draft

Draft Recommendation Statement

Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: Screening

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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May 04, 2020

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Recommendation Summary

Population Recommendation Grade
Nonpregnant adolescents and adults at increased risk for infection The USPSTF recommends screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection. B

An estimated 862,000 persons in the United States are living with chronic infection with HBV.1 Persons born in regions with a prevalence of HBV infection of 2% or greater, such as countries in Africa and Asia, the Pacific Islands, and parts of South America, often become infected at birth and account for up to 95% of newly reported chronic infections in the United States. Other high-prevalence populations include persons who inject drugs; men who have sex with men; persons with HIV infection; and sex partners, needle-sharing contacts, and household contacts of persons with chronic HBV infection.2

Up to 60% of HBV-infected persons are unaware of their infection,3 and many remain asymptomatic until onset of cirrhosis or end-stage liver disease.4, 5 This contributes to delays in medical evaluation and treatment and ongoing transmission to sex partners and persons who share objects contaminated with blood or other bodily fluids that contain HBV.3, 6 From 15% to 40% of persons with chronic infection develop cirrhosis, hepatocellular carcinoma, or liver failure, which lead to substantial morbidity and mortality.4

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The USPSTF concludes with moderate certainty that screening for HBV infection in adolescents and adults at increased risk for infection has moderate net benefit.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.7

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Patient Population Under Consideration

This recommendation applies to asymptomatic, nonpregnant adolescents and adults at increased risk for HBV infection, including those who were vaccinated before being screened for HBV infection. The USPSTF has made a separate recommendation on screening in pregnant women.8

Assessment of Risk

The risk for HBV infection varies substantially by country of origin in foreign-born persons in the United States. Persons born in countries with a prevalence of hepatitis B surface antigen (HBsAg) of 2% or greater (Table 2, Figure) account for the majority of cases of new chronic HBV infection in the United States; most persons in these countries acquired HBV infection from perinatal transmission.2 Persons born in the United States with parents from regions with higher prevalence are also at increased risk of HBV infection during birth or early childhood, particularly if they do not receive appropriate passive and active immunoprophylaxis (and antiviral therapy for pregnant women with a high viral load) (Figure).9-11 The Centers for Disease Control and Prevention (CDC) classifies HBV endemicity levels by prevalence of positive HbsAg (high [8%], moderate [2% to 7%] or low [<2%]) (Figure). The estimated prevalence of HBV infection in the general U.S. population is 0.3% to 0.5% (8-10, 12-14), which makes it reasonable to screen 1) adolescents and adults born in countries or regions with an HBsAg prevalence of 2% or greater (regardless of vaccination history in their country of origin) and 2) adolescents and adults born in the United States who did not receive the HBV vaccine as infants and whose parents were born in regions with an HBsAg prevalence of 8% or greater (regardless of their biologic mother’s HBsAg status).

HBV screening should also be offered to other risk groups defined by clinical and behavioral characteristics in which prevalence of positive HBsAg is 2% or greater. Persons from such risk groups include past or current users of injected drugs, men who have sex with men, persons with HIV; and sex partners, needle-sharing contacts, and household contacts of persons known to be HBsAg positive2, 3, 10-13, 15, 16 (Table 3). Some persons with combinations of risk factors who are not members of risk factor groups listed above may also be at increased risk for HBV infection. Clinicians should therefore consider the populations they serve when making screening decisions.

Screening Tests

Screening for hepatitis B should be performed with HBsAg tests approved by the U.S. Food and Drug Administration, followed by a confirmatory test for initially reactive results.2, 17

A positive HBsAg result indicates chronic or acute infection. Serologic panels performed concurrently with or after HBsAg screening allow for diagnosis and to determine further management. (See the “Additional Tools and Resources” section for serologic test interpretation).

Screening Intervals

For patients with negative HBsAg results who have not received the HBV vaccine series, periodic screening may be useful for patients who report continued risk for acquiring HBV transmission, such as people who continue to inject drugs and men who have sex with men. Clinical judgment should be used to determine screening frequency. The USPSTF found no evidence to determine optimal screening intervals.

