Even Insured Adults with Access to Quality Care Aren’t Screened for Hepatitis
Even adults with medical insurance and regular access to doctors are not adequately screened for hepatitis B or C, according to a U.S. Centers for Disease Control and Prevention study published in the journal of Clinical Infectious Diseases.
Researchers examined how many patients enrolled in four private health care organizations across the United States were screened for viral hepatitis over a two-year period. The screening rates were shockingly low, missing an estimated 20% of hepatitis B virus (HBV) infections and half of all hepatitis C infections in this insured patient population.
Nationwide, experts estimate that 65% of people infected with HBV and 75% of those with hepatitis C are unaware of their infections due to poor access to health care and screening. Researchers decided to see how many “missed” hepatitis diagnoses occurred in insured people who enjoyed regular access to quality care.
They studied 866,886 uninfected adults enrolled in health care plans in Pennsylvania, Michigan, the Pacific Northwest, and Hawaii over several years to determine who and how many were screened for viral hepatitis. They then compared the number screened and found to be infected with viral hepatitis against race- and age-matched national data from the National Health and Nutrition Examination Survey (NHANES) to assess the missed diagnoses.
Even with quality health care, only 18.8% (one in five) were tested for HBV infection, with 1.4% testing positive. CDC researchers estimated that at least 21.1% of HBV infections (and 43.1% of hepatitis C infections) in this patient group remained undiagnosed. Bottom line, doctors identified 1,604 hepatitis B infections in their patients, but missed 616 infections due to adequate screening.
Given the low screening rates, which adult patients were flagged for screening and which weren’t?
In compliance with medical guidelines, Asian ethnicity were screened at a higher rate (26.7%) compared to whites (17.9%). But Asian-Americans were screened at a lower rate by doctors than African-Americans, even though they have higher rates of hepatitis B infection.
Older seniors (older than 80) were screened least (9.5%) while those ages 30-39 were screened most (28.2%). Women were screened more often than men.
Elevated alanine aminotransferase (ALT) levels, which can indicate liver damage from liver infections, often failed to trigger screening for hepatitis B or C. Fewer than 45% of patients who had twice the level of ALT that they should were screened for hepatitis B or C. Providers may have thought the liver damage resulted from alcohol abuse or medications instead of viral hepatitis.
A far smaller percentage of patients with only moderately elevated ALT levels were tested for hepatitis. Many patients with hepatitis B have normal ALT levels, which will not serve as a red flag or trigger for screening.
“Even in this population with access to care and lengthy follow-up, only a fraction of expected viral hepatitis infections were identified,” researchers wrote. “Abnormal ALT levels often, but not consistently, triggered testing. These findings have implications for the identification and care of 4-5 million U.S. residents with HBV and HCV infections.”
Despite Immunizations, 28% of Children Born to HBV-Infected Mothers Have “Occult" Infections
Twenty-eight percent of children born to HBV-infected mothers were found to have an “occult” hepatitis B infection (with HBV DNA in the bloodstream, but undetectable hepatitis B surface antigen—HBsAg) despite having been immunized shortly after birth, according to a study published in the Journal of Hepatology.
Researchers screened blood from 75 uninfected (without HBsAg) children in Iran born to HBsAg-positive mothers who had been immunized at birth. The children were screened for both HBsAg and HBV DNA (viral load). The HBV DNA test would pick up on any HBV in the bloodstream, even if the children had mutations in their HBsAg that were able to evade detection by conventional lab tests.
Fifty-five of the 75 tested positive for surface antibodies, which is expected after immunization with just the HBsAg to trigger an immune response. Nine, however, had core antibodies, which indicates past exposure to the virus. Eleven tested negative for surface antigens and surface antibodies and core antibodies.
Occult hepatitis B was diagnosed in 21 children, with HBV DNA levels ranging from 77 to 9,240 copies/mL. All 21 of these patients had surface antibodies, with five testing positive for core antibodies. Among the infected patients, 13 had one or more mutations in their HBV.
“Our study is the first report on the prevalence of (occult hepatitis B) among a selected high-risk group of children born to HBsAg-positive mothers, particularly from a region with low-to-intermediate prevalence of HBV,” the researchers wrote.
They suggested that an absence of HBsAg alone, “ … is not sufficient to completely exclude HBV DNA carriers. (Occult hepatitis B) seems to be relatively frequent in immunized children born to HBsAg-positive mothers.”
They called for additional studies into occult infection, and more research on whether vaccine boosters and/or stronger vaccines are needed to truly vanquish hepatitis B in children born to infected mothers.
it is already well known that hbsag is not immunogenic and that it is used by the virus to suppress immune system but this study confirms how weak this vaccine is
there are much better vaccines, one was just approved in europe, i m not sure but it should be from dynavax or similar name, this vaccine has higher response for adults and babies at birth because it contains hbcag, hbsag, and trls.hbcag is much more imunogenic and important to build immunity to hbv than habsag alone.
current hbv vaccine fails in about 10% or more adults and 28% babies at birth from this study, so it is much better to use tenofovir when pregnant, possibly much before delivery
the current hbv vaccine just makes hbv mutantion in hbsag region making hbv even more dangerous than wildtype, there was another study in asia reporting about 7-10% presence of accult hbv due to hbsag mutants from failed hbv vaccine
Despite Childhood Immunizations, Adult HBV Infections Slowly Increase after Adolescence
Researchers who examined 1,214 blood samples found that despite hepatitis B immunization during infancy and childhood, the number of people with HBV infections, including infections with a strain of HBV with mutations in the surface antigen, increases.
