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3.0 Indications for HBV Testing

Posted in: HBV

Testing is indicated in all people from the priority populations identified in this section. Most new cases of HBV infection in Australia are identified in people from culturally and linguistically diverse (CALD) backgrounds. Testing people born in countries with intermediate and high prevalence of HBV, including new arrivals to Australia is a crucial part of Australia’s public health response to HBV. Section 3.1 and Figure 1  identify those populations that are at higher risk of infection.

Consideration of an individual’s risk of HBV infection should inform the decision to perform an HBV test. In appropriate clinical circumstances, the absence of a declared risk should not preclude HBV testing. Clinical suspicion of HBV infection may occur in the context of:

  • birth in an intermediate or high prevalence country (see Figure 1);
  • being an Aboriginal or Torres Strait Islander person;
  • children of women who are HBsAg positive;
  • unvaccinated adults at higher risk of infection (see section 3.1);
  • individual or family history of chronic liver disease or liver cirrhosis;
  • individual or family history of hepatocellular carcinoma (HCC)
  • evaluation of abnormal liver function tests;
  • acute hepatitis;
  • family, sexual or household contact with a person known or suspected to have hepatitis B.

Other situations where HBV testing may be indicated:

  • pregnant women or women contemplating pregnancy (see section 8.1);
  • health care workers who perform or may be expected to perform exposure prone procedures (EPPs) should be aware of their own hepatitis B (and HIV and hepatitis C) status;
  • contact tracing where exposure to blood of a person with the infection is documented;
  • diagnosis of another infection with shared mode of acquisition, such as hepatitis C virus (HCV) or HIV;
  • a person who reports a reactive result from an HBV test not licensed in Australia;
  • on the diagnosis of other conditions that may be caused by HBV infection e.g. glomerulonephritis, vasculitis;
  • a person who requests an HBV test in the absence of declared risk factors – a small number of individuals may request an HBV test but choose not to disclose risk factors. An individual’s choice not to declare risk factors should be recognised and HBV testing should be offered.

3.1 Priority populations for HBV testing

People from priority CALD communitiesa,b 
See Figure 1 below. Please note indigenous populations in these countries often have a higher prevalence.

 Aboriginal and Torres Strait Islander peoplesa,b
 All patients undergoing chemotherapy or immunosuppressive therapy (due to risk of reactivation).

 Unvaccinated adults at higher risk of infection

  • Other Indigenous populationsa,b
  • Partner and other household and sexual contacts of people who have acute or chronic hepatitis B infectiona,b
  • People who have ever injected drugsa,b
  • Men who have sex with menb
  • People with multiple sex partners
  • People in custodial settings or who have ever been in custodial settingsa,b
  • People with HIV or hepatitis C, or bothb
  • Patients undergoing dialysisb
  • Sex workers.a,b
  1. If HBsAg-positive persons are found in the first generation, subsequent generations should be tested;
  2. Those who are seronegative should receive hepatitis B vaccine. Vaccine is not funded for all at-risk groups and cost may be a barrier to vaccine uptake. Some jurisdictions provide vaccine free of charge for certain at-risk groups. Check with the relevant State or Territory health department for details.

Figure 1

Geographic Distribution

 

For multiple countries, estimates of prevalence of HBsAg, a marker of chronic HBV infection, are based on limited data and might not reflect current prevalence in countries that have implemented childhood hepatitis B vaccination. In addition, HBsAg prevalence might vary within countries by subpopulation and locality. Figure 1 is reprinted from Centres for Disease Control and prevention (CDC) publication; there is no copyright. HBsAg prevalence is shifting in many endemic countries which have adopted universal infant vaccination. China, for example, is now an intermediate prevalence country with the age-adjusted prevalence of hepatitis B dropping from 9.8% in 1992 to 7.2% in 2009 .

3.1.1 People from priority CALD communities

The term priority CALD communities refers to individuals and their families who were born in or born to parents who came from countries with intermediate (2-7%) to high (≥ 8%) prevalence of HBV infection (see Figure 1). This group includes first and subsequent generations who may have been exposed through ongoing perinatal and horizontal transmission in Australia before the commencement of HBV screening during pregnancy and universal neonatal vaccination.

The majority of people living with chronic hepatitis B in Australia were born overseas, particularly in the Asia Pacific region, Europe and Africa/Middle East. The Victorian Hepatitis B Serosurvey found a strong association between the proportion of residents born overseas in any local government area and HBV prevalence.25 People from CALD backgrounds from high-prevalence countries now living in Australia have been found to have the same rates of infection as their countries of birth.26

All adults from priority CALD communities should be tested once for HBsAg, anti‑HBc and anti-HBs to establish whether they have chronic hepatitis B, are immune through past infection or vaccination, or are susceptible to infection. Vaccination should be encouraged for those without immunity who are remaining at risk of infection. The purpose and implications of the test should be clearly explained before testing (see section 4.0), with the assistance of interpreters or multilingual health workers, as needed (see section 9.4). The result should be appropriately conveyed to the patient (see section 5.0) and documented clearly in the patient summary.

