Implementing the Updated Hepatitis B Vaccination and Screening: Recommendations in Family Practice

Why is hepatitis B such a major health care threat?

Hepatitis B virus is the most common cause of serious liver disease worldwide^1,2 and a leading risk factor for liver cancer.³ Individuals with unmanaged chronic hepatitis B have a 15-25% lifetime risk of dying prematurely from cirrhosis or liver cancer.⁴ In the United States an estimated 20,700 cases of acute hepatitis B infections occur each year,⁵ with up to 2.4 million people living with chronic hepatitis B.

Isn’t there a vaccine for hepatitis B?

Effective and safe vaccines have been available since 1992 and have dramatically reduced the number of acute cases. However, 70% of adults older than 19 years have not completed the hepatitis B vaccination series.⁷ Moreover, 67% of people living with hepatitis B are unaware of their infection.^8-10 Lack of awareness and accurate knowledge around hepatitis B and its connection to liver cancer are key barriers to vaccination and screening.

Why were the hepatitis B screening and vaccination recommendations updated?

The previous guidelines¹¹ for hepatitis B screening and vaccination were risk based and exacerbated barriers such as stigma and the burden on clinicians in assessing numerous risk factors. To address these limitations, the updated screening¹² and vaccination¹³ recommendations from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), respectively, remove the need for risk assessment before screening or vaccination. These recommendations include universal screening and vaccination for all adults aged 19 to 59 years, simplifying the framework for determining an adult’s need for hepatitis B screening or vaccination (Figure 1). Research also shows that universal screening and vaccination for hepatitis B is life-saving and cost effective.^14,15 The aim is to help achieve the national and global goals of eliminating hepatitis B as a public health threat by 2030.^{16, 17}

How do we implement the updated screening and vaccination recommendations in family practice?

The Hepatitis B Foundation convened a multistakeholder Advisory Council in 2022 to help stakeholders implement the updated hepatitis B vaccination and screening recommendations.¹⁸ This will require urgent action in three key areas: education around the new recommendations, multistakeholder collaborations and technology innovations, and addressing vaccine hesitancy.

Priority Action #1: Educate stakeholders about hepatitis B and the updated screening and vaccination recommendations

Family practice physicians could participate in monthly trainings/webinars, conferences, and interprofessional continuing education programs. Physicians could also use educational materials created by community organizations to learn about the new recommendations, screening and testing protocols, vaccines and dosing schedules, and guidance on counseling patients. Professional societies could consider providing hepatitis B education at their annual meetings and through collaborations with medical and clinical training programs. The materials should emphasize how the updated screening and vaccination recommendations may help address healthcare inequities.

Priority Action #2: Explore multistakeholder collaborations and technology innovations

A multistakeholder approach, as used successfully during the COVID-19 pandemic, may involve collaboration among physicians, public health professionals, nurses, pharmacists, and information technology teams to provide vaccinations to patients at large community clinics.¹⁹ The authority of pharmacy professionals to provide vaccination or screening services varies by state.^20-22 To address such restrictions and increase vaccination and/or screening capacity, primary care providers may establish collaborative practice agreements with pharmacists.²³

Primary care practices and hospital systems are encouraged to update their electronic health records (EHRs) systems to facilitate screening and/or vaccination. Strategies include the greater use of standing orders and inclusion of prompts for hepatitis B screening that automatically bundle the 3 hepatitis B tests as a triple panel.¹² Emerging research shows that universal adult screening using EHRs in primary care clinics is feasible and does not increase clinician burden.²⁴ Indeed, some healthcare centers serving disproportionately affected populations have been successfully using such EHR prompts for several years.^18,25-27 The EHR system could also add hepatitis B screening to other blood draw panels before patients’ visits with their clinicians. To ensure complete vaccination records, physicians who administer hepatitis B vaccines should report this information to their statewide registries. Linking EHR systems to state systems may facilitate such reporting.

Physicians who are able to provide vaccination but not screening services should explain to patients that they should still undergo screening even after initiation of the vaccination series. The triple panel can help identify persons who have a past, current, or ongoing infection, are susceptible to reactivation or need vaccination, or who have been vaccinated. Further testing in a person diagnosed with hepatitis B infection can help inform future clinical management.^5,12

Priority Action #4: Address vaccine hesitancy

When communicating with patients, physicians may highlight the cancer prevention benefit of hepatitis B vaccination and emphasize the established safety and efficacy profiles of hepatitis B vaccines.²⁸ They could also underscore that hepatitis B is a vaccine-preventable condition and early diagnosis can lead to timely initiation of effective treatments. Physicians may use FAQ documents created by community groups to help prepare for questions around vaccine safety and efficacy and to reduce needle anxiety.

Conclusion

Implementing the updated screening and vaccination recommendations will require action by family practice physicians and other stakeholders in three key areas: education around the new recommendations, multistakeholder collaborations and technology innovations, and addressing lack of vaccine confidence. Physicians may use the strategies described in this blog to participate in a concerted, multistakeholder national effort toward eliminating hepatitis B.

April 30 is National Adult Hepatitis B Vaccination Awareness Day and May is Hepatitis Awareness Month.

Figure 1.Updated recommendations for hepatitis B screening and vaccination

References

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