Treatment

Persons with testing results indicative of acute or chronic HBV infection generally receive education about reducing the risk of transmission to others (e.g., during childbirth or with sex and needle-sharing partners and household contacts) and consideration for indicated vaccines.18 Between 20% and 40% of patients with chronic HBV infection will require treatment4 (see the “Additional Tools and Resources” section for information on treatment). Several antiviral medications are approved by the U.S. Food and Drug Administration for treatment of chronic HBV infection.19

Implementation

Many persons at risk for HBV infection are not screened or vaccinated.4 Approximately 11% to 67% of foreign-born persons and 28% to 52% of men who have sex with men have undergone HBV screening.4 Low uptake of screening may be related to several barriers, including language, lack of awareness about HBV, limited access to health care, inability to access affordable treatment, stigmatization, concerns about suspension from jobs and other communal activities, and patients’ concerns about reporting and followup of screening results by public health authorities that may involve notification of close contacts.4, 12, 20-22 When offering screening, clinicians should understand the positive and negative implications of reporting (as required by most U.S. jurisdictions [23]), case investigations, and contact notification.22, 24

Additional Tools and Resources

Several tools may help clinicians implement this screening recommendation. The CDC provides the following.

Other Related USPSTF Recommendations

Other related USPSTF recommendations are found at https://www.uspreventiveservicestaskforce.org. These include screening for HBV infection during pregnancy;8 screening for hepatitis C virus infection in adults ages 18 to 79 years;25 screening for HIV in adolescents and adults ages 15 to 65 years;26 and behavioral counseling to prevent sexually transmitted infections.27

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In 2014, the USPSTF recommended screening for HBV in persons at high risk for infection (B recommendation).28 The current draft recommendation is consistent with the 2014 recommendation. It is bolstered by new evidence from trials and cohort studies reporting that antiviral therapy reduces risk of mortality and hepatocellular carcinoma and improves intermediate outcomes that are consistently associated with better health outcomes.

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Scope of Review

The USPSTF commissioned a systematic evidence review to update and expand on its prior review on screening for HBV infection in persons at increased risk.29 In the current review, the USPSTF examined evidence from new randomized, controlled trials and cohort studies published from 2014 to August 2019 that evaluated the benefits and harms of screening and antiviral therapy for preventing intermediate outcomes or health outcomes and the association between improvements in intermediate outcomes and health outcomes. New key questions focused on the yield of alternative HBV screening strategies and the accuracy of tools to identify persons at increased risk.

Accuracy of Screening Tests and Risk Assessment

The USPSTF previously reviewed the evidence on screening for HBV using serologic testing with HBsAg and found it to be accurate (both sensitivity and specificity were >98%).30 The current review found no studies that assessed the accuracy of tools for identifying persons at increased risk for HBV infection. 

Benefits of Early Detection and Treatment

There are currently no randomized, controlled trials comparing screening with no screening to provide direct evidence of the benefit of screening.9

Screening Strategies

Evidence on screening strategies for identifying persons with HBV infection was limited to three fair-quality, retrospective studies in private primary care practices in Germany (n=20,917), a French sexually transmitted infection clinic (n=6,194), and French clinics that served populations with high HBV prevalence (n=3,929). These studies found that screening based on broad criteria (immigration from countries with a high prevalence, other demographic risk factors, or behavioral risk factors) identified nearly all cases of HBV infection, with numbers needed to screen ranging from 32 to 148. Restricting screening to immigrants from high-prevalence (≥2%) countries was more efficient (numbers needed to screen ranging from 19 to 71) and identified 85% to 99% of patients with HBV infection in higher- prevalence clinical settings, but missed about two-thirds of HBV infections in German primary care practices. The applicability of these studies to U.S. primary care settings may be limited.9

Benefits of Treatment on Intermediate Outcomes

Eighteen fair-quality trials (total N=2,972; n=24 to 526; duration of followup, 1.8 to 86 months) of antiviral therapy reported intermediate outcomes (e.g., virologic suppression, alanine aminotransferase [ALT] normalization, histologic improvement, and HBsAg loss or seroconversion) in persons ages 24 to 46 years. Six studies were done in the United States or Europe. Trials evaluated first-line therapies (i.e., therapies with the highest proven efficacy and safety, including nonpegylated interferon and entecavir) and alternate therapies (lamivudine and adefovir).9

Pooled analysis showed that antiviral therapy was statistically significantly more effective than placebo or no treatment in achieving histologic improvement, loss of HBsAg, loss of hepatitis B e-antigen (HBeAg), HBeAg seroconversion, virologic suppression, and normalization of ALT levels.9 Although there were some differences in the magnitude of the effect when trials were stratified by geographic region, antiviral therapy was consistently associated with increased likelihood of virologic suppression across regions. Stronger effects were also seen in studies with less than 1 year of followup than in studies with longer followup.9

