Letter to the editor: Both universal screening and vaccination are essential components of a multipronged approach to hepatitis B elimination

To the editor,

We agree with Cohen et al.^[1,2] that one‐time, universal HBV screening followed by linkage to care is the optimal way to diagnose and treat HBV‐infected patients. However, detailed planning and allocation of resources are needed to optimize the benefits of this strategy. For example, many HBV‐infected patients reside in underserved communities without adequate access to health care providers. May pharmacists use the point‐of‐care tests recommended by the World Health Organization to screen HBsAg for these individuals? If screening is performed by nonmedical providers, who will interpret the screening results? During the pandemic, the Test and Trace Corp established databases and traced COVID‐19 patients in New York City. Do we have the resources to build a similar model for HBV patients? If not the responsibility of the public health system, who will see newly diagnosed HBV‐infected patients after screening by nonmedical providers? Should we not have a national infrastructure to manage the anticipated large overflow of newly diagnosed HBV patients from universal testing in a consistent and standardized manner?

More important, a universal screening policy must be part of a larger strategy including immunization to prevent infection of susceptible adults. Cohen et al. suggest that universal screening with a three‐test panel (HBsAg, HBsAb, and HBcAb) will identify susceptible persons who would benefit from vaccination. In November 2021, the Advisory Committee on Immunization Practices (ACIP) expanded its recommendations for HBV immunization from risk‐based stratification to all adults 19–59 years of age who are previously unvaccinated. In addition, those age ≥60 years with risk factors for HBV infection should also receive HBV vaccination.^[3]

Approaches to vaccination vary across health care settings in the USA and when to provide the first dose of the HBV vaccine remains controversial. The ACIP and Centers for Disease Control and Prevention (CDC) recommend that prevaccination testing should not be a barrier to vaccination of susceptible persons.^[3,4] The CDC recommends that the first dose of vaccine should ideally be administered immediately after collection of blood for serological testing.^[5] There is no increase in the risk of adverse events when vaccination is given to persons with previous HBV vaccination or patients with HBV infection, including resolved infection and chronic HBV infection.^[5] Results of screening at the time of vaccine initiation can be used to determine the need for follow‐up vaccination completion. However, some health care providers prefer to give the first dose of HBV vaccination after the screening results are known. Nevertheless, data on comparing the aforementioned approaches are lacking. In our view, several aspects of HBV vaccination should be considered (Figure 1). The vaccination approach for each person should contemplate the risk of infection and the feasibility of vaccine implementation. Pairing screening tests with the first dose of HBV vaccination may be particularly valuable in the care of transient vulnerable populations such as patients in drug/alcohol rehabilitation facilities, methadone clinics, or under incarceration.

FIGURE 1: Hepatitis B screening and vaccination approaches

In summary, infrastructures for linkage to care are urgently needed in the USA before implementing universal screening for HBV. Prevention through universal vaccination is also an essential component of a multipronged approach to disease elimination.

CONFLICT OF INTEREST

Nothing to report.

AUTHOR CONTRIBUTIONS

Calvin Q. Pan served as the primary writer for the letter. All authors contributed to revising the draft and performed a critical review. Calvin Q. Pan communicated with the journal and addressed the reviewers’ comments.