Expanded screening for chronic hepatitis B virus infection in China
Authors: Chao Wang, Fuqiang Cui
Journal: The Lancet Global Health (2022)

Hepatitis B virus (HBV) infection is a substantial global health threat.1WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 2016–2021: actions for impact. World Health Organization, Geneva2021Google Scholar WHO estimated that 296 million people were chronically infected with HBV and nearly 820 000 people died due to HBV infection in 2019.1WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 2016–2021: actions for impact. World Health Organization, Geneva2021Google Scholar China bears a heavy disease burden, with over one-third of the world's HBV infections and deaths due to HBV occurring in China.2Chen S Li J Wang D Fung H Wong LY Zhao L The hepatitis B epidemic in China should receive more attention.Lancet. 2018; 3911572Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar However, the prevalence of HBsAg in children aged 5 years in China was about 0·2% in 2016 due to the universal implementation of hepatitis B vaccination at birth, from 1992.3Cui F Shen L Li L et al.Prevention of chronic hepatitis B after 3 decades of escalating vaccination policy, China.Emerg Infect Dis. 2017; 23: 765-772Crossref PubMed Scopus (236) Google Scholar The World Health Assembly (WHA) proposed to eliminate viral hepatitis as a public health threat by 2030.4WHOGlobal hepatitis report 2017. World Health Organization, Geneva2017Google Scholar Unfortunately, over 80% of infected adults in China remain unaware that they have HBV infection and therefore they do not seek treatment, meaning the risk of HBV transmission in the unvaccinated population remains high, as does disease burden. WHO has set the target of 90% diagnostic coverage and 80% treatment coverage among the eligible population with HBV infection by 2030 (ie, those with continuos increase of alanine aminotransferase or compensated or decompensated cirrhosis).4WHOGlobal hepatitis report 2017. World Health Organization, Geneva2017Google Scholar Although major efforts have been made to improve the coverage of HBV screening in all people aged 18 years and older by the Chinese Government, screening has been limited to target populations, such as pregnant women, newborn infants, blood donors, and the premarital population.5Razavi-Shearer D Gamkrelidze I Nguyen MH et al.Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study.Lancet Gastroenterol Hepatol. 2018; 3: 383-403Summary Full Text Full Text PDF PubMed Scopus (1123) Google Scholar, 6Liu J Liang W Jing W Liu M Countdown to 2030: eliminating hepatitis B disease, China.Bull World Health Organ. 2019; 97: 230-238Crossref PubMed Scopus (263) Google Scholar One key barrier to universal screening for HBV in all Chinese adults is that its cost-effectiveness for central or local governments is unclear.7Wallace J Pitts M Liu C et al.More than a virus: a qualitative study of the social implications of hepatitis B infection in China.Int J Equity Health. 2017; 16: 137Crossref PubMed Scopus (27) Google Scholar The Article by Shu Su and colleagues8Su S Wong WCW Zou Z et al.Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation.Lancet Glob Health. 2022; 10: e278-e287Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar in The Lancet Global Health highlights the potential of universal HBV screening in China to reduce HBV-related mortality in a cost-effective way. The analysis by Su and colleagues on universal HBV screening indicated that screening could potentially identify most infected individuals and thereby decrease the heavy disease burden;8Su S Wong WCW Zou Z et al.Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation.Lancet Glob Health. 2022; 10: e278-e287Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar however, some issues need to be considered. First, how universal HBV screening should be implemented needs to be a priority, with consideration as to who should be screened, where screening should take place, and when someone should be screened. Second, social assessment, such as the impact on the federal government health budget, rather than economic simulation, should be further studied in a more comprehensive way to ensure a more thorough analysis of the impact of implementing univeral HBV screening. Third, how universal screening could be integrated with other measures to improve cost-effectiveness further, such as integrating screening with routine physical examination, which occurs in a large proportion of the Chinese population. Fourth, health-care workers should be trained in how to screen for HBV infection, the general population need to be educated on HBV infection and how to access screening, and results of screening should be managed appropriately to allow for treatment efficiancy. Fifth, discrimination against people infected with HBV deserves attention.7Wallace J Pitts M Liu C et al.More than a virus: a qualitative study of the social implications of hepatitis B infection in China.Int J Equity Health. 