A summary of presentations from the weekly Summit partner webinars
April 20, 2023 – The latest Summit Summary
- New CDC Universal Hepatitis B Screening Guidelines and Integration with Vaccination – Erin Conners (CDC)
New CDC Universal Hepatitis B Screening Guidelines and Integration with Vaccination – Erin Conners (CDC)
Erin Conners, PhD, MPH, Division of Viral Hepatitis, CDC, gave a presentation on the new CDC universal hepatitis B screening guidelines and the integration with vaccination.
- People with chronic hepatitis virus infection are at increased risk for liver cancer and cirrhosis and are 70%–85% more likely to die prematurely than the general population
- There are 660,000 people living with hepatitis B in the U.S.
- Only 50% are aware of their infection, but there is a huge opportunity to increase screening in the U.S.
Hepatitis B in the U.S.—a tale of two epidemiologies
- The majority of people living with chronic hepatitis B were born outside the U.S. and had their infection since childhood
- The other groups affected are the unvaccinated people with behavioral risk factors:
- Injection drug use
- Unprotected sex
- Acute infections as adults (lower risk of developing chronic infection)
New hepatitis B virus infections in adults age 19 and older:
- Rates are highest in adults aged 30–49 years
- In adults aged 40–49 years, rates are increasing
- In comparison the rate of acute infection in kids and adolescents age 0–19 years, has been about 0/100,000 since 2011, due largely to the effectiveness of childhood vaccination rates
Hepatitis B vaccination coverage in adults with ≥1 risk factor decreases by age
- For adults born before the universal infant vaccination recommendation, a large proportion of at risk adults remain unvaccinated.
- The rate of vaccination decreases by age
- A majority of the at risk population remains vulnerable to disease
Limitations of current risk-based testing approach
- Over 2/3 of reported acute cases were either missing risk data or reported no identified risk
Compared with current practice, universal hepatitis B screening of adults age 18–79 years would avert (per 100,000 adults):
- 7 cases of compensated cirrhosis
- 3 cases of decompensated cirrhosis
- 5 cases of hepatocellular carcinoma
- 2 liver transplants
- 10 hepatitis B-related deaths
- One major piece of data considered was the cost-effective analysis that looked at screening adults age 18–79 years. This analysis suggests a savings of $200,344 per 100,000 adults
Recommendation Language for Universal Screening
- New: Screening is recommended for all adults age ≥18 years at least once in a lifetime
- Unchanged: Screening is recommended for all pregnant people during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing
- Recommend testing for HBsAg, Anti-HBs, and total anti-HBc0
- The three of these tests together are called the triple panel and can help identify people who have current HPV infection that could be linked to care, have resolved infection and might be susceptible to reactivation if they become immunocompromised, who are susceptible and need vaccination, and who are currently immune
Testing recommendations –Test persons with symptoms or at increased risk:
- History of risk for HBV infection (all ages)
- If susceptible during the period of risk, for example, if unvaccinated
- Periodic testing for susceptible persons (all ages)
- With ongoing risk, while the risk persists
- Generally susceptible persons would be those who are unvaccinated or who didn’t receive the complete vaccine series according to the vaccine recommended schedule or who are not vaccinated
New: Anyone who requests hepatitis B testing should receive it, regardless of disclosure of risk
- Many reluctant to tell the doctor because of potential stigma
2022 ACIP recommendations adult hepatitis B vaccination:
- The following groups should receive hepatitis B vaccines:
- Adults age 19–59 years
- Adults age ≥60 years with risk factors for hepatitis B
- The following groups may receive hepatitis B vaccines:
- Adults age ≥60 years without known risk factors for hepatitis B
Integrating the screening with vaccination
- After the collection of blood for serologic testing
- People who have not completed the series should be offered the vaccines per ACIP guidelines at that visit or another visit
- Don’t need to wait for the test results to come back before vaccinating
- Screening should not be a barrier to vaccination. Even though screening can identify unvaccinated people or people with a history of infection, avoiding additional vaccine doses shouldn’t be a barrier to vaccination, especially in populations with decreased engagement or access to care
Incorporating hepatitis B screening into a clinic workflow for nonpregnant adults age ≥18 years without a known history of HBV infection
- For all adults who have never been screened before and with no or unknown vaccination status, recommend vaccination and screening per the recommendation of ACIP
- For all adults who have never been screened before and have received a complete hepB vaccination series, recommend screening
People with increased risk for HBV infection and recommended for periodic testing – three additions from 2008 guidelines:
- People currently or formerly incarcerated in a jail, prison, or other detention setting
- People with current or past hepatitis C virus infection
- People with current or past sexually transmitted infections (STIs) or multiple sex partners
Incorporating hepatitis B screening into a clinic workflow for nonpregnant adults age ≥18 years without a known history of HBV infection but the adult has been screened
- In future visits a provider can assess if additional testing is warranted based on the vaccination status and the timing of exposure. Vaccines should be offered. Slide 24 provides additional details
Incorporating hepatitis B screening into a clinic workflow for children and adolescents age 1–17 years without a known history of hepatitis B virus infection
- Per ACIP guidelines, children under 18 who were not vaccinated as infants should be offered vaccination and screening based on risk exposure
- Frequency of periodic testing should be a shared decision
- Considering the individual’s risk factors, immune status, and prior recommendation
- Individual risk factors
- Multiple sex partners
- Insufficient evidence to specify an exact number of partners and the time frame for screening to identify cases of chronic infection
- Things to consider when recommending HBV testing
- Number of partners,
- type of sex, timing of last test
- Providers can weigh the clinical benefits of screening age ≥80 years
- Multiple sex partners
Integrating Screening and Vaccination
Can you give the HBV vaccine and draw blood immediately after for serology testing?
