What tests should be ordered for a hepatitis B (HBV) titer check?

Hepatitis B Titer Check: Recommended Tests

For a complete hepatitis B titer check, order hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total or IgG, and antibody to hepatitis B surface antigen (anti-HBs). 1, 2

Core Testing Panel

• Hepatitis B surface antigen (HBsAg): Primary screening test to identify active HBV infection (acute or chronic) 2
• Hepatitis B core antibody (anti-HBc) total or IgG: Indicates previous or ongoing infection 2, 1
• Hepatitis B surface antibody (anti-HBs): Indicates immunity due to vaccination or resolved infection 2

Interpretation of Results

Test Results	Interpretation
HBsAg+, anti-HBc+, anti-HBs-	Active HBV infection (chronic) [1,2]
HBsAg-, anti-HBc+, anti-HBs+	Resolved HBV infection [1]
HBsAg-, anti-HBc+, anti-HBs-	Isolated core antibody (possible occult HBV) [1]
HBsAg-, anti-HBc-, anti-HBs+	Immunity from vaccination [2]
HBsAg-, anti-HBc-, anti-HBs-	Susceptible to HBV infection [2]

Additional Tests When Indicated

• For positive HBsAg results: Order HBeAg, anti-HBe, and quantitative HBV DNA 1

  • These tests help determine viral replication status and infectivity 1
  • HBeAg positivity typically indicates high viral replication (106-1010 IU/mL) 1

• For isolated anti-HBc positivity (HBsAg negative, anti-HBc positive, anti-HBs negative):

  • Consider quantitative HBV DNA testing to rule out occult HBV infection 1
  • This pattern may represent:
    1. Resolved infection with waned anti-HBs levels 1
    2. Chronic infection with undetectable HBsAg 1
    3. False-positive result 1

Special Considerations

• For patients starting immunosuppressive therapy: Complete panel is essential to assess reactivation risk 1, 2

  • Patients with evidence of HBV infection require risk assessment for reactivation 1
  • Prophylactic antiviral therapy may be needed for high-risk patients 1

• For patients with chronic liver disease: Testing for both HAV and HBV immunity is recommended 3

  • Coinfection with HAV or HBV in patients with chronic liver disease can lead to more severe injury 3

• For cancer patients: Do not delay anticancer therapy while obtaining HBV testing 1

  • All patients anticipating systemic anticancer therapy should be tested with all three tests 1

Common Pitfalls to Avoid

• Do not order IgM anti-HBc for routine screening; it should only be ordered when acute hepatitis B is suspected 1
• Do not rely solely on HBsAg for comprehensive screening, as it will miss past infections 2
• Do not assume vaccination history eliminates need for testing, as breakthrough infections can occur 2
• Do not interpret isolated anti-HBc as definitively indicating occult infection without further testing 1

Remember that proper interpretation of hepatitis B serologic markers is essential for accurate diagnosis and appropriate clinical management of patients with potential HBV infection.