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CME / ABIM MOC / CE

What is the New CDC Guidance for Hepatitis B Testing in Adults?

  • Authors: News Author: Lucy Hicks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 4/14/2023
  • Valid for credit through: 4/14/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, family medicine/primary care clinicians, internists, gastroenterologists, public health and prevention officials, nurses, nurse practitioners, pharmacists, physician assistants, and other members of the healthcare team involved in hepatitis B testing in adults.

The goal of this activity is for members of the healthcare team to be better able to describe updated guidelines from the Centers for Disease Control and Prevention (CDC) for hepatitis B virus (HBV) testing of adults, according to an update of their 2008 recommendations for risk-based testing and management of persons with chronic HBV infection in the United States.

Upon completion of this activity, participants will:

  • Determine the rationale underlying updated CDC guidelines for HBV testing of adults, according to an update of their 2008 recommendations for risk-based testing and management of persons with chronic HBV infection in the United States
  • Describe updated CDC guidelines for HBV testing of adults, according to an update of their 2008 recommendations for risk-based testing and management of persons with chronic HBV infection in the United States
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Lucy Hicks

    Freelance writer, Medscape

    Disclosures

    Lucy Hicks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC / CE

What is the New CDC Guidance for Hepatitis B Testing in Adults?

Authors: News Author: Lucy Hicks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/14/2023

Valid for credit through: 4/14/2024, 11:59 PM EST

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Clinical Context

Persons with chronic hepatitis B virus (HBV) infection are at greater risk for liver cancer and cirrhosis and are 70% to 85% more likely to die prematurely than the general population. Of an estimated 580,000 to 2.4 million persons living with HBV infection in the United States, two-thirds may be unaware of their infection.

Chronic HBV infection disproportionately affects persons born outside the United States, as non--US–born persons account for 14% of the general US population but 69% of persons living with chronic HBV infection. Treatment is not considered curative, but antiviral treatment, monitoring, and liver cancer surveillance can lower morbidity and mortality.

Study Synopsis and Perspective

Adults should be tested for 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 wrote 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.”

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, the agency said.

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

The guidance now recommends using the triple panel (hepatitis B surface antigen [HBsAg], anti-hepatitis B [HB], total anti-hepatitis B core [antigen] [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 wrote.

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

The document added 3 groups at higher risk for HBV infection: persons incarcerated or formerly incarcerated, people with current or past hepatitis C virus (HCV) infection, and people with current or past sexually transmitted infections (STIs) and multiple sex partners. Persons 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 said.

"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 wrote.

MMWR Recomm Rep. 2023;72:1-25.[1]

Study Highlights

  • HBV spreads through contact with blood, semen, and other bodily fluids of an infected person.
  • Risk-based testing alone has not identified most persons living with chronic HBV infection and is inefficient for clinicians to implement.
  • Compared with risk-based screening, universal screening of adults for HBV infection is cost-effective, averts liver disease and death, and offers a simpler, less stigmatizing implementation strategy.
  • Curative treatment of chronic HBV infections is not yet available, but early diagnosis and treatment lowers risk for cirrhosis, liver cancer, and death, supporting the importance of early detection of HBV infection.
  • Screening tests for HBV are reliable and inexpensive.
  • The HBV triple panel can help identify persons with active HBV infection needing linkage to care, persons with resolved infection who might be susceptible to reactivation (eg, immunosuppressed persons), persons who are susceptible and need vaccination, or persons who are vaccinated.
  • An “all adults” recommendation for universal screening was based on more feasible implementation than would be likely among specific age groups, similarly low vaccination rates among adult age groups, similar epidemiology of acute and chronic infections from surveillance data among age groups, and harms of missed identification of chronic infections.
  • Children and adolescents aged < 18 years were not included in the universal screening recommendation because of low HBV infection prevalence and high levels of HepB vaccination in this age group.
  • The new recommendations are complementary to the 2022 ACIP recommendations to vaccinate all adults aged 19 to 59 years against HBV infection by providing a means to establish immunity or any history of infection or the need for vaccination to protect from future infection.
  • New recommendations include HBV screening using 3 laboratory tests (HBsAg, anti-HBs, total anti-HBc) at least once during a lifetime for adults aged ≥ 18 years.
  • New risk-based testing recommendations now include persons with a history of STIs or multiple sex partners and persons with a history of HCV infection.
  • As recommended previously, persons who should be tested are those incarcerated or formerly incarcerated in a jail, prison, or other detention setting; men who have sex with men; household contacts or former household contacts of persons with known HBV infection; needle-sharing or sexual contacts of persons with known HBV infection; persons on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis; and persons with elevated alanine aminotransferase or aspartate aminotransferase levels of unknown origin.
  • Persons at higher risk for HBV should be screened periodically, based on shared decision making between clinician and patient and on individual risk and immune status.
  • Everyone with a history of risk for HBV infection, regardless of age, should be tested if they might have been susceptible during the period of risk, including persons never infected with HBV (total anti-HBc negative) who either did not complete a HepB vaccine series as recommended by the Advisory Committee on Immunization Practices (ACIP) or who are known vaccine nonresponders.
  • To provide increased access to testing, anyone requesting HBV testing should receive it, regardless of risk disclosure, because many people may be reluctant to disclose stigmatizing risks.
  • Regardless of vaccination status or testing history, pregnant women should be screened ideally in the first trimester of each pregnancy.
  • Pregnant women or others who have already received timely triple-panel HBV screening and who have no new HBV exposures only need HBsAg screening or use of appropriate tests.
  • Others who should be tested are infants born to HBsAg-positive pregnant women, persons born in regions with HBV infection prevalence of ≥ 2%, and US-born persons not vaccinated as infants whose parents were born in regions with HBV infection prevalence of ≥ 8%.
  • Combined with vaccination strategies, universal screening of adults and appropriate testing of persons at increased risk for HBV infection should improve health outcomes, reduce US prevalence of HBV infection, and advance viral hepatitis-elimination goals.
  • Further research is needed regarding the optimal frequency of periodic testing.
  • After collection of blood for serologic testing, persons who have not completed a vaccine series should be offered vaccination per ACIP recommendations.
  • All persons testing positive for active HBV infection should be given information on how to prevent transmission to others.

Clinical Implications

  • Compared with risk-based screening, universal screening of adults for HBV infection is cost-effective; averts liver disease and death; and offers a simpler, less stigmatizing implementation strategy.
  • New recommendations include hepatitis B screening using 3 laboratory tests (HBsAg, anti-HBs, total anti-HBc) at least once during a lifetime for adults aged ≥ 18 years.
  • Implications for the Healthcare Team: Regardless of vaccination status or testing history, members of the healthcare team should screen pregnant women in the first trimester of each pregnancy.

 

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