Twelve good- or fair-quality trials (N=4,127; n=44 to 715; duration, 3.7 to 22 months) in adults compared first-line versus alternate regimens, specifically entecavir versus lamivudine (k=6), entecavir versus telbivudine (k=2), pegylated interferon versus lamivudine (k=1), or tenofovir disoproxil fumarate (TDF) versus adefovir (k=3). In one trial of pegylated interferon and in pooled analysis of six trials of entecavir, both first-line regimens achieved significantly higher virologic suppression or ALT normalization compared with lamivudine.9

Benefits of Treatment on Health Outcomes

Seven fair-quality randomized trials (N=1,042; n=42 to 356; duration, 12 to 86 months) compared the effects of antiviral therapy versus placebo or no treatment on cirrhosis, hepatocellular carcinoma, or mortality in adults. Three trials were conducted in the United States or Europe; the remainder were conducted in Asia or multiple countries with varied HBsAg prevalence. Four trials assessed various interferon alpha regimens; four assessed lamivudine. Pooled analysis revealed that treatment was associated with significant reduction in mortality (3 trials; relative risk [RR], 0.15 [95% CI, 0.03 to 0.69]) and lower risk of incident cirrhosis (2 trials; RR, 0.72 [95% CI, 0.29 to 1.77]) or hepatocellular carcinoma (4 trials; RR, 0.60 [95% CI, 0.16 to 2.33]) that were not statistically significant. None of the trials evaluated effects of antiviral therapy in adolescents or how effects varied by age, race/ethnicity, or sex.9

Seven fair-quality cohort studies (N=~50,912; n=632 to 43,190; duration, 2.7 to 8.9 years) compared antiviral therapy with no antiviral therapy in adults in the United States (2 trials) or Asia (5 trials). Most studies adjusted for patient age, sex, and stage of fibrosis; some also adjusted for level of HBV DNA, ALT levels, or medical comorbid conditions. The trials assessed lamivudine (k=1), entecavir (k=1), or various regimens (k=5). All studies found that antiviral therapy was associated with a decreased risk of hepatocellular carcinoma (adjusted hazard ratios [HRs] ranged from 0.24 to 0.64), including two U.S. studies with median followup of 5.2 years (adjusted HR, 0.39 [95% CI, 0.27 to 0.56]) or 8.9 years (adjusted HR, 0.24 [95% CI, 0.15 to 0.39]).9

 Association Between Intermediate Outcomes and Health Outcomes

Nine fair-quality cohort studies (N=3,893; n=63 to 1,531; duration, 3.2 to 9.9 years) assessed the association between intermediate outcomes after treatment and health outcomes in adults in the United States or Europe (6 trials) or Asia (3 trials) with varied baseline characteristics (e.g., HBeAg status, presence of cirrhosis). The trials assessed interferon (6 trials), entecavir (2 trials), or lamivudine (1 trial). HBeAg loss or seroconversion was associated with a lower risk of cirrhosis (1 trial; adjusted HR, 0.41 [95% CI, 0.32 to 0.88]), hepatocellular carcinoma (1 trial; adjusted HR, 0.13 [95% CI, 0.08 to 0.57]), or a composite health outcome (1 trial, adjusted HR, 0.06 [95% CI, 0.01 to 0.61]). Other studies found associations between virologic suppression, ALT normalization, histologic improvement, or composite intermediate outcomes and a lower risk of hepatocellular carcinoma or composite health outcomes, but several associations were not statistically significant.9

Harms of Early Detection and Treatment

No randomized, controlled trials comparing HBV screening with no screening currently exist to provide direct evidence of the harms of screening.9

