Time to broaden the screening strategy for chronic hepatitis B virus infection beyond the emergency department

It is with a great interest that we read the article by Llaneras et al [1]Llaneras J. Ruiz-Cobo J.C. Rando-Segura A. et al.Integrating viral hepatitis management into the emergency department: A further step towards viral hepatitis elimination.JHEP Rep. 2023; 6 (Published 2023 Oct 12)100932https://doi.org/10.1016/j.jhepr.2023.100932Abstract Full Text Full Text PDF Scopus (0) Google Scholar, highlighting the role of the emergency department as a main healthcare gateway for hepatitis B virus (HBV) screening. HBV infection remains a significant global health problem and an important cause of cirrhosis, liver failure, and especially hepatocellular carcinoma. The World Health Organization (WHO) estimated that 296 million people were living with chronic hepatitis B infection in 2019, of whom only 30 million had been diagnosed [2]WHO Hepatitis B key facts. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b Date: July 18, 2023, Date accessed: December 24, 2023Google Scholar. In Australia, an estimated 222,559 people were living with HBV at the end of 2020, equating to approximately 1 in 100 people [3]King J, McManus H, Kwon A, et al. 2022, HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2022, The Kirby Institute, UNSW Sydney, Sydney, Australia. http://doi.org/10.26190/sx44-5366Google Scholar. Despite increases in the proportions of people receiving clinical care for HBV from 8.5% in 2016 to 10.7% in 2020 [4]McCulloch K, Romero N, MacLachlan JH, et al. (2021). National Surveillance for Hepatitis B Indicators: Measuring the progress towards the targets of the National Hepatitis B Strategy – Annual Report 2020. WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute. https://www.doherty.edu.au/uploads/content_doc/National_Surveillance_for_Hepatitis_B_Indicators_2020_final.pdfGoogle Scholar and efforts to improve HBV screening, testing rates in Australia do not meet the WHO hepatitis B proposed elimination targets for 2030. WHO targets include the 90% diagnostic coverage and 80% treatment coverage among the eligible population with HBV infection [5]McCulloch K. Romero N. MacLachlan J. et al.Modeling Progress Toward Elimination of Hepatitis B in Australia.Hepatology. 2020; 71: 1170-1181https://doi.org/10.1002/hep.30899Crossref PubMed Scopus (29) Google Scholar,[6]Xiao Y. Howell J. van Gemert C. et al.Enhancing the hepatitis B care cascade in Australia: A cost-effectiveness model.J Viral Hepat. 2020; 27: 526-536https://doi.org/10.1111/jvh.13252Crossref PubMed Scopus (8) Google Scholar. Unfortunately, it is estimated that 37% of people living with chronic hepatitis B in Australia remain undiagnosed and therefore they do not seek treatment, posing a risk of further HBV transmission in the unvaccinated population [7]MacLachlan J, Stewart S, Cowie B. Viral hepatitis mapping project: national report 2020. Sydney: Australasian Society for HIV, Viral Hepatitis, and Sexual Health Medicine, 2021. https://ashm.org.au/wp‐content/uploads/2022/04/ASHM_ViralHepReport_2020_WEB_final.pdf (accessed 24 December 2023).Google Scholar. In Australia, the national hepatitis B testing policy is limited to target populations with evidence of liver disease or risk factors for HBV infection, pregnant women, newborn infants, blood and tissue donors, and people working in healthcare sector. However, this symptom- or risk-based testing is inadequate in general practice and captures only a fraction of the HBV infected population. Therefore, a cost-effective universal screening strategy would increase diagnosis rates and thereby decrease the disease burden especially when combined with appropriate clinical management. In this study, we performed a real-world service evaluation of routine HBV testing, looking to develop and expand on existing practice, which was already in place. The aim was first to explore the prevalence of HBV infection within populations accessing outpatient services beyond the emergency departments at Blacktown-Mount Druitt Hospital, Western Sydney, Australia. For this, electronic medical records of patients that attended antenatal, oncology, dialysis, and metabolic outpatient clinics, between 2019 and 2021 (n=11,006) were retrospectively reviewed for point‐of‐care HBV surface antigen (HbsAg) testing. Data collected also included blood born virus (BBV) status, fibrosis-4 (FIB-4), AST to platelet ratio index (APRI), demographic and risk factors. Results demonstrate that the prevalence of HBsAg positive individuals per 100,000 patients was 664 in antenatal, 1,392 in oncology, 2,797 in dialysis and 2,548 in metabolic clinics, respectively. This was