What is the recommended screening test for Hepatitis B (HBV)?

Recommended Screening Tests for Hepatitis B Virus (HBV)

The recommended screening test for Hepatitis B is hepatitis B surface antigen (HBsAg) testing, followed by confirmatory testing for initially reactive results. 1

Primary Screening Tests

• Hepatitis B surface antigen (HBsAg): The primary screening test to identify active HBV infection (acute or chronic) 1
• Confirmatory testing: Initially reactive HBsAg results should be followed by a licensed, neutralizing confirmatory test 1

Comprehensive Screening Panel

For a complete assessment of HBV status, the following tests are recommended:

• HBsAg: Detects active infection 1
• Hepatitis B core antibody (anti-HBc): Indicates previous or ongoing infection 1
• Hepatitis B surface antibody (anti-HBs): Indicates immunity due to vaccination or resolved infection 1

Implementation Considerations

Who Should Be Screened

• All adults aged ≥18 years should be screened at least once in their lifetime 1, 2
• Persons at risk for HBV reactivation should be tested before starting immunosuppressive therapy 1
• Persons from countries with HBsAg prevalence ≥2% (Asia, Africa, Pacific Islands, parts of South America, Eastern Europe) 1
• Persons with high-risk behaviors (injection drug use, men who have sex with men) 1
• HIV-positive individuals 1
• Household contacts or sexual partners of HBV-infected persons 1

Screening Algorithm

1. Initial screening: Test for HBsAg, anti-HBc, and anti-HBs 1
2. If HBsAg positive: Indicates active HBV infection (acute or chronic) 1
   • Chronic infection is confirmed by persistence of HBsAg for ≥6 months or absence of IgM anti-HBc 1
   • Further testing should include HBV DNA to determine viral load 1
3. If HBsAg negative but anti-HBc positive: Indicates past infection or occult HBV 1
   • Consider HBV DNA testing, especially before immunosuppressive therapy 1
4. If anti-HBs positive only: Indicates immunity from vaccination 1, 3
5. If all markers negative: Indicates susceptibility to HBV infection 1, 3

Special Considerations

• For patients at risk of HBV reactivation (e.g., those receiving immunosuppressive therapy), both HBsAg and anti-HBc testing are essential 1
• Periodic screening is recommended for persons with ongoing risk factors (e.g., current injection drug use, multiple sexual partners) 1
• Screening should be performed regardless of vaccination history, as breakthrough infections can occur 1

Common Pitfalls to Avoid

• Incomplete screening: Testing only for HBsAg without anti-HBc may miss individuals with occult HBV infection who are at risk for reactivation during immunosuppressive therapy 1
• Misinterpreting results: A negative HBsAg result does not rule out past infection or immunity 1, 3
• Neglecting confirmatory testing: Initially reactive HBsAg results should always be confirmed with a neutralizing confirmatory test 1
• Overlooking high-risk populations: Screening should be prioritized for individuals from endemic regions and those with high-risk behaviors 1

Interpretation of Results

Test Results	Interpretation
HBsAg+, anti-HBc+, anti-HBs-	Active HBV infection (acute or chronic) [1]
HBsAg-, anti-HBc+, anti-HBs+	Resolved HBV infection with immunity [1,4]
HBsAg-, anti-HBc-, anti-HBs+	Immunity from vaccination [1,3]
HBsAg-, anti-HBc+, anti-HBs-	Possible interpretations: resolved infection, "low-level" chronic infection, or false-positive anti-HBc [4,3]
HBsAg-, anti-HBc-, anti-HBs-	Susceptible to HBV infection [1,4]