When is a full hepatitis panel recommended?

When to Run a Full Hepatitis Panel

A full hepatitis panel is recommended for universal screening of all adults aged 18 years or older, as well as for individuals with specific risk factors, abnormal liver function tests, or suspected liver disease.

Universal Screening Recommendations

• One-time, routine, opt-out HCV screening is recommended for all individuals aged 18 years or older, regardless of risk factors 1
• Universal screening for hepatitis B is recommended for all adults aged 18 years and older by testing for HBV surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total hepatitis B core antibody (anti-HBc) 1
• Universal screening aligns with goals of eliminating viral hepatitis as a public health threat by 2030 1
• Universal screening bypasses barriers in obtaining accurate risk factor assessments 1

Risk-Based Screening Indications

High-Risk Behaviors

• Injection drug use (current or past, even if only once) 1
• Intranasal illicit drug use 1
• Men who have sex with men 1
• Multiple sexual partners or history of sexually transmitted infections 1
• Unprotected sex with HCV-infected partners 1

High-Risk Exposures

• Long-term hemodialysis (ever) 1
• Percutaneous/parenteral exposures in unregulated settings 1
• Healthcare workers after needlestick or mucosal exposure to infected blood 1
• Prior recipients of blood transfusions or organ transplants before July 1992 1
• Recipients of clotting factor concentrates before 1987 1
• History of incarceration 1, 2
• Children born to HCV-infected mothers 1

Medical Conditions

• HIV infection 1
• Unexplained chronic liver disease or elevated liver enzymes 1
• Individuals starting pre-exposure prophylaxis (PrEP) for HIV 1
• History of HCV infection (for HBV testing) 2

Periodic Repeat Testing

• Annual HCV testing for people who inject drugs 1
• Annual HCV testing for men with HIV who have unprotected sex with men 1
• Periodic testing for those with ongoing risk factors, with frequency determined by individual risk assessment 1
• Testing should be performed whenever a person develops elevated ALT, AST, or bilirubin levels 1

Components of a Full Hepatitis Panel

Hepatitis B Testing

• HBsAg - primary marker for active HBV infection 3
• Anti-HBc total - indicates current or previous HBV infection 3
• Anti-HBc IgM - indicates acute infection when positive 3
• Anti-HBs - indicates recovery from infection or successful vaccination 3
• HBeAg - marker of high viral replication 3
• Anti-HBe - usually indicates lower viral replication 3
• HBV DNA quantification - essential for assessing viral replication and disease activity 3

Hepatitis C Testing

• HCV antibody testing with reflex HCV RNA PCR testing is recommended for initial screening 1
• Quantitative HCV RNA testing is recommended prior to antiviral therapy 1
• HCV genotype testing may be considered when it would alter treatment recommendations 1

Additional Testing

• Liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin) 3
• Albumin and prothrombin time/INR to assess synthetic liver function 3
• Testing for coinfections (HAV, HDV, HIV) in high-risk groups 3
• Alpha-fetoprotein and ultrasound for baseline evaluation in high-risk patients 3

Special Considerations

• For suspected acute HCV infection, both HCV antibody and HCV RNA testing are needed, as antibodies may be negative during the first 6 weeks after exposure 1
• In immunosuppressed individuals, HCV antibody testing may yield false negatives, making HCV RNA testing essential 1
• For individuals with previous HCV clearance (spontaneous or treatment-related), HCV RNA testing is recommended for reinfection monitoring, as antibody tests will remain positive 1
• Testing should be performed for anyone who requests it, regardless of disclosed risk factors, due to potential stigma 2

Common Pitfalls to Avoid

• Failing to order reflex HCV RNA testing with antibody testing, requiring a return visit for confirmation 1
• Misinterpreting a positive HCV antibody with negative RNA as active infection (indicates resolved infection or false positive) 1
• Overlooking the need for coinfection testing, particularly in high-risk populations 3
• Failing to recognize the "window period" when both HBsAg and anti-HBs may be negative in acute HBV infection 3
• Misinterpreting isolated anti-HBc positivity, which requires follow-up testing 3

By implementing comprehensive hepatitis screening according to these guidelines, clinicians can identify infections earlier, prevent transmission, and improve outcomes through timely intervention and treatment.