Updated Immunization and Screening Recommendations Aim to Eradicate Hepatitis B

Kenny Lin, MD, MPH
Posted on May 1, 2023

In November 2021, the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) replaced risk factor–based eligibility in adults with a recommendation for universal hepatitis B vaccination in people 19 to 59 years of age. The ACIP noted that despite routine administration of hepatitis B vaccine in infancy, as of 2018 only 30% of U.S. adults had received the full vaccine series, and one-half of acute hepatitis B cases occurred in people 30 to 49 years of age. A national survey of family physicians in February 2022 (published in AFP in August 2022) found that more than half of respondents were not aware of the updated guidelines, and only 8% had fully implemented them.

Gaps in screening and treatment also put patients at greater risk of developing chronic hepatitis B and its complications. An analysis of insurance claims data from 2015 to 2020 found that even though all pregnant patients should be screened for hepatitis B at their first prenatal visit to prevent perinatal transmission, 14.6% did not have hepatitis B surface antigen (HBsAg) testing, representing as many as half a million births each year. Another study found that between 2016 and 2019, fewer than 30% of people with chronic hepatitis B and cirrhosis started antiviral therapy within 12 months of diagnosis.

Because access to hepatologists is a barrier to patients with hepatitis B receiving appropriate management, a previous AFP Community Blog post described a practice model for family doctors to evaluate and treat these patients “in-house.” However, the complexity of screening and management guidelines has led to calls for a simplified approach to hepatitis B. In response, the CDC recently recommended that adults 18 years and older be tested for hepatitis B at least once during their lifetimes, regardless of prior immunizations or risk factors, mirroring the universal screening approach to hepatitis C and HIV. (Notably, the U.S. Preventive Services Task Force currently recommends a risk-based screening strategy in adolescents and adults.) To facilitate interpretation, screening should include HBsAg, antibody to HBsAg, and antibody to hepatitis B core antigen.

In a JAMA Viewpoint, Dr. Samuel So and colleagues asserted that as two-thirds of non-institutionalized persons with chronic hepatitis B are unaware of their infection, universal screening and vaccination of adults “are a major step forward to reducing chronic hepatitis B-related morbidity and mortality in the U.S.” Another commentary emphasized focusing on health equity in the national push to eradicate hepatitis B and hepatitis C, which is the target of a recently proposed national initiative. A white paper that I co-authored for the Hepatitis B Foundation presented challenges to implementing the updated CDC recommendations, best practices in primary care and hospital settings, and priority action items involving education, multistakeholder collaborations and technology innovations, and addressing vaccine hesitancy.