clear that early identification of high-risk patients and immunizing them if appropriate is the most important strategy. And we need systems/resources to support that.

to be added to the email list: contact me at gmodest@uphams.org

Geoffrey Modest, MD