3.1.2 Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander people are approximately 2.6% of the Australian population, but are estimated to represent 10% of people living with chronic hepatitis B. Estimates of prevalence vary from approximately 2% of urban Aboriginal and Torres Strait Islander populations to 8% for rural Aboriginal and Torres Strait Islander populations, with prevalence likely to be even higher in remote communities. More than a quarter of Aboriginal and Torres Strait Islander people live in remote or very remote areas. There are higher rates of death from liver-related causes in the Indigenous population compared with non-indigenous Australians, linked to HBV infection. The majority of cases of chronic hepatitis B in the Aboriginal and Torres Strait Islander population are believed to have been acquired by vertical transmission at birth, or infection in early childhood, increasing the likelihood of unknown long-term infection and long term complications. Clinicians should stress that perinatal and early childhood exposures have been the primary routes of exposure for Aboriginal and Torres Strait Islander people.

Hepatitis B vaccine was introduced in many Aboriginal and Torres Strait Islander communities in the mid-1980s to early 1990s, with catch-up hepatitis B vaccination programs for Aboriginal and Torres Strait Islander children and adolescents in the late 1990s, or earlier in some jurisdictions. There is some evidence of early vaccination program failure, thought to be due to limited program roll-out and imperfect adherence to vaccine storage/refrigeration (cold-chain) guidelines. Cold chain guidelines were revised and improved in 2005.

All Aboriginal and Torres Strait Islander adults should be tested once in adulthood for HBsAg, anti-HBc and anti-HBs to establish whether they have chronic hepatitis B, are immune through past infection, or are susceptible to infection. Vaccination should be discussed with those without immunity who are remaining at high risk. The purpose and implications of the test should be clearly explained before testing (see section 4.0), with the assistance of Aboriginal health workers, as needed. The result should be appropriately conveyed to the patient (see section 5.0) and documented clearly in the patient summary.

See section 8.0 for children born to mothers who are HBV DNA or HBsAg positive.

3.1.3 All patients undergoing chemotherapy or immunosuppressive therapy

Patients who are undergoing any sort of chemotherapy, prolonged (greater than 4 weeks) steroid therapy or significant immunosuppressive therapy (including biologic modifiers such as anti TNF agents, or agents for transplantation of immunological diseases) should be tested for HBV.

Patients with chronic hepatitis B (HBsAg positive) are at risk from a serious and sometimes life threatening flare of their disease, often occurring after chemotherapy has finished. All HBsAg positive patients should, therefore receive prophylaxis with anti-viral therapy commencing at the same time or as soon as possible after the commencement of chemotherapy or immunosuppressive therapy.

Patients undergoing rituximab based chemotherapy, or bone marrow transplantation are at particularly high risk of HBV reactivation. If these patients have serology suggestive of prior exposure to HBV (anti-HBc positive) including the high risk subgroup with occult HBV (low level but detectable HBV DNA), they shouldalso be given antiviral prophylaxis for the duration of their treatment and ideally 12 months thereafter.

3.1.4 Partner and other household and intimate contacts of people who have acute or chronic hepatitis B infection

Unvaccinated individuals, who have frequent and prolonged contact with a person with HBV infection, have a higher risk of acquiring hepatitis B. The virus can be transmitted by sharing personal or sharp objects such as razors, toothbrushes, ear-rings and nail clippers; it cannot be transmitted by casual contact through kissing, touching or sharing food utensils. Because HBV has the potential given the right environmental conditions to survive for at least 7 days on surfaces and objects contaminated with traces of blood, these objects remain infectious for a long time after their use by a person with HBV infection. Child-to-child transmission, through everyday occurrences such as cuts, bites, abrasions and scratches, has been documented.

