Hepatitis Testing Recommendations
For individuals at risk of hepatitis virus infection, comprehensive hepatitis testing is strongly recommended to prevent morbidity, mortality, and improve quality of life. 1
Who Should Be Tested for Hepatitis
Hepatitis B Testing
- All individuals at risk of HBV reactivation should be tested for hepatitis B before starting immunosuppressive therapy 1
- Testing should include at minimum:
Hepatitis C Testing
- Universal screening for all adults aged 18 years and older 1, 3
- Birth cohort screening for all persons born between 1945-1965 1
- Risk-based screening for:
- Injection drug use (current or ever, including one-time use)
- Intranasal illicit drug use
- Long-term hemodialysis
- Tattoos received in unregulated settings
- Healthcare workers after needlesticks/exposures
- Children born to HCV-infected women
- Prior recipients of transfusions or organ transplants before July 1992
- Recipients of clotting factor concentrates before 1987
- History of incarceration
- HIV infection
- Unexplained chronic liver disease or elevated ALT 1
Testing Protocol
Hepatitis B Testing
Initial testing should include:
If HBsAg and/or anti-HBc is positive, proceed with:
Hepatitis C Testing
- Initial screening with FDA-approved anti-HCV antibody test 1, 3
- If anti-HCV positive, confirm with HCV RNA nucleic acid test (NAT) to identify active infection 1, 3
Interpretation of Results
Hepatitis B
| Serologic Pattern | Interpretation |
|---|---|
| HBsAg+, anti-HBc+ | Current HBV infection |
| HBsAg-, anti-HBc+ | Past or occult HBV infection (risk for reactivation) |
| HBsAg-, anti-HBc- | No HBV infection [1,3] |
Hepatitis C
| Serologic Pattern | Interpretation |
|---|---|
| Anti-HCV+, HCV RNA+ | Current active HCV infection |
| Anti-HCV+, HCV RNA- | Past resolved HCV infection or false positive antibody |
| Anti-HCV- | No HCV infection [1,3] |
Special Considerations
HBV Reactivation Risk
- Patients receiving immunosuppressive therapy are at risk for HBV reactivation
- Risk stratification based on:
- HBV serologic status (HBsAg+ vs. HBsAg-/anti-HBc+)
- Type of immunosuppressive therapy 1
- High-risk therapies include B-cell depleting agents, anthracycline derivatives, and high-dose corticosteroids 1
Coinfection Testing
- All HCV-infected patients should be tested for HBV before starting HCV treatment due to risk of HBV reactivation 3, 2
- Consider testing for HIV in patients with risk factors for both infections 1, 3
- Consider testing for hepatitis D (HDV) in HBV-infected patients, as coinfection leads to more severe liver disease 4
Follow-up Testing
- For persons with ongoing risk factors (e.g., injection drug use, HIV-positive MSM), at least annual HCV testing is recommended 1
- Patients with chronic hepatitis should have regular monitoring of liver function tests to assess disease progression 3, 5
- Patients with advanced fibrosis/cirrhosis require surveillance for hepatocellular carcinoma with ultrasound every 6 months 3
Common Pitfalls to Avoid
Failing to test for HBV before starting immunosuppressive therapy - This can lead to severe HBV reactivation, potentially causing fulminant hepatitis and death 1, 2
Relying solely on liver enzymes for diagnosis - ALT/AST levels can fluctuate and may be normal even in chronic infection; they reflect inflammation but not necessarily disease severity 1, 5
Missing occult HBV infection - Patients who are HBsAg-negative but anti-HBc-positive can still experience HBV reactivation when immunosuppressed 1
Stopping at antibody testing for HCV - A positive anti-HCV test must be followed by HCV RNA testing to confirm active infection 1, 3
One-time testing only - Patients with ongoing risk factors need periodic testing, not just a single test 1, 3
By implementing comprehensive hepatitis testing according to these guidelines, clinicians can identify infections early, prevent disease progression, and reduce mortality and morbidity associated with chronic viral hepatitis.