What are the recommended tests and treatments for patients at risk of hepatitis A (infectious hepatitis), hepatitis B (serum hepatitis), and hepatitis C (liver inflammation due to hepatitis C virus)?

Recommended Testing for Hepatitis A, B, and C

For patients at risk of viral hepatitis, comprehensive serological testing should be performed for all three viruses (HAV, HBV, HCV), with initial screening using antibody tests followed by confirmatory testing as indicated, and treatment initiated based on test results and disease severity.

Hepatitis C Testing

Initial Screening

• Initial test: HCV antibody (anti-HCV) testing using an FDA-approved assay 1
• Ideally, positive HCV antibody tests should automatically reflex to HCV-RNA testing to confirm active infection 1
• For high-risk populations (PWID, HIV-positive MSM), annual HCV testing is recommended 1

Confirmatory Testing

• If anti-HCV positive: Confirm with HCV-RNA testing to determine active infection 1
• If HCV-RNA positive: Indicates current (active) HCV infection requiring further evaluation 1
• If HCV-RNA negative with positive antibody: Indicates resolved infection or false positive; no further testing needed unless ongoing risk factors 1

Pre-Treatment Testing

• Quantitative HCV-RNA to determine baseline viral load 1
• HCV genotyping (may be considered if it would alter treatment recommendations) 1
• Evaluation for advanced fibrosis using non-invasive markers or liver biopsy 1
• Testing for coinfections (HBV, HIV) 1

Hepatitis B Testing

Initial Screening

• Standard panel: HBsAg, anti-HBs, and anti-HBc 2, 1
• This combination allows accurate classification of HBV status 2

Interpretation of Results

• Current infection: Positive HBsAg, negative anti-HBs, positive anti-HBc 2
• Resolved infection with immunity: Negative HBsAg, positive anti-HBs, positive anti-HBc 2
• Vaccine-induced immunity: Negative HBsAg, positive anti-HBs, negative anti-HBc 2
• No immunity (susceptible): Negative HBsAg, negative anti-HBs, negative anti-HBc 2
• Isolated anti-HBc positive: Consider HBV DNA testing to rule out occult hepatitis B 2

Additional Testing for Chronic HBV

• HBeAg/anti-HBe to assess viral replication status 1
• HBV DNA quantification to determine viral load 1
• Liver function tests to assess disease activity 1

Hepatitis A Testing

• Initial test: Total anti-HAV antibodies or IgG anti-HAV 2
• For suspected acute infection: IgM anti-HAV 3
• Positive IgG anti-HAV indicates immunity from past infection or vaccination 3

Management Recommendations

Hepatitis C Management

1. For confirmed active HCV infection:

   • Evaluate for liver fibrosis severity 1
   • Screen for coinfections (HBV, HIV) 1
   • Counsel on alcohol abstinence 1
   • Provide education on preventing transmission 1
   • Consider treatment with direct-acting antivirals (DAAs) based on genotype and liver disease severity 1

2. Treatment monitoring:

   • Pre-treatment: Baseline HCV RNA, genotype (if needed), fibrosis assessment 1
   • Post-treatment: Sustained virologic response (SVR) assessment 1

Hepatitis B Management

1. For chronic HBV infection:

   • Regular monitoring of ALT, HBV DNA levels 1
   • Consider antiviral therapy for those with elevated ALT and HBV DNA >20,000 IU/ml 1
   • Screen for hepatocellular carcinoma in high-risk patients 1

2. Warning: Test all HCV patients for HBV before starting DAA therapy due to risk of HBV reactivation 4

Prevention Recommendations

• Vaccination: Hepatitis A and B vaccines recommended for all susceptible persons with HCV infection 1, 5
• Early vaccination is crucial as response decreases with advancing liver disease 5
• Pneumococcal vaccination recommended for all persons with cirrhosis 1

Important Considerations

• HBV reactivation risk: All patients should be tested for HBV (HBsAg and anti-HBc) before initiating HCV treatment with DAAs 4
• Coinfection impact: HBV or HIV coinfection with HCV is associated with poorer prognosis 1
• Alcohol abstinence: Critical for all patients with viral hepatitis to prevent disease progression 1
• Vaccination timing: Vaccinate early in disease course for better immune response 6, 5

Common Pitfalls to Avoid

• Failing to test for all three hepatitis viruses in at-risk individuals
• Not confirming positive HCV antibody tests with HCV-RNA testing
• Overlooking HBV testing before starting HCV treatment with DAAs
• Delaying vaccination until advanced liver disease develops
• Not screening for hepatocellular carcinoma in patients with cirrhosis

By following this comprehensive testing and management approach, clinicians can effectively diagnose, treat, and prevent complications in patients with viral hepatitis.