significantly higher than the general NSW HBV notification rate in 2019 of 23.2 per 100,000 person (p<0.001) (table 1). Importantly, only 1.25% of the positive cases identified as Aboriginal and/or Torres Strait Islander. Among the four cohorts, 83.75% of HBV positive patients had no known risk factors, whereas 3.75% had current or previous intravenous drug misuse. Approximately 12.5% were suspected to have had vertical transmission and 10% had a FIB-4 score of >1.75 and 8.75% APRI >0.5, suggesting higher risk of liver fibrosis. The low estimated fibrosis levels also mean that these patients would not been picked up through liver fibrosis screening alone. Amongst those who were identified with HBV infection, only 35% were either referred to or followed up by specialists for monitoring of disease activity or treatment initiation, and only 7.5% had HBV DNA levels measured.Table 1Prevalence of HBsAg positive cases within populations accessing outpatient services (antenatal, oncology, dialysis and metabolic clinics) at Blacktown-Mount Druitt Hospital, Western Sydney, AustraliaTotal tested (person)n=11,006HBV antigen positive80 (0.73%)Gender Female71 Male9Age (Mean)36 [17,77]Region of Birth Australia/New Zealand9 Oceania other6 Asia44 Europe2 Africa19FIB-4 Mild (<1.45)72 Moderate (1.45-3.25)4 Severe (>3.25)4Antenatal cohort (n=9,789) HBsAg positive (per 100,000)664Oncology cohort (n=287) HBsAg positive (per 100,000)1,392Dialysis cohort (n=250) HBsAg positive (per 100,000)2,797Metabolic cohort (n=156) HBsAg positive (per 100,000)2,548Abbreviations: HBsAg: Hepatitis B virus surface antigen, FIB-4: fibrosis-4, n: number. Open table in a new tab Abbreviations: HBsAg: Hepatitis B virus surface antigen, FIB-4: fibrosis-4, n: number. Our data demonstrate that HBV prevalence was significantly higher in all the four cohorts compared to the estimated NSW notifications rate for 2019 [8]National cancer Control indicators, hepatitis B and C notification, published 24 June 2022, https://ncci.canceraustralia.gov.au/prevention/hepatitis/hepatitis-b-and-hepatitis-c-notification#:∼:text=Hepatitis%20B%20notifications&text=The%20notification%20rate%20for%20hepatitis,(21.0%20cases%20per%20100%2C000). (accessed 24 December 2023)Google Scholar. These figures may be even greater due to the impact of the COVID-19 pandemic (2019-2021) reducing HBV testing and diagnosis, as well as travel restrictions reducing migration between Australia and countries with higher hepatitis B prevalence [7]MacLachlan J, Stewart S, Cowie B. Viral hepatitis mapping project: national report 2020. Sydney: Australasian Society for HIV, Viral Hepatitis, and Sexual Health Medicine, 2021. https://ashm.org.au/wp‐content/uploads/2022/04/ASHM_ViralHepReport_2020_WEB_final.pdf (accessed 24 December 2023).Google Scholar. Therefore, to achieve WHO hepatitis B elimination targets in Australia, current testing practices should be expanded to include non-targeted population that are opportunistically screened [9]Allard N.L. MacLachlan J.H. Tran L. et al.Time for universal hepatitis B screening for Australian adults [published correction appears in Med J Aust. 2021 Sep 20;215(6):258].Med J Aust. 2021; 215: 103-105.e1https://doi.org/10.5694/mja2.51114Crossref PubMed Scopus (13) Google Scholar,[10]Xiao Y. Hellard M.E. Thompson A.J. et al.The cost-effectiveness of universal hepatitis B screening for reaching WHO diagnosis targets in Australia by 2030.Med J Aust. 2023; 218: 168-173https://doi.org/10.5694/mja2.51825Crossref Scopus (1) Google Scholar. The WHO, state and national targets are unlikely to be reached under current practice protocols and hence an intensified testing policy is needed. Our study highlights the need to increase awareness and educate healthcare providers regarding appropriate HBV point of care testing and management, as 65% of the patients had no post-test referral to appropriate care and approximately 92% did not have appropriate testing to assess for the extent of infectious status. Finally, universal HBV screening represents a solution to reach the national and the WHO 2030 targets. There is a need to broaden the screening circuits for HBV infection to involve non-conventional gateways and not only restricted to the emergency department. Although the feasibility and exact impact of such screening in relieving the health burden of HBV still needs to be evaluated. Ethics approval was obtained from the Human Research Ethics Committee at Western Sydney Local Health District (Ethics Approval 2021/ETH00149). The study conforms to the ethical guidelines of the Declaration of Helsinki. The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. The authors have no conflict of interest to report. None.