CDC Recommends Universal Hepatitis B Screening of Adults

Lucy Hicks

March 10, 2023

UPDATED March 27, 2023 //  Editor's Note: This story has been updated to include new comments from experts in the field.

Adults should be tested for hepatitis B virus (HBV) at least once in their lifetime, according to updated guidelines from the Centers for Disease Control and Prevention (CDC).

This is the first update to HBV screening guidelines since 2008, the agency said.

"Risk-based testing alone has not identified most persons living with chronic HBV infection and is considered inefficient for providers to implement," the authors write in the new guidance, published in the CDC's Morbidity and Mortality Weekly Report. "Universal screening of adults for HBV infection is cost-effective compared with risk-based screening and averts liver disease and death. Although a curative treatment is not yet available, early diagnosis and treatment of chronic HBV infections reduces the risk for cirrhosis, liver cancer, and death."

Howard Lee, MD, an assistant professor in the section of gastroenterology and hepatology at Baylor College of Medicine in Houston, agreed that risk-based screening has not been effective. A universal screening approach "is the way to go," he told Medscape Medical News. With this new screening approach, patients can get tested without having to admit that they may be at risk for a chronic disease like HIV and HBV,  which can be stigmatizing, said Lee, who was not involved with making these recommendations.

An estimated 580,000 to 2.4 million individuals are living with HBV infection in the United States, and two thirds may be unaware they are infected, according to the CDC.

The virus spreads through contact with blood, semen, and other body fluids of an infected person.

The guidance now recommends using the triple panel (HBsAg, anti-HBs, total anti-HBc) for initial screening.

"It can help identify persons who have an active HBV infection and could be linked to care; have [a] resolved infection and might be susceptible to reactivation (eg, immunosuppressed persons); are susceptible and need vaccination; or are vaccinated," the authors write.

Patients with previous HBV infection can have the infection reactivated with immunosuppressive treatments, Lee noted, which is why detecting prior infection via the triple panel screening is important.

Pregnant people should be screened ideally in the first trimester of each pregnancy, regardless of vaccination status or testing history. Pregnant people who have already received timely triple panel screening for hepatitis B and who have no new HBV exposures only need HBsAg screening, the guidelines state. 

The document added three groups at a higher risk for HBV infection: those incarcerated or formerly incarcerated, people with current or past hepatitis C virus infection, and people with current or past sexually transmitted infections and multiple sex partners. Those at higher risk for HBV should be screened periodically, based on shared decision-making between the provider and patient as well as individual risk and immune status.

Additional research into the optimal frequency of periodic testing is necessary, the authors say.

"Along with vaccination strategies, universal screening of adults and appropriate testing of persons at increased risk for HBV infection will improve health outcomes, reduce the prevalence of HBV infection in the United States, and advance viral hepatitis elimination goals," the authors write.

The new recommendations now contrast with the 2020 screening guidelines issued by the US Preventive Services Task Force (USPSTF) that recommend risk-based screening for hepatitis B.

"When that recommendation was published, the Task Force was aligned with several other organizations, including the CDC, in supporting screening for hepatitis B in high-risk populations — and importantly, we're all still aligned in making sure that people get the care that they need," said Michael Barry, MD, chair of the USPSTF, in an emailed statement to Medscape Medical News. "The evidence on clinical preventive services is always changing and the Task Force aims to keep all recommendations current, updating each recommendation approximately every 5 years."

"In the meantime, we always encourage clinicians to use their judgment as they provide care for their patients — including those who may benefit from screening for hepatitis B — and to decide together with each patient which preventive services can best help them live a long and healthy life," Barry said.

The American Association for the Study of Liver Diseases is currently updating their HBV screening recommendations, Lee added, and he expects other professional societies to follow the CDC recommendations.

"It's not uncommon that we see the CDC or [professional] societies making recommendations and the USPSTF following along, so hopefully that's the case for hepatitis B as well," Lee said.

MMWR Recomm Rep. Published March 10, 2023. Full text

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