Nearly 850,000 people in the United States are living with chronic hepatitis B virus (HBV) infection, and about 14,000 people die from it each year. About two out of three patients are not aware of their infection, so HBV transmission often occurs unknowingly.
However, chronic HBV infection rates can be reduced by screening at-risk adults, increasing HBV vaccination rates and linking patients with the infection to care.
These recommendations were included in a joint clinical guideline(annals.org) from the American College of Physicians (ACP) and the CDC that was published online Nov. 21 in Annals of Internal Medicine.
"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, M.D., in a news release.(www.acponline.org) "Hepatitis B vaccination and screening are cost-effective interventions to reduce the burden of chronic hepatitis B infection. Utilization, however, remains low."
Transmission of HBV occurs when blood, semen or another body fluid from an individual with HBV infection enters the body of another person. This can happen through sexual contact, by sharing needles or syringes, or via transmission from mother to baby at birth.
- The American College of Physicians and CDC released a clinical guideline on hepatitis B virus (HBV) infection that covers vaccination, screening and linking patients to care.
- The guideline, published online Nov. 21 in Annals of Internal Medicine, includes three best practice statements.
- The recommendations are generally consistent with the AAFP's current recommendations on HBV immunization and screening.
HBV infection can be a short- or long-term illness for patients. For those with chronic HBV infection, 15 percent to 40 percent will develop cirrhosis, hepatocellular carcinoma or liver failure, and 25 percent will die prematurely from these complications.
The ACP's High Value Care Task Force and the CDC developed their guideline using a narrative literature review of clinical guidelines, systematic reviews, randomized trials and intervention studies on hepatitis B vaccination, screening and linkage to care that were published between January 2005 and June 2017.
Selected resources were then screened to include the most recent guidelines on vaccination, screening and treatment for chronic HBV infection; barriers to screening and linkage to care; adverse events associated with vaccination; and strategies to increase screening, vaccination and linkage to a health care professional experienced in treating HBV infection.
The resulting ACP/CDC guideline offers three best practice advice statements on HBV vaccination, screening and linkage to care.
Best Practice Advice Statement No. 1
Clinicians should vaccinate all unvaccinated adults at risk for HBV infection, including those who
- are at risk by sexual exposure (sex partners of hepatitis B surface antigen [HBsAg]-positive people, sexually active individuals who are not in a mutually monogamous relationship, people seeking evaluation or treatment for a sexually transmitted infection, and men who have sex with men [MSM]);
- are at risk by percutaneous or mucosal exposure to blood (adults who are recent or current users of injection drugs; household contacts of people who are HBsAg-positive; residents and staff of facilities for people with developmental disabilities; incarcerated, health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids);
- have chronic liver disease, including but not limited to hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis or an alanine aminotransferase (ALT) or aspartate aminotransferase level greater than twice the upper limit of normal;
- have end-stage renal disease, including those receiving predialysis care, hemodialysis, peritoneal dialysis and home dialysis; and
- have HIV infection.
Additional patients who should be vaccinated include
- pregnant women who are at risk for HBV infection during pregnancy (e.g., have had more than one sex partner during the previous six months, have been evaluated or treated for a sexually transmitted infection, have recent or current injection drug use, or have an HBsAg-positive sex partner);
- international travelers to regions with high or intermediate levels of endemic HBV infection; and
- any adult seeking protection from HBV infection.
"Hepatitis B vaccination is the most effective measure to prevent HBV infection and its complications," said Winston Abara, M.D., Ph.D., CDC medical epidemiologist, in the news release. "Because of HBV transmission risk and low hepatitis B vaccination coverage, increasing hepatitis B vaccination coverage among unvaccinated adults is essential."
Best Practice Advice Statement No. 2
Clinicians should screen high-risk patients for HBV infection (using HBsAg, antibody to hepatitis B core antigen and antibody to HBsAg serologic testing), including patients who are
- born in countries with 2 percent or higher HBV prevalence,
- users of injection drugs,
- household and sexual contacts of people with HBV infection,
- requiring immunosuppressive therapy,
- with end-stage renal disease (including hemodialysis patients),
- blood and tissue donors,
- infected with hepatitis C virus,
- with elevated ALT levels (greater than or equal to 19 IU/L for women and greater than or equal to 30 IU/L for men),
- infants born to HBV-infected mothers.
Best Practice Advice Statement No. 3
Clinicians should provide or refer all patients identified as having HBV infection (i.e., HBsAg-positive) for post-test counseling and hepatitis B-directed care.
Additionally, the two groups recommended that all patients with chronic HBV infection should be routinely evaluated for hepatocellular carcinoma and treatment eligibility through a history and physical exam.
Finally, in addition to the three best practice advice statements, the guideline discussed barriers to HBV vaccination, screening and linkage to care and offered evidence-based strategies to overcome them.
Family Physician's Perspective
Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that these recommendations are generally consistent with the AAFP's current recommendations on HBV immunization and screening.
In addition, the ACP/CDC guideline reflects the CDC's Advisory Committee on Immunization Practices' recommendations for immunizing against hepatitis B, which the AAFP supports.
Although the new guideline is generally consistent with the AAFP's HBV screening recommendations, it does expand the screening group to include patients with end-stage renal disease and those with hepatitis C infection, Frost said.
"The rate of hepatitis B infection is decreasing in this country, largely due to immunization," she said. "The AAFP is committed to disease prevention through immunization, screening and healthy lifestyle choices."
"The ACP and CDC have written a guideline that shares that goal, highlighting the need to do a better job by increasing immunization and screening for high-risk populations."
Related AAFP News Coverage
ACIP Offers Revised, Single-dose HepB Infant Revaccination Option