- Screening should not be a barrier to vaccination
- Blood collection immediately after vaccination is not recommended
- One-timing screening with a triple panel should still be offered during future visits where a blood draw is available
- Transient HBsAg positivity can occur up to 18 days after vaccination
When should you repeat hepatitis B testing after vaccination?
- Serologic testing for immunity is not routinely recommended after vaccination of infants, children, or adults except in specific populations.
- Postvaccination serologic testing 1–2 months after vaccination is recommended for the following people whose subsequent clinical management depends on knowledge of their immune status:
- Infant born to a person with positive or unknown status
- People on hemodialysis
- People with HIV
- Sex partners of positive persons
- Other immunocompromised people
Hypothetical Clinical Scenario
- Male with no HBV risk factors
- One year ago received first dose hepatitis B (of a three dose series)
- Wants another dose
- No evidence he has been screened for hepatitis B before
- Since he hasn’t completed his series or been screened, he should receive screening with a triple panel and vaccination
- Visit one: Draw blood for the triple panel prior to vaccination and vaccinate at the same visit
- When feasible, use vaccine from the same manufacturer to complete the series. If unable to, it’s okay.
- The provider ordered three tests since the man had never been screened before.
- Two came back negative
- Antibody to surface antigen was positive
- There is no current infection or history of infection
- Currently immune but the ability of the immunity is unknown
- Recommend that he come back in two months to complete the series
Implementation Next Steps
Education to increase awareness
- Providers -empower to message and order vaccine
- Patients – Messages from trusted sources to encourage uptake of screening and vaccination.
- Setting-specific implementation guides
- Electronic health record alerts
- Integrating screening and vaccination
Chronic hepatitis B panels
- With clear summary and overall interpretation of results
- Streamlining reimbursement for screening by eliminating the requirement for providers to report hepatitis b screening with additional ICD-10-CM diagnosis codes or risk behaviors
- Possible U.S. Preventative Services Taskforce alignment to endorse coverage
- Hepatitis B Online – University of Washington
- Hepatitis B Management: Guidance for the Primary Care Provider
- Hepatitis B Foundation: https://www.hepb.org/
- Web MD: https://www.medscape.org/viewarticle/972018?src=acdmpart_cdc_972018
- org: https://www.immunize.org/askexperts/experts_hepb.asp
Hepatitis Awareness Month: www.cdc.gov/hepatitis/awareness
Help spread the word with CDC’s free resources:
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Q: How can we better address provider apathy towards hepatitis b vaccination?
Erin Conners: There is a lack of knowledge on hepatitis B. It’s perceived as less common than it is and there’s a lack of understanding that people continue to be at risk who are U.S. born. There is a higher prevalence than might be perceived. Early testing, motoring, and treatment is an effective way to prevent long-term disease but even better, that they don’t get infected in the first place. Vaccination is the first step so that we don’t have to have that long-term management for the patients and for all. There needs to be better awareness that it is a disease that affects a lot of people and is a very serious disease that should be prevented with the excellent vaccine we have.
Lakshmi Panagiotakopoulos: I think there’s a lot of fatigue when it comes to vaccinations in general, as well as having gone through COVID-19. It’s impacted a lot of other vaccines. Our division is planning some provider interviews and more details information on how to target some of our communication resources. We are hoping to learn more specific information about specific hepatitis b barriers to vaccination.
Q: The percent of adults who get acute hepatis b that don’t have a risk factor is large. Is there anything you can say about that as being one of the reasons for this universal screening?
Erin Conners: From our surveillance data, of the acute cases reported, only 30% had a risk identified. Some of that reflects surveillance reporting issues. The survey is also time consuming for providers to go through during a primary care visit. This needs to be simplified for providers to ask all the questions, as well as reducing some of the stigma among having patients feeling singled out with the screening.
Q: Do you have numbers regarding maternal-child transmission of acute hepatis B?
Erin Conners: The numbers are very low, although we know we are missing a proportion of pregnant people who aren’t screened during each pregnancy. When the birth dose is applied, the transmission is very low. We are interested in getting more accurate estimates for pregnant people.
Q: Are there going to be joint efforts to promote screening for hepatitis C and hepatitis D together or will there be separate screening?
Erin Conners: They are separate, but we would love for them to be coupled together, especially in clinics where we could link STI screenings and drug testing clinics. It depends on the setting of how they are packaged together, but there is some opportunity for some cross-promotion.
Q: You mentioned a new law in CA about hepatitis B screening and primary care. Can you expand on that?
Erin Conners: This passed within the last year. Primary care providers are required to offer hepatitis B and C screening to all their primary care adult patients. It was a huge effort on the part of advocates to promote hepatitis screening. Since they started the universal approach already we are interested in how it will integrate. SEE BILL.
Q: What are the plans for involvement of community organizations to help with screening efforts? What are the partnership opportunities?
Erin Conners: We have really strong partners with hepatitis B foundation and Hep B United, as well as several local groups that are passionate and involved. They focus on what the community needs for event and also couple that with vaccination and screening. It’s exciting to see how people are integrating their events by piggybacking it off of something that’s more well known like blood pressure management. Another example is that for different Asian populations, the community-based organizations made sure to have in-language outreach in different channels that are culturally appropriate.
Q:. Do you have estimates of cost per screening and what are the plans to help supplement cost of screening people who are uninsured?
Erin Conners: For the triple panel it’s about $28, private insurance may be up to $60 for the three panel test. That’s what we found to be cost-effective for screening all adults.
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