Hep B Screening – Is it a Game-Changer?

A recommendation by the Centers for Disease Control and Prevention advising universal screening for hepatitis B has focused renewed attention on one of the most prevalent liver diseases. It could be a game-changer.

As many as 2.4 million are living with hep B virus (HBV) in the United States, according to the CDC, and the rates of acute infections have risen a whopping 50% to 450% in states impacted by the opioid crisis. Globally, the numbers are even more dire. An estimated two billion people — or one out of three — have been infected, with another 1.5 million people newly infected each year.

In spite of this pervasiveness, most people don’t know they have HBV, which deprives them of life-saving treatment. Each year, up to 1 million people die from hepatitis B, though it’s preventable and treatable. Estimates by the CDC reveal that 2 out of 3 HBV cases go undiagnosed, while other sources say only 10% of the infected patients are actually diagnosed.

The new CDC recommendations mean that individuals who were not previously screened as part of an at-risk group can now be tested during a regular primary doctor visit, says Kalyan Ram Bhamidimarri, M.D., M.P.H., FACG, FAASLD, a hepatologist with the University of Miami Health System. (Screening includes three blood tests, which distinguish between those who are vaccinated, those with an active infection, and those with a chronic infection.)

“The one-time screening for HBV will result in diagnosing more cases who are living unaware of the infection,” Dr. Bhamidimarri says, “and it will also make a favorable difference in health outcomes by linking the infected individuals to appropriate medical care.”

Because symptoms don’t show up until the infection is advanced, HBV damages the liver silently, potentially leading to liver cancer and liver diseases such as cirrhosis. According to the CDC, as many as 85% of infected patients who don’t get treatment will die prematurely of liver cancer or liver failure. What’s more, undiagnosed individuals can spread this highly infectious virus to others without knowing it.

In some cases, the disease has damaged the liver or caused liver cancer, and the patients “may need a liver transplant despite being on antiviral treatment,” Dr. Bhamidimarri says. 

To understand how hep B spreads unnoticed, it’s important to know more about the biology of the virus and how it lives in our bodies,

There are two kinds of presentations: acute and chronic. Acute cases are short-term and may not always present with symptoms. If they do, an individual will suffer from fever, fatigue, nausea and vomiting, abdominal discomfort, and yellowed skin and eyes. Their body may clear the virus on its own. 

Chronic HBV develops when the virus sticks around after the acute phase — sometimes living in the host for decades without symptoms. In fact, an individual may not show any signs of disease until developing liver cancer or late-stage liver disease. Symptoms of chronic hep B reactivation are similar to the acute version but may also include fluid buildup in the legs and abdomen, gastrointestinal bleeding, and confusion from the toxins circulating in the body. 

Hepatitis B is like herpes or HIV in the sense that it enters the host cell and then settles in the nucleus, where it replicates.

In contrast, Hepatitis C, which is perhaps the best known of the hepatitis viruses, remains in the cytoplasm or the outside of the nucleus. Hep A and Hep C are curable, but not Hep B, although there is also a vaccine and treatment for the latter. Both B and C viruses are transmitted through contact with infected blood or bodily fluids. On the other hand, hepatitis A spreads by consuming contaminated water or food. Hep A is contagious and usually spreads via the feco-oral route caused by poor sanitation. Not so with hep B.

Though hep B and hep C are blood-borne pathogens, most cases of the former virus are transmitted from mother to child at birth. However, Hep C is more commonly spread through unclean needles when injecting drugs, MSM (homosexual men), and unsafe sexual practices.

While the consequences of untreated HBV can be fatal, Dr. Bhamidimarri points out that “the treatment is simple and highly efficacious. We may not have a cure, but we can prevent death and liver complications.”

Treatment consists of taking an antiviral medication orally once a day, usually for the rest of a patient’s life.

There’s also a hepatitis B vaccine, which has been around since the 1980s and is recommended for all ages, says Dr. Bhamidimarri.

The CDC’s latest recommendations for HBV screening build on earlier recommendations issued in 2008. That advisory listed about 20 categories of at-risk populations that would benefit from screening, but there are other individuals with HBV who may not have explicitly stated their risks due to social stigma or cultural barriers.

“The new CDC recommendation only makes it simpler for the primary care physician as it provides the opportunity to diagnose infection in those that are unaware but also vaccinate those who are susceptible,” he explained. “Overall, it is a highly cost-effective strategy that will substantially advance our goals for viral hepatitis elimination.”

Universal screening will likely be a giant leap forward.

“It will be widely available, and it simplifies the process. Everyone can be tested as part of a regular office work up.”

Ana Veciana-Suarez is a regular contributor to the University of Miami Health System. She is a renowned journalist and author who has worked at The Miami Herald, The Miami News, and The Palm Beach Post. Visit her website at anavecianasuarez.com or follow @AnaVeciana on Twitter.

Tags: Dr. Kalyan Ram Bhamidimarri, hepatitis B, liver damage