Population-based screening works: Effect of integrating screening for hepatitis B and C into the general health check-up in Germany

Successful Amendment of an Existing Hepatitis B Screening Programme by a Guideline Recommended Hepatitis D Screening in the Primary Care Setting

BACKGROUND

Despite European guidelines recommending anti-hepatitis D virus (HDV) screening for all hepatitis B surface antigen (HBsAg)-positive cases, screening rates remain insufficient.

AIMS

We analysed anti-HDV screening rates in primary care and implemented prospective HDV screening in HBsAg-positive cases identified in the preventive medical examination from the age of 35 ("Check-Up 35+").

METHODS

From 2012 to 2021, we reviewed anti-HDV and HDV RNA test rates in HBsAg-positive patients at 11 sites of a large German laboratory group. From 2022 to 2023, we prospectively screened HBsAg-positive samples from the "Check-Up 35+" for anti-HDV. Anti-HDV positive patients were then contacted again for HDV RNA testing.

RESULTS

Retrospectively, 2792/13,905 (20%) HBsAg-positive cases were tested for anti-HDV, with 142/2792 (5.1%) being positive. HDV RNA was tested in 57/142 (40%) anti-HDV-positive cases, with 26/57 (46%) being positive. In the prospective screening, 1159/225,901 (0.51%) individuals were HBsAg-positive. Of these, 700 (60%) were tested for anti-HDV, with 18/700 (2.6%) positive test results. 4/18 (22%) were successfully contacted again for HDV RNA analysis, with one case testing positive. Neither the HBsAg nor the anti-HDV positive result was known prior to screening in these cases. Anti-HDV testing could not be performed in 459/1159 (40%) HBsAg-positive cases, primarily due to insufficient blood sample volume (310/459 cases, 68%), with others missed due to logistical errors.

CONCLUSIONS

Retrospective data show insufficient anti-HDV screening in clinical routine. The prospective anti-HDV screening provides a blueprint for using existing hepatitis B virus screening programms for population-based HDV double reflex testing, provided that adequate logistical prerequisites are established.

TRIAL REGISTRATION

German Clinical Trial Register: DRKS00029180.

[Significant increase in newly diagnosed hepatitis B and C cases in Germany due to screening]

In 2016, the World Health Organization (WHO) decided on an initiative to identify 90% of the world's existing hepatitis B and C virus infections by 2030, treat 80% and reduce the mortality by 65%. In 2016, the federal government endorsed these goals. From Oct 1, 2021, the G-BA included a one-time screening for hepatitis B and C in the health examination (GU) for people aged 35 and over who have statutory health insurance. The previous participation rates in the GU were evaluated and the effectiveness of the program is documented using the reporting data on hepatitis B and C of Robert Koch Institute (RKI).Notifications from Central Institute of Statutory Health Insurance (ZI) and Scientific Institute of the local health insurance companies (WIdO) were compiled with regard to the GU, the reporting data from the RKI were collected and analyzed using SURVSTAT@RKI 2.0 as well as billing data from the Association of Statutory Health Insurance Physicians (KBV).Between 2007 and 2021, around 83% of all insured persons took part in a GU at least once. From the fourth quarter of 2021, the number of newly diagnosed cases of hepatitis B and C increased. In 2022, the increase for hepatitis B was 91.9% and for hepatitis C 68%. This trend continued in 2023, with new diagnoses of hepatitis B increasing by 160% (to 22,795 cases) and hepatitis C increasing by 121% (to 10,508 cases) compared to 2021. The analysis of the KBV billing data showed that the increase in new diagnoses shows a strong correlation between the number of new diagnoses within the GU and the total number of diagnoses.The decision of the Federal Joint Committee (G-BA) to include hepatitis B and C screening in the GU seems to be a success in detecting previously undetected cases of the disease. Based on the billing data from the KBV, a high level of agreement could be demonstrated between the number of new diagnoses within the GU and the increase in the total number of diagnoses. The goals of the WHO may be achievable.

Successful hepatitis B and C screening in the health check-up in the German primary care setting

Background & Aims

A goal of the World Health Organization's global hepatitis strategy is the elimination of chronic hepatitis C virus (HCV) infection by 2030. As part of its strategy, the Federal Joint Committee (Germany) decided to include hepatitis B and C screening in a preventive medical examination, which is performed at the primary care level in Germany. We investigated the results 1 year after implementation of screening between October 2021 and September 2022.

Methods

HBsAg/HBV DNA and anti-HCV/HCV RNA screenings were identified by billing categories in 286,192 individuals of 11 ambulatory healthcare centers.

Results

Compared to 30,106 HBsAg and 31,266 anti-HCV laboratory requisitions in the year 2018, the number of tests increased to 286,192 during the screening period. Compared to routine care, additional anti-HCV positive tests age dependently increased the tally by 98% (177 plus 170 positive cases in males) and 123% (96 plus 118 positive cases in females) in those aged 35-44 years up to 518% (17 plus 88 positive cases in males) and 514% (29 plus 149 positive cases in females) in those aged 75-84 years. Similar results were observed for HBsAg. Prevalences of HBsAg, anti-HCV and HCV RNA were 0.54%, 0.79% and 0.13%, respectively.

Conclusions

A structured hepatitis screening program at the primary care level has been successfully established and leads to age- and-sex-dependent large additional effects compared to routine care.

Impact and implications

Strategies to eliminate chronic hepatitis B and C virus infection are country specific and vary between clinical scenarios. Our analysis proves the efficacy of a screening program by primary care physicians compared to routine care in a low-prevalence country. This program should be accompanied by additional efforts in risk populations like people who inject drugs who are under-represented in the current screening approach.

[Diagnosis and treatment of viral hepatitis B and D in 2024]

Despite the availability of vaccines, hepatitis B remains a significant cause of fulminant hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. The increase in reported hepatitis B cases in Germany is attributed to factors such as immigration and the hepatitis B surface antigen (HBsAg) screening introduced in 2020 as part of health check-ups. The indication for treatment depends on various factors, including the level of hepatitis B virus (HBV) DNA and inflammatory activity. Nucleos(t)ide analogues are the preferred treatment option, but functional cure, defined as HBsAg loss, is rare. In principle, treatment with nucleos(t)ide analogues should usually be discontinued after loss of HBsAg, but can be stopped earlier under certain conditions and is currently the subject of ongoing research. Pregnancy and immunosuppression in the context of hepatitis B require special attention. In addition, a possible hepatitis D virus co-infection must always be taken into account, which is why every HBsAg-positive person should be tested for anti-HDV. Since 2020, the entry inhibitor bulevirtide has become a new treatment option alongside pegylated interferon alfa, which represents a significant advance in the treatment landscape.