An update of the U.S. Preventive Services Task Force recommendation for hepatitis B screening shows little change from the 2014 version, but some wonder if it should have gone farther than a risk-based approach.
The recommendation, which was published in JAMA, reinforces that screening should be conducted among adolescents and adults who are at increased risk of hepatitis B virus (HBV) infection. The USPSTF named six categories of individuals at increased risk of infection: Persons born in countries with a 2% or higher prevalence of hepatitis B, such as Asia, Africa, the Pacific Islands, and some areas of South America; unvaccinated individuals born in the United States to parents from regions with a very high prevalence of HBV (≥8%); HIV-positive individuals; those who use injected drugs; men who have sex with men; and people who live with people who have HBV or who have HBV-infected sexual partners. It also recommended that pregnant women be screened for HBV infection during their first prenatal visit.
“I view the updated recommendations as an important document because it validates the importance of HBV screening, and the Grade B recommendation supports mandated insurance coverage for the screening test,” said Joseph Lim, MD, who is a professor of medicine at Yale University and director of the Yale Viral Hepatitis Program, both in New Haven, Conn.
Still, the recommendation could have gone further. Notably absent from the USPSTF document, yet featured in recommendations from the Centers for Disease Control and Prevention and the American Association for the Study of Liver Disease, are patients who have diabetes, are on immunosuppressive therapy, or have elevated liver enzymes or liver disease. Furthermore, a single-center study found that, among physicians administering immunosuppressive therapy, a setting in which HBV reactivation is a concern, there were low rates of screening for HBV infection, and the physicians did not reliably identify high-risk patients.
“This may also be viewed as a lost opportunity. Evidence suggests that risk factor–based screening is ineffective for the identification of chronic conditions such as hepatitis B. Risk factor–based screening is difficult to implement across health systems and exacerbates the burden on community-based organizations that are motivated to address viral hepatitis. It may further exacerbate labeling, stigma, and discrimination within already marginalized communities that are deemed to be at high risk,” said Dr. Lim.
A similar view was expressed by Avegail Flores, MD, medical director of liver transplantation at the Michael E. DeBakey Veterans Affairs Medical Center and assistant professor of medicine at Baylor College of Medicine, both in Houston. “This is a good launching point, and with further evidence provided, hopefully it will also bring in a broader conversation about other persons who are at risk but not included in these criteria.” Neither Dr. Lim nor Dr. Flores were involved in the study.
She noted that resistance to universal screening may be caused by the relatively low prevalence of hepatitis B infection in the United States. However, the CDC estimates that only about 61% of people infected with HBV are aware of it. “I don’t think we have done a good job screening those who are at risk,” said Dr. Flores.
Universal screening could help, but would have a low yield. Dr. Flores suggested expansion into other at-risk groups, such as Baby Boomers. With respect to other risk groups that could be stigmatized or discriminated against, Dr. Flores recalled her medical school days when some students went directly into underserved communities to provide information and screening services. “We have to think of creative ways of how to reach out to people, not just relying on the usual physician-patient relationship.”
The issue is especially timely because the World Health Organization has declared a target to reduce new hepatitis B infections by 90% by 2030, and that will require addressing gaps in diagnosis. “That’s why these recommendations are so consequential. We are at a critical juncture in terms of global hepatitis elimination efforts. There is a time sensitive need to have multistakeholder engagement in ensuring that all aspects of the care cascade are addressed. Because of the central role of screening and diagnosis, it’s of critical importance that organizations such as USPSTF are in alignment with other organizations that have already issued clear guidance on who should be screened. It is (my) hope that further examination of the evidence-base will further support broadening USPSTF guidance to include a larger group of at-risk individuals, or ideally a universal screening strategy,” said Dr. Lim.
The recommendation’s authors received travel reimbursement for their involvement, and one author reported receiving grants and personal fees from Healthwise. Dr. Flores has no relevant financial disclosures. Dr. Lim is a member of the American Association for the Study of Liver Disease’s Viral Hepatitis Elimination Task Force.
SOURCE: U.S. Preventive Services Task Force. JAMA. 2020 Dec 15. doi: 10.1001/jama.2020.22980.
Updated Jan. 20, 2021