Approximately 847,000 persons in the United States have chronic hepatitis B virus (HBV) infection; 67% are unaware of their status, and 14,000 die annually. Screening and vaccination are beneficial in identifying and preventing HBV; however, these interventions are often not used, with only about one-fourth of adults receiving a full HBV vaccination series. For these reasons, increasing the use of screening and vaccination is a public health priority.

Because guidance from health care organizations varies, the American College of Physicians (ACP) and Centers for Disease Control and Prevention (CDC) chose to highlight the consensus among these recommendations, with recent evidence, to develop a best practice advice statement for vaccination, screening, care, and treatment of patients at risk of or who currently have HBV infection. Barriers to appropriate vaccination, screening, and care may include patient lack of knowledge about HBV or the vaccine, misinformation, difficulties with language, lack of health insurance, and trouble navigating the health care system. Physician barriers include lack of familiarity with HBV guidelines and risk of infection in certain patient populations.

Vaccination

The HBV vaccination series, which is typically given as three or four doses, is the most effective method for preventing infection and the associated complications. All persons at risk of HBV infection should receive the vaccination. This includes persons at risk because of sexual exposure (e.g., those with a sexually transmitted infection, men who have sex with men, persons who are sexually active and not in a monogamous relationship) or blood exposure (e.g., injection drug users, health care personnel); persons with chronic liver disease (including hepatitis C, nonalcoholic fatty liver and alcoholic liver disease, elevated liver enzymes over twice the upper limit of normal, and autoimmune hepatitis), end-stage renal disease, or human immunodeficiency virus infection; pregnant women at risk of HBV infection (e.g., injection drug user, treated for an sexually transmitted infection); international travelers to regions endemic for HBV infection; and those who want protection from HBV infection. Rare harms of vaccination can include mild fever, injection site soreness, and anaphylaxis.

Screening

Persons at risk of HBV infection should be screened with hepatitis B surface antigen or hepatitis B core antibody or surface antigen antibody testing. These persons include those born in countries with at least a 2% prevalence of HBV, men who have sex with men, injection drug users, persons with human immunodeficiency virus infection, contacts of persons with HBV infection, those receiving immunosuppressive therapy, persons with end-stage renal disease, blood and tissue donors, persons with hepatitis C virus and high alanine transaminase levels, persons who are incarcerated, pregnant women, and infants of women with HBV infection.

Referral

Persons diagnosed with HBV infection should be provided or referred for care, including treatment if needed, hepatocellular carcinoma surveillance, behavioral risk reduction counseling, and vaccination of appropriate contacts. Although only 20% to 40% of patients will ultimately receive treatment, based on history and physical examination including measurement of transaminase levels and HBV DNA levels, all patients evaluated should continue to be monitored for hepatocellular carcinoma.

Guideline source: American College of Physicians and Centers for Disease Control and Prevention

Evidence rating system used? No

Systematic literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Yes

Recommendations based on patient-oriented outcomes? Yes

Published source:Ann Intern Med. December 5, 2017;167(11):794–804

Available at:http://annals.org/aim/fullarticle/2664089/hepatitis-b-vaccination-screening-linkage-care-best-practice-advice-from