ACP and CDC issue recommendations for hepatitis B screening, vaccination, and care

1. ACP and CDC issue recommendations for hepatitis B screening, vaccination, and care 2 out of 3 people with hepatitis B are unaware that they are infected
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1106
FREE Summary for Patients: http://annals.org/aim/article/doi/10.7326/P17-9050 URLs go live when the embargo lifts

The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) say that hepatitis B is a serious health threat and should be a public health priority. They recommend screening at-risk adults, increasing hepatitis B vaccination rates, and linking infected persons to care. A joint clinical practice guideline is published in Annals of Internal Medicine.

Hepatitis means inflammation of the liver and it is most often caused by a virus. Hepatitis B, which is caused by the hepatitis B virus (HBV), is transmitted when blood, semen, or another body fluid from a person infected with HBV enters the body of someone who is not infected. About two of every three persons chronically infected with HBV are unaware of their infection, contributing to ongoing transmission. This is an issue because up to 40 percent of persons with chronic hepatitis B will develop cirrhosis, hepatocellular carcinoma, or liver failure and 25 percent will die prematurely from these complications.

ACP and the CDC advise physicians to vaccinate against HBV in all unvaccinated adults, including pregnant women, at risk for infection due to sexual, skin, or mucous exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease, including hemodialysis patients, or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection.

ACP and the CDC also advise physicians to screen for HBV in high-risk persons, including persons born in countries with 2 percent or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease, including hemodialysis patients, blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels, incarcerated persons, all pregnant women, and infants born to HBV-infected mothers.

Physicians should provide or refer all patients identified with HBV for post-test counseling and hepatitis B-directed care, ACP and the CDC advise. All patients with chronic hepatitis B should be routinely evaluated for hepatocellular carcinoma and treatment eligibility through a history and physical exam.

Media contact: For an embargoed PDF or an interview with Jack Ende, MD, please contact Steve Majewski at smajewski@acponline.org or 215-351-2514.

2. Testing for specific proteins significantly improves sensitivity of stool-based colorectal cancer screening
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1068
URLs go live when the embargo lifts

Testing for novel protein biomarkers in stool finds significantly more colorectal cancers (CRC) and advanced adenomas (precursors to cancer) compared to testing for hemoglobin alone. The proteins can be detected in a small sample of the fecal immunochemical test (FIT), which suggests that they can be applied in population screening. The findings are published in Annals of Internal Medicine.

CRC screening can save lives by detecting cancer in its early stages when it is still treatable. Colonoscopy is the gold standard for detecting colorectal tumors, but the test is costly and invasive. As such, most population-wide screening programs use noninvasive stool-based tests, such as the FIT, for triage to colonoscopy. The FIT tests for hemoglobin, or blood protein, in the stool, however, its sensitivity for detecting CRC and advanced adenomas is suboptimal.

Researchers from the Netherlands Cancer Institute and VU University Medical Center sought to identify novel protein biomarkers in stool that could outperform or complement hemoglobin in detecting CRC and advanced adenomas. The researchers used mass spectrometry to search for proteins that were present in stool specimens from persons with CRC or advanced adenomas, and which were virtually absent from stool specimens from controls. By using a combination of four novel protein biomarkers, in this study the investigators found that they were able to detect almost twice as many colorectal cancers and 5 times as many advanced adenomas, compared to using hemoglobin alone.

According to the researchers, this new test has the potential to be easily integrated into population-wide screening programs upon successful clinical validation. Because it uses the same technology as the current standard stool-based test, few adjustments to the screening program would be needed.

Media contacts: For an embargoed PDF, please contact Cara Graeff. For more information or interview requests, please contact Monique Bottinga or Sanne Hijlkema, Science Information Officer at the Netherlands Cancer Institute (communicatie@nki.nl, 31-20-512-28-50).

3. Providing unlimited, immediate access to opioid agonist therapy to people with opioid use disorders could save billions and improve outcomes
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0611
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2854
URLs go live when the embargo lifts

Providing immediate access to opioid agonist treatment with methadone is more effective and less costly than medically supervised withdrawal for patients with opioid use disorder. The findings of a model-based cost-effectiveness analysis are published in Annals of Internal Medicine.

Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Addressing the opioid crisis is a national public health priority, but the best approach to treatment is up for debate. For example, in California, a state with the largest number of persons with an opioid disorder in the United States, publicly funded treatment programs require patients to "fail" at medically supervised withdrawal before being considered eligible for opioid agonist treatment, despite scientific evidence that medication reduces illicit opioid use, relapse risk, and overdoses.

Researchers from the British Columbia Centre for Excellence in HIV/AIDS and the UCLA Integrated Substance Abuse Programs used state-level linked administrative data on drug treatment, criminal justice system engagement and vital statistics to determine the cost-effectiveness of immediate access to opioid agonist treatment versus medically supervised withdrawal for all patients seeking treatment in California's publicly funded treatment program. The computer model which synthesized the state-level data and other relevant evidence compared health benefits (measured with accumulated quality-adjusted life-years) and lifetime costs for Californians receiving initial treatment of opioid use disorder in 2014. The model suggested that immediate access to medication could improve health and save up to $3.8 billion over a treatment lifetime in this cohort.

According to the authors of an accompanying editorial from Yale University School of Medicine, these findings provide further scientific evidence that less health care resources should be used on medically supervised withdrawal "beds" and more should be used for outpatient "chairs" for opioid agonist therapy. They warn that threats to health care funding may have lasting consequences, especially if lawmakers do not heed the most science-based and policy-applicable data as decisions are being made about how to address the opioid crisis.

Media contacts: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Bohdan Nosyk, PhD, please contact media relations at the BC Centre for Excellence in HIV/AIDS - Rena Heer, Rena.Heer@Edelman.com.

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Also in this issue:

Characteristics of U.S. Physician Marriages, 2005-2015: An Analysis of Data From a U.S. Census Survey
Dan P. Ly, MD, MPP; Seth A. Seabury, PhD; Anupam B. Jena, MD, PhD
Brief Research Report
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1758