Twelve trials (N=2,106) reported on harms of treatment compared with no treatment or placebo. Pooled analyses found no significant differences in the risk of serious adverse events (4 trials; RR, 0.92 [95% CI, 0.45 to 1.85]), any adverse event (5 trials; RR, 1.01 [95% CI, 0.90 to 1.11]), renal adverse events (3 trials; RR, 1.27 [95% CI, 0.31 to 3.55]), or study withdrawal due to adverse events (3 trials; RR, 4.44 [95% CI, 0.95 to 20.77]). Nine trials (N=3,408) compared harms of first-line antiviral regimens with harms of alternate regimens. Pegylated interferon was associated with an increased risk of any adverse event compared with lamivudine in one trial (N=543; RR 1.58 [95% CI, 1.41 to 1.78]). No significant differences in risk of serious adverse events or withdrawal due to adverse events were found in trials that compared entecavir with lamivudine or compared TDF with adefovir. One fair-quality cohort study of Asian patients in the United States (n=1,224) that compared risk of incident osteopenia or osteoporosis in patients treated with TDF or entecavir with patients receiving no therapy found no significance differences in these outcomes.9

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The USPSTF identified important gaps related to HBV screening and recommends research on the following.

  • Development and validation of clinical decision support tools to help clinicians efficiently and accurately identify adolescents and adults at increased risk for HBV infection.
  • Investigating alternative screening strategies defined by a person’s country of origin or other health or behavioral factors in the United States.
  • Development of rapid, point-of-care HBsAg tests for use in the United States to facilitate screening and linkage to care for patients at risk for loss to followup.
  • Additional trials with adequate duration and statistical power to evaluate the association between current first-line therapies (including recently approved tenofovir alafenamide) on long-term health outcomes of cirrhosis, end-stage liver disease, disease-specific and all-cause mortality, and quality of life and risk of HBV transmission.
  • In the absence of randomized, controlled trials, the development of registries that monitor treatment efficacy could be informative.
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Several organizations have issued recommendations about screening nonpregnant adolescents and adults. The CDC, the American College of Physicians, and the American Association for the Study of Liver Diseases recommend screening for HBV infection in asymptomatic, high-risk persons, including all persons born in countries with an HBsAg prevalence of 2% or greater regardless of vaccination history; U.S.-born persons not vaccinated as infants whose parents were born in regions with an HBsAg prevalence of 8% or greater; persons who inject drugs; men who have sex with men; and persons with HIV infection, persons with HCV infection, inmates of correctional facilities, and household contacts and sexual partners of HBsAg-positive persons.2, 4, 19, 31 Both the CDC and the American Association for the Study of Liver Diseases also recommend screening patients with conditions requiring immunosuppressive therapy, predialysis, hemodialysis, peritoneal dialysis, or home dialysis; patients who have elevated ALT levels of unknown etiology; or developmentally disabled persons and staff in residential facilities.2, 4, 19 The American Association for the Study of Liver Diseases also recommends screening persons with multiple sexual partners or a history of sexually transmitted infections.19 The American Academy of Family Physicians32 endorses the 2014 USPSTF recommendation on HBV screening.

