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.