Recommended Hepatitis Screening and Treatment Guidelines
Universal screening for hepatitis B and C is recommended for all adults aged 18 years and older at least once in their lifetime, with additional risk-based testing for those with ongoing risk factors. 1, 2
Hepatitis B Screening
Who to Screen
- All adults aged ≥18 years should be screened at least once in their lifetime 3
- Persons from countries with HBsAg prevalence ≥2% (Asia, Africa, Pacific Islands, parts of South America, Eastern Europe) 3
- Persons with high-risk behaviors (injection drug use, men who have sex with men) 3
- HIV-positive individuals 3
- Household contacts or sexual partners of HBV-infected persons 3
- Patients who will undergo immunosuppressive therapy 1
Recommended Testing Panel
- Initial screening should include three tests: 4
- Hepatitis B surface antigen (HBsAg)
- Hepatitis B core antibody (anti-HBc) total or IgG
- Antibody to hepatitis B surface antigen (anti-HBs)
Interpretation of Hepatitis B Results
| Test Results | Interpretation |
|---|---|
| HBsAg+, anti-HBc+, anti-HBs- | Active HBV infection (chronic) [4] |
| HBsAg-, anti-HBc+, anti-HBs+ | Resolved HBV infection [4] |
| HBsAg-, anti-HBc+, anti-HBs- | Isolated core antibody (possible occult HBV) [4] |
| HBsAg-, anti-HBc-, anti-HBs+ | Immunity from vaccination [4] |
| HBsAg-, anti-HBc-, anti-HBs- | Susceptible to HBV infection [4] |
Additional Testing for Positive HBsAg
- For positive HBsAg results, order: 4
- HBeAg
- Anti-HBe
- Quantitative HBV DNA
Hepatitis C Screening
Who to Screen
- Universal one-time screening for all adults aged 18-79 years 2, 5
- All pregnant women during each pregnancy 5
- Risk-based screening for persons <18 years with risk factors 2
- Periodic testing for those with ongoing risk factors 2
- Annual testing for people who inject drugs and men with HIV who have unprotected sex with men 2
Recommended Testing Approach
- Initial screening with HCV-antibody testing with reflex HCV RNA PCR testing 2
Special Testing Considerations
- For recent exposure (within 6 months), consider HCV RNA testing or follow-up antibody testing ≥6 months after exposure 2
- For immunocompromised patients, consider direct HCV RNA testing 2
- For patients at risk of reinfection, use HCV RNA testing since antibody tests remain positive after prior clearance 2
Treatment Recommendations
Hepatitis B Treatment
- All HBsAg-positive persons should be referred to a specialist or primary care provider experienced in treating hepatitis B 1
- Treatment decisions should be based on: 1
- HBeAg status
- ALT levels
- HBV DNA levels
- Evidence of liver inflammation/fibrosis
- First-line treatment options include pegylated interferon alfa-2a, entecavir, and tenofovir 6
Hepatitis C Treatment
- For treatment-naive adults without cirrhosis or with compensated cirrhosis: 5
- Eight weeks of glecaprevir/pibrentasvir, OR
- Twelve weeks of sofosbuvir/velpatasvir
- These regimens result in >95% cure rates 5
- Sustained virologic response (undetectable HCV RNA 12 weeks after completing therapy) is considered a virologic cure 5
Post-Diagnosis Management
Hepatitis B
- Initial evaluation should include: 1
- Thorough history and physical examination
- Family history of HBV infection and liver cancer
- Assessment of risk factors for coinfections
- Alcohol use evaluation
- Laboratory tests should assess: 1
- Liver disease severity
- Markers of HBV replication
- Testing for coinfection with other viruses in at-risk individuals
- Screening for hepatocellular carcinoma should be conducted in all HBsAg-positive persons ≥20 years old 1
Hepatitis C
- For patients with compensated cirrhosis: 5
- Surveillance for hepatocellular carcinoma with abdominal ultrasonography every six months
- Upper endoscopy every two to three years for esophageal varices
- In the absence of cirrhosis, no liver-related follow-up is recommended 5
Common Pitfalls to Avoid
- Do not order IgM anti-HBc for routine screening; only order when acute hepatitis B is suspected 4
- Do not rely solely on HBsAg for comprehensive HBV screening 4
- Do not assume vaccination history eliminates the need for testing 4
- Do not interpret isolated anti-HBc as definitively indicating occult infection without further testing 4
- Relying solely on HCV antibody testing can miss active infection or incorrectly classify resolved infections as current 2