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1. Patel EU, Thio CL, Boon D, Thomas DL, Tobian AA. Prevalence of hepatitis B and hepatitis D virus infections in the United States, 2011-2016. Clin Infect Dis. 2019;69(4):709-712.
2. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(No. RR-1):1-31
3. Cohen C, Holmberg SD, McMahon BJ, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18:377-383.
4. Abara WE, Qaseem A, Schillie S, et al. Hepatitis B vaccination, screening, and linkage to care: best practice advice from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017;167:794-804.
5. McMahon BJ. The natural history of chronic hepatitis B virus infection. Hepatology. 2009;49(5 Suppl):S45-55.
6. Lin SY, Chang ET, So SK. Why we should routinely screen Asian American adults for hepatitis B: a cross-sectional study of Asians in California. Hepatology. 2007;46:1034-40.
7. U.S. Preventive Services Task Force. Procedure Manual. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual. Accessed April 20, 2020.
8. US Preventive Services Task Force. Screening for hepatitis B virus infection in pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;322(4):349-354.
9. Chou R, Blazina I, Bougatsos C, et al. Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: A Systematic Review for the U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 194. AHRQ Publication No. 20-05262-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2020.
10. Kim HS, Rotundo L, Yang JD, et al. Racial/ethnic disparities in the prevalence and awareness of hepatitis B virus infection and immunity in the United States. J Viral Hepat. 2017;24(11):1052-1066.
11. Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al; Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57(RR-8):1-20.
12. Shing JZ, Ly KN, Xing J, Teshale EH, Jiles RB. Prevalence of hepatitis B virus infection among US adults aged 20–59 years with a history of injection drug use: National Health and Nutrition Examination Survey, 2001–2016. Clin Infect Dis. 2019.
13. Schweitzer A, Horn J, Mikolajczyk R, Krause G, Ott J. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet. 2015;386(10003):1546-1555.
14. Le MH, Yeo YH, Cheung R, Henry L, Lok AS, Nguyen MH. Chronic hepatitis B prevalence among foreign-born and U.S.-born adults in the United States, 1999-2016. Hepatology. 2020;71(2):431-443.
15. Nelson P, Mathers B, Cowie B, et al. The epidemiology of viral hepatitis among people who inject drugs: results of global systematic reviews. Lancet. 2011;378(9791):571-583.
16. Thio CL. Hepatitis B and human immunodeficiency virus coinfection. Hepatology. 2009;49(5):S138-S145.
17. Abara WE, Schillie SF. Chapter 4: Hepatitis B. Manual for the Surveillance of Vaccine-Preventable Diseases. May 31, 2018. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt04-hepb.html. Accessed April 9, 2020.
18. Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep. 2015:64(RR3);1-137.
19. Terrault NA, Lok AS, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67(4):1560-1599.
20. Hepatitis B Foundation. Know Your Rights. 2020. https://www.hepb.org/resources-and-support/know-your-rights/. Accessed April 9, 2020.
21. Centers for Disease Control and Prevention. Guidelines for Viral Hepatitis Surveillance and Case Management. January 2005. https://www.cdc.gov/hepatitis/statistics/surveillanceguidelines.htm. Accessed April 9, 2020.
22. World Health Organization. Guidelines on Hepatitis B and C Testing. February 2017. https://www.who.int/hepatitis/publications/guidelines-hepatitis-c-b-testing/en/. Accessed April 9, 2020.
23. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance – United States. Hepatitis B Tables and Figures (Table 3.3). Nov 14, 2019. https://www.cdc.gov/hepatitis/statistics/2017surveillance/TablesFigures-HepB.htm#tabs-1-3. Accessed April 9, 2020.
24. Spradling PR, Xing J, Rupp LB, et al. Infrequent clinical assessment of chronic hepatitis B patients in United States general healthcare settings. Clin Infect Dis. 2016;63:1205-1208.
25. US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2020 Mar 2.
26. US Preventive Services Task Force. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326-2336.
27. U.S. Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):894-901.
28. U.S. Preventive Services Task Force. Screening for hepatitis B virus infection in nonpregnant adolescents and adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(1):58-66.
29. Chou R, Dana T, Bougatsos C, Blazina I, Zakher B, Khangura J. Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 110. AHRQ Publication No. 12-05172-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
30. U.S. Preventive Services Task Force. Screening for hepatitis B virus infection in pregnancy. Ann Intern Med. 2009;150(12):869-73.
31. Centers for Disease Control and Prevention. Hepatitis B Questions and Answers for Health Professionals. March 16, 2020. https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#C17. Accessed on April 9, 2020.
32. American Academy of Family Physicians. Clinical Preventive Services: Hepatitis B Virus Chronic Infection. 2014. www.aafp.org/patient-care/clinical-recommendations/all/hepatitis.html. Accessed February 2, 2020.
33. Harris AM. Chapter 4: Travel-Related Infectious Diseases. CDC Yellow Book 2020: Health Information for International Travel. https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b#5182. Accessed April 9, 2020.

