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HBV HDV Screening
Harnessing HBV and HDV Screening for Earlier Diagnosis

Released: January 05, 2024

Expiration: January 04, 2025

Douglas Dieterich
Douglas Dieterich, MD
Camilla S. Graham
Camilla S. Graham, MD, MPH
Robert Wong
Robert Wong, MD, MS
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Key Takeaways
  • For HBV, the CDC recommends that all adults be screened at least once in their lifetime, with a triple panel test for surface antigen, surface antibody, and core antibody.
  • CDC also now recommends universal HBV vaccination for all adults aged 19-59 years.
  • For HDV, universal testing for all people who are hepatitis B surface antigen positive, rather than risk-based screening, can significantly improve screening rates and reduce disease burden.

The benefits of timely hepatitis B virus (HBV) and hepatitis delta virus (HDV) diagnosis are far-reaching. For the individual, a timely diagnosis reduces the risk of cirrhosis, hepatocellular carcinoma (HCC), and liver-related mortality. For society at large, earlier diagnosis helps to reduce risk of transmission and can help inform the decision of who needs to be vaccinated. However, recent studies reveal that major gaps in testing, diagnosis, and linkage to care still exist, particularly among racial and ethnic minority groups and underserved populations.

Universal HBV Testing
A primary cause of the disparity in HBV care is the risk-based testing guidelines. Risk-based testing requires healthcare professionals to go through 20 or so risk factors, many of which are not well characterized in the electronic medical record system. They are complicated and convoluted, and as evidenced by the data, result in many infections going undiagnosed.

In response, the CDC has recently come up with updated screening recommendations. Now, the CDC recommends that all adults be screened at least once in their lifetime, with a triple panel test for surface antigen, surface antibody, and core antibody. The screening guidelines also recommend that all pregnant persons be screened in first trimester with every pregnancy, as well as continued, periodic risk-based screening recommended for individuals at ongoing high risk for acquisition, such as people who are incarcerated or have a history of sexually transmitted infections, multiple sex partners, or hepatitis C virus.

Universal testing reduces stigma and facilitates linkage to care and treatment by simplifying the path to a timely diagnosis. Universal testing can even better identify people who would truly benefit from vaccination and avoid inadvertent vaccination of people with chronic HBV infection who might be falsely reassured that they are protected from a serious infection. [Coder link to: https://clinicaloptions.com/CE-CME/infectious-disease/indications-for-hbv-treatment/18438-26658]

We have instituted universal HBV screening in our primary care clinics, and with the assistance of coordinators and navigators, we have managed to link 70% of patients with positive hepatitis B surface antigen to care.

Similar to the CDC’s expanded screening guidelines, the Advisory Committee on Immunization Practices also expanded their HBV vaccination guidelines in 2022 to include all adults aged 19-59 years and adults aged 60 years or older, if they have risk factors. Even if older adults do not have risk factors, the guidelines state that they may be vaccinated.

Addressing the major gaps in HBV diagnosis is a complex process, with no one-size-fits-all answer. We acknowledge that a comprehensive approach is needed, individualized to each health system, community, and demographic, to address the multifaceted barriers to timely diagnosis and linkage to care for people with chronic HBV.

Universal HDV Testing
The challenge with HDV is the lack of awareness and screening that contributes to underestimation of its true prevalence. This gap in diagnosis is of crucial importance because people with HDV and HBV coinfection are at a much higher risk of downstream complications, such as cirrhosis, HCC, end-stage liver disease, and death. Earlier diagnosis and linkage to care would be pivotal in preventing these complications.

Whom to screen? This is where some of the confusion lies and contributes to undertesting.

Although the World Health Organization has no recommendations for HDV testing, there are 3 other major guidelines on whom to test.

The European Association for the Study of the Liver (EASL) and the Asian Pacific Association for the Study of the Liver both recommend that all people with HBV be tested for HDV.

The American Association for the Study of Liver Diseases (AASLD) is in the process of updating their guidelines—a welcome update because their 2018 guidelines still recommend a risk-based approach, which the data have shown is inadequate. Hopefully, the new guidelines will move toward more universal testing.

It is hard to overemphasize how important establishing the HDV diagnosis is to guiding treatment. Although the guidelines still vary on whom to test, I think most experts align more with the EASL guidelines than the AASLD guidelines: Most experts agree that universal screening in people who are hepatitis B surface antigen positive should be done and that this reflex testing to hepatitis delta antibody and/or delta polymerase chain reaction can significantly increase screening and reduce the burden of HDV.

Your Thoughts?
How many patients do you screen for HBV and HDV? Leave a comment to join the discussion.