Universal screening of adults for chronic hepatitis B virus (HBV) infection in the United States could prevent 23,000 chronic HBV-related deaths and save an estimated $596 million, according to the results of a modeling study published in Clinical Infectious Diseases.

The current national HBV screening recommendation includes pregnant women and asymptomatic adults who were born in an endemic country in which the hepatitis B surface antigen (HBsAg) prevalence is 2% or more. Because screening based on place of birth is not captured by most health systems, testing for HBV has remained low. As such, researchers used a Markov model to calculate the health impact and cost-effectiveness of a 1-time universal screening for chronic HBV infection in addition to current clinical practice.

An estimated base prevalence of 0.24% was used for undiagnosed chronic HBV infection based on the National Health and Nutrition Examination Survey (NHANES) of 2011 to 2016 among adults aged 18 to 69 years. Testing of HBsAg was based on the Medicare reimbursement rate ($10.33), and the researchers assumed that generic tenofovir or entecavir would be used for treatment with an annual cost of $502.

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Outcomes included screening, clinical endpoints, and lifetime costs, with cost-effectiveness based on a willingness to pay $50,000 per quality-adjusted life-year (QALY).

Compared with current clinical practice alone, a 1-time universal HBsAg screening along with current clinical practice was found to be cost-effective if the cost of antiviral treatment remained below $894 per year; it would cease to be cost-effective if the cost were $9692 or more per year. Universal screening would “avert an additional 7.4 cases of compensated cirrhosis, 3.3 cases of decompensated cirrhosis, 5.5 cases of hepatocellular carcinoma, 1.9 liver transplants, and 10.3 HBV-related deaths” at a savings of $263,000 per 100,000 adults screened, noted the researchers.

Limitations of the study include the researchers assuming that screening was a part of regular visits to health care providers. In addition, this analysis did not take into consideration vaccination policies or people coinfected with HIV, hepatitis C virus, or hepatitis D virus.

“If the prevalence of [chronic HBV infection] in the United States is 2-3 times higher than the NHANES estimate as several studies have reported, as many as 45,000 to 68,000 deaths could be averted with trillions of dollars in cost-saving,” concluded the researchers.


Toy M, Hutton D, Harris AM, Nelson N, Salomon JA, So S. Cost-effectiveness of one-time universal screening for chronic hepatitis B infection in adults in the United States. Clin Infect Dis. Published online May 6, 2021. doi:10.1093/cid/ciab405