According to a report from the Institute of Medicine(nationalacademies.org), or IOM, inadequate resources are being allocated to viral hepatitis prevention, control and surveillance programs in the United States, and a lack of awareness among health care professionals and people in at-risk populations is creating a barrier to prevention and control efforts.
Many health care providers -- especially primary care health professionals -- are unaware of the high prevalence of hepatitis B virus, or HBV, and hepatitis C virus, or HCV, infection in some U.S. populations and often fail to identify infected individuals and those at risk for infection so they can be managed appropriately, says the report.
However, some of the actions recommended in the report -- specifically those related to screening -- conflict with existing guidelines from the AAFP and the U.S. Preventive Services Task Force, or USPSTF.
About 5 million Americans are living with chronic hepatitis B or hepatitis C, says the report, and an estimated 43,000 Americans develop acute HBV infections each year. In addition, 15,000 people annually die of liver disease related to hepatitis B or hepatitis C.
"Unless action is taken to prevent chronic hepatitis B and hepatitis C, thousands more Americans will die each year from liver cancer or liver disease related to these preventable diseases," the report warns.
It singles out primary care providers (e.g., physicians, physician assistants and nurse practitioners) and social services providers (e.g., staff of drug treatment programs, needle-exchange programs and immigrant services centers) as having "generally poor" knowledge of chronic hepatitis B and hepatitis C.
For example, says the report, one survey of primary care health professionals found that 44 percent of respondents didn't know that chronic HBV infection could be controlled with medication.
The report calls for improved surveillance and integration of viral hepatitis services. Specifically, it recommends that the CDC collaborate with stakeholders -- including professional and health care organizations and educational institutions -- to develop educational programs for health care and social services providers that address factors such as
- the overall incidence and prevalence of acute and chronic HBV and HCV infection;
- guidance on screening for risk factors;
- prevention strategies and monitoring of chronically infected patients;
- prevention of transmission in health care settings; and
- health care disparities related to hepatitis B and hepatitis C.
The CDC's Advisory Committee on Immunization Practices, or ACIP, has recommended that children in the United States receive routine hepatitis B vaccinations since 1991. According to the CDC(www.cdc.gov), the reported incidence of acute HBV infection in children and adolescents dropped by more than 95 percent from 1991 to 2007, and the overall incidence among all age groups decreased by 75 percent.
A 2008 CDC survey(www.cdc.gov) estimated that nearly 92 percent of teens ages 13-15 had completed the three-dose hepatitis B vaccine series.
Still, say the report's authors, in 2004, less than 55 percent of adults considered to be at increased risk for HBV infection had received the vaccine. Among health care workers, who are one of the groups recommended for vaccination, only 75 percent had received the three-dose vaccine series.
Martin Sepulveda, M.D., vice president of integrated health services for IBM Corp. and a member of the IOM committee that produced the report, told AAFP News Now that there were few instances when the committee was at odds with the ACIP's recommendations. However, he noted, committee members wanted more clarity from the USPSTF regarding subpopulations for whom routine, aggressive HBV screening is warranted.
The IOM committee defined a two-part process for identifying infected individuals:
- risk-factor screening (i.e., determining whether a person is at risk for being chronically infected or becoming infected with HBV or HCV, such as by being born in a country where the disease is prevalent or engaging in specific high-risk behaviors, including illicit drug use and having multiple sexual partners) and
- serologic testing (i.e., laboratory testing of blood specimens for biomarker confirmation of hepatitis B or hepatitis C viral infection).
From that perspective, said Sepulveda, "screening" doesn't necessarily mean serologic testing but, rather, screening for risk by first asking questions. For primary care physicians, he added, this means that they need to understand not only where their patients were born, but also where their patients' parents were born, because the risk is highest for first-generation immigrants.
Both the AAFP and the USPSTF recommend using serologic testing to screen all pregnant women for HBV during their first prenatal visit. However, the two groups recommend against routinely screening the general asymptomatic population for chronic HBV infection, saying that strategies used to identify individuals at high risk have poor predictive value because 30 percent to 40 percent of infected individuals don't have any easily identifiable risk factors.
The main risk factors for HBV infection in the United States, according to the USPSTF, include
- diagnosis with an STD,
- a history of intravenous drug use or sexual contact with multiple partners,
- male homosexual activity, and
- household contacts of chronically infected individuals.
In addition to the at-risk groups specifically identified by the USPSTF, the American Association for the Study of Liver Diseases recommends that the following groups also be screened for HBV infection using serologic testing:
- inmates of correctional facilities;
- people with chronically elevated alanine transaminase or aspartate transaminase levels;
- people infected with HCV or HIV;
- patients undergoing renal dialysis; and
- people born in areas with high and intermediate prevalence rates of HBV infection.
In the long term, said Doug Campos-Outcalt, M.D., M.P.A., who is the AAFP's liaison to the ACIP, concerns about hepatitis B screening could prove moot, given the continuing success of national efforts to boost hepatitis B vaccine uptake among children and adolescents.
The IOM report is similarly critical of primary care health professionals' knowledge about hepatitis C, although it acknowledges that far less research has been published on this topic.
The AAFP and the USPSTF recommend against routine screening for HCV infection in asymptomatic adults who are not at increased risk. In addition, the Academy and the task force have found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk for infection.
The USPSTF said in its recommendations that it found no evidence that screening for HCV infection in high-risk adults improves long-term health outcomes.
Campos-Outcalt, who also is associate head of the department of family and community medicine at the University of Arizona College of Medicine, Phoenix, and the AAFP's staff liaison to the USPSTF, reiterated that hepatitis C screening has not been shown to improve long-term outcomes; in addition, it increases health care costs.
Sepulveda, however, said increased screening for those at high risk could help prevent the spread of disease. He also said the committee's recommendations were based on more recent data than the AAFP and USPSTF recommendations, which were made in 2004.