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Rationale Nonpregnant Adolescents and Adults at Increased Risk
Detection
  • Adequate evidence that the identification of HBV infection is accurate based on laboratory-based immunoassays for detecting hepatitis B surface antigen (HBsAg), with reported sensitivity and specificity exceeding 98%.
Benefits of Early Detection and Intervention
  • Inadequate direct evidence on benefits of screening on health outcomes due to lack of studies.
  • Convincing evidence that antiviral treatment of patients with chronic HBV infection is effective at improving intermediate outcomes, including hepatitis B e-antigen (HBeAg) loss and virologic suppression.
  • Adequate evidence from clinical trials and cohort studies that antiviral treatment of patients with chronic HBV infection improves health outcomes, such as reduced risk of mortality or hepatocellular carcinoma.
  • Adequate evidence that improvements in intermediate outcomes of chronic HBV infection related to antiviral treatment (such as HBeAg clearance and virologic suppression) are associated with reduced risk of adverse health outcomes (such as cirrhosis and hepatocellular carcinoma).
Harms of Early Detection and Intervention
  • Inadequate direct evidence on the harms of screening for HBV infection due to lack of studies.
  • Adequate evidence to bound the harms of screening as small to none based on the nature of the intervention and the low likelihood of serious harms. (When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.)
  • Adequate evidence that the magnitude of harms of treatment is small based on several trials showing that risks of adverse events, nausea, and diarrhea are not significantly greater in persons receiving treatment than in persons receiving placebo or no treatment, and that some adverse events resolve after discontinuing therapy.
USPSTF Assessment
  • Moderate certainty that screening for HBV infection in nonpregnant adolescents and adults at increased risk for infection has a moderate net benefit given the accuracy of screening tests and the effectiveness of antiviral treatment.
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Prevalence Category Countries With Estimated Prevalence Within Prevalence Range
High ≥8% Prevalence Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Congo, Côte d’Ivoire, Djibouti, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Haiti, Kiribati, Kyrgyzstan, Laos, Liberia, Malawi, Mali, Mauritania, Mongolia, Mozambique, Namibia, Nauru, Niger, Nigeria, Niue, Papua New Guinea, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Swaziland, Togo, Tonga, Uganda, Vanuatu, Vietnam, Yemen, Zimbabwe
High moderate 5%–7.9% Prevalence Albania, Bhutan, Cape Verde, China, Democratic Republic of the Congo, Ethiopia, Kazakhstan, Kenya, Marshall Islands, Moldova, Oman, Romania, Rwanda, Samoa, South Africa, Tajikistan, Tanzania, Thailand, Tunisia, Tuvalu, Uzbekistan, Zambia
Low moderate 2%–4.9% Prevalence Algeria, Azerbaijan, Bangladesh, Belarus, Belize, Brunei Darussalam, Bulgaria, Cambodia, Colombia, Cyprus, Dominican Republic, Ecuador, Eritrea, Federated States of Micronesia, Fiji, Georgia, Italy, Jamaica, Kosovo, Libya, Madagascar, Myanmar, New Zealand, Pakistan, Palau, Philippines, Peru, Russia, Saudi Arabia, Singapore, South Korea, Sri Lanka, Suriname, Syria, Tahiti, Turkey
Low ≤1.9% Prevalence Afghanistan, Argentina, Australia, Austria, Bahrain, Barbados, Belgium, Bolivia, Bosnia and Herzegovina, Brazil, Canada, Chile, Costa Rica, Croatia, Cuba, Czech Republic, Denmark, Egypt, France, Germany, Greece, Guatemala, Hungary, Iceland, India, Indonesia, Iran, Iraq, Ireland, Israel, Japan, Jordan, Kuwait, Lebanon, Lithuania, Malaysia, Mexico, Morocco, Nepal, Netherlands, Nicaragua, Norway, Palestine, Panama, Poland, Portugal, Qatar, Serbia, Seychelles, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine, United Kingdom, United Arab Emirates, United States of America, Venezuela
No data available Andorra, Antigua and Barbuda, Armenia, The Bahamas, Botswana, Chad, Comoros, Cook Islands, Dominica, El Salvador, Finland, Grenada, Guinea-Bissau, Guyana, Honduras, Latvia, Lesotho, Lithuania, Luxembourg, Macedonia, Maldives, Malta, Mauritius, Monaco, Montenegro, North Korea, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, San Marino, Sao Tome and Principe, Timor-Leste, Trinidad and Tobago, Turkmenistan, Uruguay

*Adapted from References 2 and 13. Estimates of prevalence of HBsAg, a marker of chronic hepatitis B virus infection, are based on limited data published from 1965 through 2013 and may not reflect current prevalence in countries that have implemented childhood hepatitis B virus vaccination. In addition, the prevalence of HBsAg may vary within countries by subpopulation and locality. 

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Risk Group Proportion With HBV Infection, % References
HIV-positive persons* 3.3–17.0 9, 13, 15-17
Persons who inject drugs 2.7–19.7 9, 10, 13, 14
Household contacts or sexual partners of persons with hepatitis B virus infection 3.0–20.0 2, 13
Men who have sex with men 1.1–2.3 13

*Data from the United States and Western Europe.

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Figure shows world map with hepatitis B prevalence rates color coded by country. Table 2 gives prevalence rates by specific country.

*Figure reprinted from reference 33; based on prevalence data through 2013 reported in reference 13.

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