When an individual with HBV infection is identified, close contacts including household, family and intimate contacts, including all children, should be offered testing for HBsAg, anti-HBs and anti-HBc. Those without immunity should be offered vaccination. Post-vaccination serological testing 4 to 8 weeks after completion of the primary course is recommended (anti-HBs). Non-immune household members should have repeat testing for HBsAg after 3 months. For further information please see The Australian Immunisation Handbook.11

3.1.5 People with a history of injecting drug use

In 2011, the estimated prevalence of HBV among people who inject drugs (PWID) was 4%.  Historically, up to 50% of people who have injected drugs had serological markers of HBV infection, and PWID continue to be a population at high risk of HBV infection. PWID often experience significant barriers to accessing health services including HBV testing, vaccination and treatment. Access to free hepatitis B vaccination is not consistent across States and Territories. In this context, it is critical that testing is conducted in an appropriate and non-judgemental setting to assist people with a history of injecting drug use through the testing and diagnosis process. How testing is carried out will have a profound effect on the person’s understanding of their condition and their likelihood of future engagement with the health system. This includes understanding the current relevance of injecting drug use in the person’s life.  Peer education and support may optimise testing uptake and is recommended where these resources are available. Staff in specialist and primary health care services should be cognisant of issues relating to illicit drug use, harm reduction, addressing stigma and discrimination and managing vein care issues. Hepatitis B vaccination should be offered if testing reveals neither immunity nor current infection.

As people with a history of injecting drug use are also at increased likelihood of having acquired HCV or HDV infection, testing for these should be considered (see section 2.1).

3.1.6 Men who have sex with men

Historically, unvaccinated men who have sex with men (MSM) had a prevalence of serological markers of past or current HBV infection of approximately 38% although more recent estimates are substantially lower. As they are commonly infected in adulthood most MSM will clear acute HBV infection, but a small percentage of MSM remain HBsAg positive. Despite having an increased risk of HBV infection, uptake of vaccination remains suboptimal. MSM should be tested for HBsAg, anti-HBs and anti-HBc (see section 2.2). Hepatitis B vaccination should be offered if testing reveals neither immunity nor current infection.

3.1.7 People in custodial settings or who have ever been in custodial settings

Imprisonment is an independent risk factor for HBV transmission and a history of ever being in custodial settings is an indication to offer testing for HBV with appropriate discussion of risk and benefits (see section 4.0). People entering custodial settings have higher rates of previous HBV infection compared to the general community but only around 50% of people entering custodial settings have immunity to hepatitis B. People should be screened upon entering custodial settings if their hepatitis B status is unknown. Hepatitis B vaccination should be offered if testing reveals neither immunity nor current infection.

An overrepresentation of people from CALD and Aboriginal communities presents an additional burden and risk in custodial settings which requires further consideration in relation to screening, treatment and care delivered in a culturally competent and culturally safe manner. 

3.1.8 People with HIV or hepatitis C, or both

Patients with HIV infection or HCV infection or both are at a greater risk for HBV infection because of shared transmission routes. Routine screening and immunisation are recommended for all people living with HIV or HCV to prevent primary HBV infection. Double dosing of hepatitis B vaccine is recommended for people living with HIV, and booster vaccination every 6-12 months as dictated by anti-HBs titres. For further information please see The Australian Immunisation Handbook.

3.1.9 Patients undergoing dialysis

The frequency of HBV infection is higher in dialysis patients than in the general population because of their potential constant exposure to blood, frequent transfusions and sharing of dialysis equipment, reduced response to vaccination, and reduced durability of vaccine-derived immunity. It is recommended that all people receiving renal dialysis should have hepatitis B vaccination and vaccination is strongly recommended for patients with chronic kidney disease, dialysis-dependent or not, who are candidates for kidney transplantation. Patients should be tested every 6 months for HBsAg/anti-HBs. Double dosing of hepatitis B vaccine is recommended for people receiving dialysis, and booster vaccination every 6-12 months as dictated by anti-HBs titres. For further information please see The Australian Immunisation Handbook

3.1.10 Children born to mothers who are HBV DNA or HBsAg positive

See section 8.0

3.1.11 Transmission and infection control in health care settings

  • HBV testing of health care workers and students exposed to clinical settings should be conducted in accordance with the general principles set out in this document with regard to privacy, confidentiality and access to appropriate health care and support services.
  • Health care workers who test positive for HBV DNA are currently prevented from performing exposure-prone procedures. They should be encouraged and supported to undergo regular testing.
  • Testing for all blood borne viruses should be undertaken for health care workers following occupational exposure to blood or body substances, for example through needle stick injury.
  • Principles of informed consent (see section 4.0) and conveying a test result (see section 5.0) should be conducted with both the source of the occupational exposure and the recipient. Where patients are involved in occupational exposures, their informed consent to be tested must be sought (see section 1.4.2 for exceptions). 

3.1.12 Sex workers

Sex workers are at an increased risk of HBV infection, particularly if engaging in unprotected sex. Hepatitis B vaccination should be offered if testing reveals neither immunity nor current infection.

 

 

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Development of this site and the 2014 and 2017 revisions of the testing policies was supported by: Australian Government Department of Health and Ageing