Experts identify best practices for HBV screening, vaccination

Last Updated: 2017-11-20

By Will Boggs MD

NEW YORK (Reuters Health) - All at-risk individuals should be vaccinated against hepatitis B virus (HBV), according to best practices identified by experts from the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC).

Recommendations for vaccination, screening, and linkage to care to reduce the burden of chronic HBV infection vary across organizations, and their implementation has been suboptimal.

To improve these parameters, the High Value Care Task Force of the ACP and the CDC have presented three best-practice statements in the Annals of Internal Medicine online November 21.

First, clinicians should vaccinate all unvaccinated adults at risk for HBV infection. Risk factors include sexual exposure, percutaneous or mucosal exposure to blood, chronic liver disease, end-stage renal disease (ESRD), HIV infection, behavioral exposures during pregnancy, and international travel to regions with high or intermediate levels of endemic HBV infection. Beyond these risk factors, the experts recommend vaccination for "any adult seeking protection from HBV infection."

Second, clinicians should screen for HBV in all high-risk persons: those born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, patients requiring immunosuppressive therapy, people with ESRD, blood and tissue donors, people infected with hepatitis C virus, patients with elevated alanine aminotransferase (ALT) levels, incarcerated individuals, pregnant women, and infants born to HBV-infected mothers.

Third, clinicians should provide all patients identified with positive HBV test results with post-test counseling and hepatitis B-directed care, or refer them to such services.

The panelists note that adverse effects from hepatitis B vaccination are rare and mild and that HBV vaccination, screening, and linkage to care have been shown to be cost-effective.

The document also lists several barriers to evidence-based practice along with approaches to overcoming them. For example, lack of awareness and assessment for HBV infection should be countered by routinely asking about risk factors for HBV infection during clinical encounters.

Dr. Mindie H. Nguyen from Stanford Medicine, in California, who was not involved in preparing this best-practice advice, told Reuters Health by email, "While the title of this article includes linkage to care, the focus is largely vaccination and screening, which are important, but linkage to care and appropriate care are also very important. Linkage to care also includes appropriate evaluation of patients already cared for in clinical practice and appropriate monitoring and treatment, such as hepatocellular carcinoma surveillance and antiviral therapy for patients meeting guideline criteria, both of which have been shown to be poor."

We need to "increase physician (targeting primary care and community physicians) education and patient education," she said. "However, we have been saying this for >10 years. There should be more system-based changes, built-in electronic medical records and accountability, and more focus on community research and outreach.

"Screening, vaccination, and linkage to care for HBV are poor - and much more research, especially community-based interventional research, education, and public advocacy - are needed," Dr. Nguyen said.

Dr. Amir Qaseem from ACP, one of the best-practice authors, did not respond to requests for comment.

SOURCE: http://bit.ly/2hHme9r

Ann Intern Med 2017.