What tests are included in a hepatitis panel and how do I order one?

Hepatitis Testing: Comprehensive Panel and Ordering Guidelines

A standard hepatitis panel should include HBsAg, anti-HBc, anti-HBs, anti-HCV with reflex HCV RNA testing, and liver function tests. 1

Core Hepatitis Panel Components

Hepatitis B Testing

• HBsAg (Hepatitis B surface antigen) - Primary screening test for current HBV infection 1
• Anti-HBc (Total Hepatitis B core antibody) - Detects both recent and past HBV infections 1
• Anti-HBs (Hepatitis B surface antibody) - Determines immunity status from vaccination or resolved infection 1
• For positive HBsAg results, additional testing should include:
  • HBeAg (Hepatitis B e antigen)
  • Anti-HBe (Antibody to HBeAg)
  • HBV DNA quantification 2, 1
• IgM anti-HBc - To distinguish between acute and chronic HBV infection 1

Hepatitis C Testing

• Anti-HCV antibody - Primary screening test for HCV infection 1
• HCV RNA - Reflex testing for positive anti-HCV to confirm current infection 2, 1

Liver Function Assessment

• ALT, AST - Assess liver inflammation 2
• Albumin, bilirubin, INR - Assess liver synthetic function 2
• Complete blood count with platelet count - Evaluate for portal hypertension 2

How to Order a Hepatitis Panel

1. Order the standard liver aetiology screen (core panel) which should include:

   • Abdominal ultrasound
   • HBsAg, anti-HBc, anti-HBs
   • Anti-HCV (with reflex to HCV RNA if positive)
   • Anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody
   • Serum immunoglobulins
   • Serum ferritin and transferrin saturation 2

2. For children, the panel should also include:

   • Anti-liver kidney microsomal antibody
   • Coeliac antibodies
   • Alpha-1-antitrypsin level
   • Caeruloplasmin (for children >3 years) 2

3. For suspected acute viral hepatitis, consider adding:

   • IgM anti-HAV (Hepatitis A)
   • IgM anti-HBc (Hepatitis B)
   • Testing for Hepatitis E and cytomegalovirus 2

Special Considerations

High-Risk Populations

• For patients with suspected recent exposure (<6 months), order direct viral testing (HBV DNA or HCV RNA) as antibodies may not have developed 1
• For immunocompromised patients, rely on nucleic acid testing rather than antibody tests 1

Interpretation of Results

• Positive HBsAg indicates current acute or chronic HBV infection 1
• Isolated positive anti-HBc may indicate:
  • Window period between acute and resolved infection
  • Remote resolved infection with waned anti-HBs
  • Occult HBV infection (requires HBV DNA testing) 1
• Positive anti-HCV with positive HCV RNA confirms current HCV infection 2, 1
• Positive anti-HCV with negative HCV RNA indicates resolved infection or false positive 2

Common Pitfalls to Avoid

• Relying solely on HBsAg for HBV screening may miss occult HBV infections 1
• Testing only for anti-HCV without confirmatory HCV RNA testing cannot distinguish between current and resolved infection 1
• Repeating the same abnormal liver tests without investigating the cause is not recommended; determine the etiology instead 2
• Failing to consider coinfections in high-risk individuals (HBV/HCV, HBV/HDV, HBV/HIV) 2

Follow-up for Positive Results

• Patients with confirmed HBV or HCV infection should be referred to specialists experienced in treating viral hepatitis 2
• Patients with evidence of hepatitis B (HBsAg positive), hepatitis C (HCV RNA positive), autoimmune hepatitis, primary biliary cholangitis, or hemochromatosis require specialist referral 2
• Vaccination for hepatitis A should be administered to persons with chronic hepatitis B who are not immune to hepatitis A 2