Hepatitis B and C Screening
Abstract & Commentary
By Lin H. Chen, MD, Assistant Clinical Professor, Harvard Medical School and Director, Travel Medicine Center, Mt. Auburn Hospital, Cambridge, MA. Dr. Chen has received research grants from the Centers for Disease Control and Prevention and Xcellerex.
This article originally appeared in the December 2012 issue of Travel Medicine Advisor.
Synopsis: Adults with private health care insurance in the United States have suboptimal testing for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV). Clearly, increased awareness is needed regarding HBV and HCV infections, epidemiology, risk, and screening.
Source: Spradling PR, et al. Hepatitis B and C virus infection among 1.2 million persons with access to care: Factors associated with testing and infection prevalence. Clin Infect Dis 2012;55:1047-1055.
This observational cohort study was conducted among1.25 million adults from four private U.S. healthcare organizations (HCO): Geisinger Health System, Danville, Pennsylvania; Henry Ford Health System, Detroit, Michigan; Kaiser Permanente-Northwest, Portland, Oregon; Kaiser Permanente, Honolulu, Hawaii. The study included persons who had ≥ one clinical encounter during 2006-2008 and ≥ 12 months of follow-up before 2009. The data on infections from this cohort were compared with those from the National Health and Nutrition Examination Survey (NHANES).
Hepatitis B virus (HBV) testing was done on 18.8% of 866,886 persons without a previous diagnosis, resulting in a 1.4% positive rate. Hepatitis C virus (HCV) testing was done on 12.7% of 865,659 persons without previous diagnosis, resulting in 5.5% positive. Among persons with at least two abnormal serum alanine aminotransferase (ALT), less than half were tested for HBV or HCV. Tests found that Asians were most likely to be infected with HBV (adjusted OR 6.33 compared to whites) whereas persons aged 50-59 years were most likely to be infected with HCV (adjusted OR 6.04 compared to age < 30 years). The investigators estimate from NHANES that nearly one half of HCV and one fifth of HBV infections still remain unidentified.
It is estimated that 1-2% of the U.S. population has chronic HBV or HCV infection, about 3.5-5.3 million persons, or 3-5 times more frequent than HIV infection. Among them, about 800,000-1.4 million have chronic HBV, while 2.7-3.9 million have chronic HCV.1 The last few years have brought advances in treatment for both HBV and HCV (for example, tenofovir, entecavir, telaprevir, and boceprevir), and early therapy of chronically infected persons may provide sustained virologic response.
Both HBV and HCV are bloodborne infections. HBV can be transmitted vertically from infected mothers to infants during birth, as well as via sexual contact, sharing needles, and needle stick injuries. Foreign-born persons from endemic countries have an increased likelihood of being chronically infected. Asians and Pacific Islanders are the predominant groups of Americans with chronic HBV infection as well as having a disproportionately high incidence of hepatocellular carcinoma (HCC). However, African-American adults have the highest rate of acute infection, particularly in the South.1
HCV is usually transmitted via percutaneous blood exposure, including receipt of a blood transfusion before 1992 when testing for HCV became available, injection drug use, tattooing by unregulated shops, needle sticks, invasive procedures prior to universal precautions, and also sexual contact. African Americans and Hispanics have higher HCV infection rates than whites.1
Spradling and colleagues have demonstrated the low testing rates for HBV and HCV among large cohorts in the United States who have private health insurance. Their data substantiate the increased risk for HBV associated with Asian race. They also illustrate the low rate of HBV and HCV testing (14.9%) following determination of an elevated serum ALT, which only increases to 42-44% following a second elevated ALT.
Because more than half of new HBV infections diagnosed in the United States were in foreign-born persons, the Centers for Disease Control and Prevention (CDC) expanded testing recommendations for HBV infection in 2008 to include persons born in countries with HBsAg prevalence of ≥ 2%. Despite this recommendation, and despite the demonstration of cost-effectiveness using 2% prevalence for screening chronic HBV, testing for HBV in the foreign-born has remained inconsistent. Many health care providers still lack knowledge about HBV infection, available tests, screening, and vaccination in these high-risk populations. The Boston Area Travel Medicine Network (BATMN), a research collaboration of five travel clinics in the greater Boston Area, found that only 25% of persons born in countries with HBV prevalence of ≥ 2% had been tested before their pre-travel consultations. An additional 11% of the at-risk travelers tested at the travel clinic visits led to new diagnosis of chronic HBV infection in 3.3%.9
Similarly, the CDC has recommended HCV testing for persons with possible exposures since 1998. However, risk-based testing strategy has yielded suboptimal results in identifying HCV-infected persons; a number of studies have found that providers lacked knowledge about HCV prevalence, natural history, diagnostic tests and treatment, and recommendations for testing. Moreover, only 55% of persons with HCV infection reported known exposure risk, and the remaining 45% reported no recognized exposure risk.10 In 2012, CDC also expanded routine screening for HCV infection to include persons born between 1945-1965.10
The Institute of Medicine has identified deficiencies in knowledge and awareness, surveillance, immunization, and services for viral hepatitis in the United States, and recommended strategies to optimize prevention and control of HBV and HCV, policies fully endorsed by the Department of Health and Human Services and CDC.1,3,10 Early diagnosis of chronic HBV and HCV infections can lead to improved therapeutic response, lower viral loads, halt progression to cirrhosis, and prevent HCC. Immunization should also be recommended for non-immune persons at risk for HBV exposure, household members, and sexual contacts of HBV-infected individuals.
Specialists in fields with expertise in hepatitis and who may evaluate patients for reasons such as international travel — including those in travel and tropical medicine, infectious diseases, and gastroenterology — can reach this broader population that needs to be screened. Through the collaboration of specialists with primary care providers, significant improvement of screening in high-risk populations is achievable.
1. Colvin HM, et al. Editors; Committee on the Prevention and Control of Viral Hepatitis Infections; Institute of Medicine. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. (Summary available at: http://www.nap.edu/catalog/12793.html. Accessed March 20, 2013.) The National Academies Press, Washington, DC, 2010.
2. Centers for Disease Control and Prevention (CDC). Hepatocellular carcinoma – United States, 2001-2006. MMWR 2010;59:517-520.
3. Weinbaum CM, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR 2008; 57(RR-8):1-28.
4. Hutton DW, et al. Cost-effectiveness of screening and vaccinating Asian and Pacific Islander adults for hepatitis B. Ann Intern Med 2007;147:460-469.
5. CDC. Screening for chronic hepatitis B among Asian/Pacific Islander populations in New York City, 2005. MMWR 2006;55:505-9.
6. CDC. Characteristics of persons with chronic hepatitis B – San Francisco, California, 2006. MMWR 2007; 56:446-448.
7. Ferrante JM, et al. Family physicians’ knowledge and screening of chronic hepatitis and liver cancer. Family Med 2008;40:345-351.
8. Dulay M, et al. Are primary care clinicians knowledgeable about screening for chronic hepatitis B infection? Abstracts from the 30th annual meeting of the Society of General Internal Medicine, Toronto, Canada. J Gen Intern Med 2007;22(Suppl 1):100.
9. Chen LH, et al. Hepatitis B screening in US travelers seen in the Boston Area Travel Medicine Network. J Travel Med 2012, in press.
10. Smith BD, et al. Centers for Disease Control and Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR 2012;61(RR-4):1-32.
11. Department of Health and Human Services. Combating the silent epidemic of viral hepatitis: Action plan for the prevention, care & treatment of viral hepatitis. Available at: http://www.hhs.gov/ash/initiatives/hepatitis/actionplan_viralhepatitis2011.pdf. Accessed March 20, 2013.