Call to screen all Aussie adults for hepatitis B

The CDC has beefed up its hepatitis B guidelines to include testing for all people over the age of 18 years, regardless of risk.

---

Hepatitis B testing should be routinely offered to all Australians over the age of 18 years, regardless of risk or background, says an Australian expert.

The advice follows the release of new recommendations for hepatitis B screening and testing by the US CDC, which call for all adults aged 18 years and older to be screened at least once in their lifetime using a triple panel test.

Infectious diseases physician Professor Gail Matthews, who heads the Therapeutic Research and Vaccine Program at The Kirby Institute, said she supported the recommendations.

Professor Matthews, who is also head of infectious diseases St Vincent’s Hospital Sydney, said Australians would benefit from a similar approach that also took Australian epidemiology of the virus into account. She believes it could identify tens of thousands of Australians who are unaware they have the virus.

“The thing is to pick up two groups of people – those who are not immune and may need vaccination, but most importantly it is really about identifying those people who are living with hepatitis B who do not know it,” Professor Matthews told The Medical Republic.

“And there’s around 70,000 people in Australia by estimates that applies to – at the very minimum.”

The CDC this month updated its screening and testing recommendations for hepatitis B, expanding on guidelines published in 2008. In addition to advising all adults be screened at least once in their lifetime, the recommendations add two other key points:

• That periodic risk-based testing be expanded to include people incarcerated, people with a history of STIs or multiple sex partners and people with hepatitis C virus infection;
• That anyone who requested a test be offered one, regardless of risk.

The CDC recommended the use of the triple panel test which includes hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen (total anti-HBc).

The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) released a decision-making toolkit for health professionals in November last year, which also endorsed the triple panel test. It added that if acute hepatitis B virus was suspected, through recent risk, presentation, or both, an anti-HBc IgM test could also be ordered.

The toolkit stopped short of advocating universal screening, providing a list of people who should be offered testing. These include people born in intermediate or high prevalence countries; Aboriginal and Torres Strait Islander peoples; patients undergoing chemotherapy or immunosuppressive therapy; pregnant women; infants and children born to mothers who have had hepatitis B for nine months or more; people with clinical presentation of liver disease and/or elevated ALT/AFP of unknown aetiology; health professionals who perform exposure-prone procedures; partner/household/sexual contacts of people with acute or chronic HBV; people who have ever injected drugs; men who have sex with men; people with multiple sex partners; people in custodial settings or who have ever been in custodial settings; people with HIV or hepatitis C, or both; patients undergoing dialysis; sex workers; people initiating HIV pre-exposure prophylaxis; and anyone upon request.

Professor Matthews said she believed there was a groundswell of support from both experts and the community in Australia to move away from the risk-based approach to universal testing.

“[Currently] anybody can be tested for hepatitis B if they ask for it, but essentially for the GPs, the approach has been to assess risk and then target screening for those who are considered to be at risk,” she said.

“Clearly when you have that kind of policy though, it relies on asking the right questions, then the patient being willing to disclose what are perceived as risks, which may not happen.

“So that policy of risk-based testing is failing to pick up a significant number of people who are living with hepatitis C – we estimate that probably only around 70% are diagnosed, if that.”

Professor Matthews said there was also a “massive drop-off between people being diagnosed and then linked to care”.

“We’ve got to improve that cascade of care and that means diagnosing more people and certainly then also linking them through into care if we’re going to limit hepatitis B deaths and morbidity.”

She said formalising a universal screening standard for hepatitis B would put GPs in a stronger position to have conversations with patients around testing, risk and vaccination.

“It’s important to also realise it’s not compulsory testing in any sense,” she said.

“It’s just recommended that everybody at some point in their life gets a triple test [in the US]. Using those three tests, we can classify everybody into a stage and identify people who may need vaccination.

“You can identify those who are hepatitis B positive and want to be engaged and linked into care. And you can identify those people who are immune and need no further intervention.”