Hepatitis B: Screening, Awareness, and the Need to Treat
The interpretation of HBV screening serology is shown in Table 3. Persons with chronic HBV infection are treated, if needed, per practice guidelines based on the initial test results and interpretation of the stage of the disease and counseled regarding transmission of infection. 9,10 Vaccination is recommended for uninfected persons.
Hepatitis B Education
There is relatively poor awareness of HBV among highrisk individuals and health care professionals (HCPs). A study examining the prevalence of chronic hepatitis B in an Asian and Pacific Islander population reported that about 15% of participants had not been previously tested for hepatitis B.11 Another study that surveyed 3,163 Asian American adults in the San Francisco Bay Area found that of those screened and identified with chronic HBV infection (8.9%), two-thirds were unaware that they were infected.12
Primary care providers in San Francisco correctly identified that Chinese immigrants have a higher prevalence of chronic hepatitis B than that of non-Hispanic white or U.S.-born Chinese people, but the providers incorrectly identified persons with HIV infection, men who have sex with men, and persons who inject drugs as having higher prevalence than that of Chinese immigrants in a survey.13 Lack of awareness probably contributes to poor outcomes from the infection among at-risk persons as well as continued transmission to susceptible individuals. Furthermore, lack of knowledge is a barrier to testing, prevention, and care. Increased awareness to identify the at-risk population and early treatment is an important step to prevent morbidity and mortality from chronic hepatitis B.
Public Awareness
Many at-risk populations are unaware of HBV, its possible routes of transmission, or that a safe and effective vaccine exists for HBV prevention. Moreover, many foreign-born persons with chronic HBV infection feel stigmatized by others or have cultural barriers against Western medicine and prefer alternative therapies. As a result, the Institute of Medicine (IOM) has suggested that innovative approaches need to be developed to promote a better understanding of transmission, prevent and treat HBV, increase HBV vaccination rates among children and at-risk adults, educate women about vertical transmission risk, reduce stigmatization, and provide culturally sensitive and understandable educational material.14
Awareness Among Health Care Professionals
Studies have identified knowledge gaps among HCPs regarding the prevalence of HBV in the general U.S. population, outcome of infection, who should be screened and vaccinated against HBV, appropriate methods for screening and interpretation of serologic tests for HBV, and proper treatment of persons with chronic infection. As a consequence, the IOM recommended educational programs for HCPs on the prevalence of HBV infection in the general U.S. population and at-risk populations, particularly foreign-born persons. In addition, these educational programs should target all levels of HCPs, including undergraduates and postgraduates, and include information on screening and prevention, testing, and interpretation of tests.14
Need to Treat
The global HBV disease burden remains high despite the existence of an effective vaccine. Worldwide, there are an estimated 4.5 million new infections and 780,000 HBVrelated deaths each year.15 In the U.S., the highest rates of mortality are seen in Asians and Pacific Islanders and among persons aged 55 to 64 years. Asians and Pacific Islanders also have the highest rate of liver cancer deaths.16,17
The natural history of chronic hepatitis B is highly variable and dependent on a complex interplay between the virus and the host immune response. It is estimated that between 25% and 40% of persons with chronic hepatitis B will be at risk for progression to cirrhosis.7,18,19 In a study among persons with cirrhosis, the 5-year cumulative risk of developing hepatocellular carcinoma was 17% in Asian patients and 10% in white Americans and Europeans. The 5-year liver-related death rate was 14% among East Asians and 15% among white Europeans.18
A significant proportion of individuals infected with HBV are unaware of their diagnosis, not enrolled in care, or not receiving therapy.7,12,20-24 Data from several prospective and retrospective cohort studies have demonstrated that prolonged viral suppression achieved with therapy is associated with regression of fibrosis and reversal of cirrhosis in a substantial proportion of individuals.25,26 Treatment has also been associated with a reduction in rates of liver decompensation, HCC, liverrelated, and all-cause mortality among patients with liver cirrhosis.27
Given the risk of serious complications and the availability of safe and effective therapy, it is imperative that persons identified as having chronic hepatitis B be referred for evaluation to determine whether therapy is warranted. However, it is also important to recognize that a cure for HBV infection is currently not available, and most patients who initiate therapy will require longterm treatment. In addition, persons who are not currently treatment candidates may become candidates due to changes in disease activity. This underscores the point that patients with chronic hepatitis B require lifelong monitoring regardless of whether they are receiving treatment.
Conclusions
The primary reasons to screen for HBV are to reduce morbidity and mortality related to liver disease and to prevent transmission. Significant barriers remain to screening and referral for care for HBV in the U.S. Educational programs to increase knowledge and awareness among HCPs and the public together with improved access to care are critical to improve disease outcomes and prevent transmission. Despite the availability of an effective vaccine for 3 decades, the global prevalence of HBV has not substantially declined. Further research is needed to explore strategies to overcome screening barriers, improve vaccination rates, and to develop new models of health care delivery to reduce the burden of disease-related to HBV.
