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Hepatitis B virus (HBV) infection remains a large cause of morbidity and mortality in worldwide despite it being preventable through screening and vaccination.
In 2016, WHO set out to eliminate HBV infection as a public health threat by 2030. We are far from this goal. Vaccine implementation has been suboptimal in a number of important patient populations, including patients with rheumatologic diseases, as well as other immunocompromising diseases like HIV.
Screening and vaccinating such populations is of utmost importance because hepatitis B surface antigen (HBsAg – chronic infection) and even core antibody (HBcAb – resolved infection) positive patients are at risk of reactivating infection in the setting of immunosuppression, in particular rituximab.
In 2010, survey data was published in Arthritis Care and Research authors queried 1,000 rheumatologists nationwide about familiarity with published guidelines for hepatitis B screening and their awareness of risk of HBV reactivation. While response rate was low they found that depending on the drug 19-53% of physicians were aware of the package insert warning re: HBV reactivation, 42% routinely screened for HBV reactivation prior to starting DMARDs and 69% before biologics. This article is 7 years old but I do not doubt that these low numbers still ring true. (https://buff.ly/2mJ6ftw)
A study published in the Annals of Internal medicine in December 2017 sought to estimate the prevalence of hepatitis B vaccination among U.S. patients with HIV in 2009 through 2012. Out of 18,000 they found that over 1/3 of these patients had missed opportunities to initiation the vaccine series. (https://buff.ly/2DKiPkr)
The current CDC/ACP recommendations state that clinicians should vaccinate all unvaccinated adults at risk including at risk by sexual exposure, percutaneous or mucosal exposure (e.g. healthcare workers), chronic liver disease, ESRD and HIV infection.
While patients requiring immunosuppression are not included here, they are recommended for screening (with HBsAg, HBcAb and HBsAb). What are the ACR guidelines for screening for HBV? They are not exactly clear.
They recommend screening “high-risk” patients receiving leflunomide or methotrexate, and that appropriate evaluation “might include” HBsAg, HBsAb and HbcAb. They mention no recommendation to screen before starting biologics.
With the growing use of immunosuppression, in particular biologics, we must be aware of the risk of HBV reactivation, which can lead to interruption of treatment and adverse liver consequences, all of which are largely preventable by timely screening and vaccination.