2017; 16: 137Crossref PubMed Scopus (27) Google Scholar Although discrimination against people infected with HBV is prohibited in the workplace by law, it is still prevalent among those with insufficient awareness of risk factors and modes of transmission of HBV. Finally, although screening itself might be deemed cost-effective, the additional costs that occur post-screening also need to be factored into budgeting. Policy makers should consider whether the Chinese health-care system will be able to effectively monitor individuals identified as HBV carriers, conduct follow-ups with carriers or infected individuals, and provide appropriate treatment for those with HBV infection, if universal HBV screening were to be implemented. Universal HBV screening will help China achieve the WHO 2030 target, although the exact impact of relieving the health and economic burden of HBV in China still needs to be quantified. Furthermore, to reach the 2030 target and further reduce incidence of HBV infection and mortality, various challenges must first be overcome, particularly in China where HBV infection rates are high and diagnostic rates are low.9Zhang Q Qi W Wang X et al.Epidemiology of hepatitis B and hepatitis C infections and benefits of programs for hepatitis prevention in northeastern China: a cross-sectional study.Clin Infect Dis. 2016; 62: 305-312Crossref PubMed Scopus (57) Google Scholar China must maintain current HBV vaccination rates in children, expand HBV vaccination to include high-risk populations (such as medical employees and unvaccinated family members of infected individuals), prioritise development of the screening policy in high-risk populations, and eventually improve HBV treatment coverage.3Cui F Shen L Li L et al.Prevention of chronic hepatitis B after 3 decades of escalating vaccination policy, China.Emerg Infect Dis. 2017; 23: 765-772Crossref PubMed Scopus (236) Google Scholar, 9Zhang Q Qi W Wang X et al.Epidemiology of hepatitis B and hepatitis C infections and benefits of programs for hepatitis prevention in northeastern China: a cross-sectional study.Clin Infect Dis. 2016; 62: 305-312Crossref PubMed Scopus (57) Google Scholar Vaccine regulatory authorities should also develop supportive policies to facilitate universal HBV screening, such as a mechanism of linkage-to-care. Using a Markov cohort model, Su and colleagues8Su S Wong WCW Zou Z et al.Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation.Lancet Glob Health. 2022; 10: e278-e287Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar generated estimates of cost effectiveness of different screening strategies in various age groups, by inputting data from heterogeneous studies or other data sources. This method makes the findings more tangible for policy makers and practitioners to use in the design and implementation of universal screening programmes. Several findings of this study deserve attention. First, the WHO 2030 target will not be achieved in China if the current screening and linkage-to-care strategy has not been expanded. Of individuals infected with HBV, it is estimated that only 18·9% are diagnosed and 12·6% are treated over their lifetime.8Su S Wong WCW Zou Z et al.Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation.Lancet Glob Health. 2022; 10: e278-e287Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Second, universal HBV screening is suggested as a cost-effective way to protect people from HBV infection or any related malignant lesion. As repoerted by Su and colleagues, all screening strategies would require an additional US$2 179 119–4 747 176 per 100 000 persons compared with the status quo, but these strategies would result in 14 905–16 273 quality-adjusted life-years gained. Moreover, early implementation of universal screening would lead to health benefits, such as early diagnosis and treatment to HBV infection, which would not be possible with a delayed strategy. Universal screening is more important for the age group that missed having the universal birth-dose of hepatitis B vaccine before 2002.10Chang K Chang M Chen H et al.Universal infant hepatitis B virus (HBV) vaccination for 35 years: moving toward the eradication of HBV.J Infect Dis. 2021; (published online Aug 7.)DOI:10.1093/infdis/jiab401Crossref Scopus (10) Google Scholar 90% diagnostic coverage and 80% treatment coverage for HBV infection is unlikely to be reached under current protocols in China; an intensified policy is needed. Universal HBV screening presents a cost-effective solution to reach the WHO 2030 target and will have many benefits, including prevention of HBV infection and timely treatment for infected individuals. The paper by Su and colleagues presents a helpful menu of options for China to choose from depending on the socioeconomic circumstances of each region. We declare no competing interests. Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluationThe five-test universal screening strategy in people aged 18–70 years, implemented within the next 10 years, is the optimal HBV screening strategy for China. Other screening strategies could be cost-effective alternatives, if budget is limited in rural areas. Delaying strategy implementation reduces overall cost-effectiveness. Early screening initiation will aid global efforts in achieving viral hepatitis elimination. Full-Text PDF Open Access