According to the article published in the journal Gastroenterology, Taiwanese children immunized during infancy were protected from infection through adolescence, but beginning at age 18, the number of vaccinated adults with HBV DNA in their blood stream began to slowly increase.
In the study, researchers measured hepatitis B surface antigens and antibodies and hepatitis B core antibodies in Taiwanese ranging from infants to adults older than 87.
HBV DNA levels were measured in HBV-vaccinated patients who tested positive for the core antibody (meaning they had been infected at some point) and those who were infected and tested positive for HBsAg.
Patients born after Taiwan’s HBV vaccination program began in 1984 had significantly lower HBsAg and core antibodies compared to older participants (1% vs. 9.3% for HBsAg, and 2.3% vs. 43.9% for core antibodies.)
However, researchers noted over time that even those who had been vaccinated during infancy had increasing rates of core antibody and limited numbers of surface antibodies.
Core antibodies were found in 0.4% aged 10-14, 1.9% aged 14-18, and 8.1% of those 18-21. HBV infection (evidenced by HBsAg) was found in 2% of those 18-21 compared to a zero infection rates in younger participants.
HBV DNA in the blood was also more common among older patients (3% of those aged 18-21) compared with 0.2% in younger participants.
Among eight fully-vaccinated participants who tested positive for HBV DNA, five had HBsAg mutations. Investigators noted that this increase in surface mutations after adolescence requires careful monitoring, because this “occult” infection can also cause liver damage.
“Universal vaccination effectively controls HBV infection in children and adolescents,” the researchers wrote. “However, after adolescence, there is a significant increase in the seroprevalence of surface antibodies, core antibodies and HBV DNA, indicating that new preventive strategies are needed for adults. Monitoring the prevalence of HBV infection by sensitive HBV DNA assays in subjects beyond adolescence in [the] postvaccination era is mandatory.”
Hepatitis B Virus Nucleocapsid but Not Free Core Antigen Controls Viral Clearance in Mice
Yi-Jiun Lina, Hui-Lin Wua,b, Ding-Shinn Chenb and Pei-Jer Chena,b
+ Author Affiliations
aGraduate Institute of Clinical Medicine
bHepatitis Research Center, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
We have recently shown that hepatitis B virus (HBV) core antigen (HBcAg) is the major viral factor for HBV clearance using a hydrodynamics-based mouse model. Knockout of HBcAg hampers the development of antiviral immune responses and thus promotes HBV persistence. Here, we further demonstrated that only in the capsid form, but not the free or dimer form, can HBcAg exert its contributory role in HBV clearance. HBcAg is the main structural protein of HBV icosahedral nucleocapsid. A mutant HBV DNA which expresses an assembly-defective HBcAg, HBcAgY132A, surprisingly prolonged HBV surface antigenemia in both C57BL/6 and BALB/c mice without affecting viral transcription and translation. This result was not due to a loss of the possible immune epitope caused by the single-amino-acid substitution of HBcAg. Moreover, the particular HBV mutant failed to induce robust humoral and cellular immunity against HBV. These data revealed the requirement of capsid structure for inducing adequate immunity that leads to HBV clearance in mice.
Health care is really bad here.. I am sure you have heard. Even though it costs outrageously high.. They missed my HepB when I went to emergency room 10 days after my possible exposure, when I was sick. I was just charged $780 for two hours that I was there. Doctor that evaluated me, and give Doxyclyling billed me for $480 too :) Yep it is that sick. When you test positive for HepB, C, or HIV the state registers you, and you can never buy a health insurance.. Now it has changes though thanks to President Obama. In 2014 insurance companies will not deny medical coverage to very sick people or impose premium caps they are willing to cover.
It became industry like sales bottom line. So that is why it is what it is.. 0 preventative measures are done. That is why Americans are one of the sickest nations compared to all the industrialized nations.. Here health care is a service not a Right.
There are huge debates about it almost daily in the news papers.. But Republicans appose everything regarding health care. They don't want European socialism. :)
It has been a year, since you wrote this post. How true it is today in the wake of government shutdown.
In some countries people work on developing better hep B vaccines. Better than the ones we have (imperfect). In other countries the basic "old" ones are still beyond the reach for many.
Healthcare should never be a business.
The so called Obama Care will kick in in 2014. I dont know what is the big deal about it. It only prohibits insurance companies from denying medical coverage to people with chronic diseases or imposing treatment caps. Health insurance companies will still be there and I am sure will find ways to limit quality of care some way.
It is still not a free health care system like in most other countries. But eventually it will come to it. As medical costs are reaching astronomical heights. And more and more people in the US understand that a right to health care is just a basic civil liberty. When you are sick and in need of help and you call a doctor office. And they ask you. "And what kind of insurance do you have" before anything else I dont think it can get any worse then that.
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