CDC Provides New Hepatitis B Testing and Screening Guidelines

Today the CDC launched new recommendations for screening and testing for hepatitis B (HBV). Some of the biggest changes include that CDC now recommends that all adults in the United States be universally tested for HBV at least once in their lifetime, and to test for total antibody to HBcAg, which may determine HBV in the window period and pick-up recent infection.

The new guidance is published in the MMWR Recommendations and Reports / Vol. 72 / No. 1.

This is the first update since 2008, and it's aimed at providing more awareness around HBV and getting more people involved in the continuum of care. CDC is expanding continual risk-based testing to include more groups, activities, exposures, and conditions, while noting the limitations to risk-based testing.

“Risk-based testing alone has not identified most persons living with chronic HBV infection and is inefficient for providers to implement,” the MMWR authors wrote.

Listed below are the new screening/testing HBV recommendations put forth:

Universal HBV screening

• HBV screening at least once during a lifetime for adults aged ≥18 years (new recommendation)
• During screening, test for hepatitis B surface antigen (HBsAg), antibody to HBsAg, and total antibody to HBcAg (total anti-HBc) (new recommendation)

Screening pregnant persons

• HBV screening for all pregnant persons during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing*

• Pregnant persons with a history of appropriately timed triple panel screening and without subsequent risk for exposure to HBV (i.e., no new HBV exposures since triple panel screening) only need HBsAg screening

Risk-based testing

• Testing for all persons with a history of increased risk for HBV infection, regardless of age, if they might have been susceptible during the period of increased risk†
• Periodic testing for susceptible persons, regardless of age, with ongoing risk for exposures, while risk for exposures persists†

* Source: Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1):1–31.

† Susceptible persons include those who have never been infected with HBV (i.e., total anti-HBc negative) and either did not complete a HepB vaccine series per Advisory Committee on Immunization Practices recommendations or who are known to be vaccine nonresponders.

A Need for Greater Public Awareness
HBV awareness remains a significant health care challenge, despite existing therapies to treat it as well as prophylactic HBV vaccines to prevent it. It’s estimated that more than half of people with hepatitis B are unaware of their infection. Part of the issue is the virus presents asymptomatically for most people who are positive. Some people do eventually develop chronic hepatitis (elevation of AST/ALT), cirrhosis, or liver cancer.

Although there is no cure for HBV, treatment with any of the number of multiple antivirals available can make the virus a manageable, chronic condition.

On the vaccine side, there are prophylactic HBV vaccines, but uptake is limited. It has been reported that 70% of adults in the US were unvaccinated as of 2018.

Future Considerations

In addition to the comprehensive screening and testing updates, the authors would like to see continued collaboration with laboratories to bundle the three HBV tests so they can be ordered together. And they also acknowledge the need to understand hepatitis D (HDV) more effectively to guide future recommendations for HDV screening among persons with HBV infection.