What serology would be positive in a patient with a previous Hepatitis B (Hep B) infection?

From the Guidelines

A patient with a previous Hepatitis B infection would have positive Hepatitis B core antibody (anti-HBc) and typically positive Hepatitis B surface antibody (anti-HBs), indicating immunity developed after recovery from the infection. The presence of both anti-HBc and anti-HBs without Hepatitis B surface antigen (HBsAg) is the classic serological pattern of resolved Hepatitis B infection, as noted in the 2018 study by the Advisory Committee on Immunization Practices 1.

Serological Markers

• Hepatitis B core antibody (anti-HBc) IgG persists for life after infection
• Hepatitis B surface antibody (anti-HBs) typically positive, indicating immunity developed after recovery from the infection
• The presence of both anti-HBc and anti-HBs without HBsAg is the classic serological pattern of resolved Hepatitis B infection

In some cases, anti-HBc may be the only detectable marker if anti-HBs levels have waned over time, as seen in individuals who have recovered from natural HBV infection but whose anti-HBs levels have decreased 1. This pattern differs from vaccination-induced immunity, where only anti-HBs would be positive without anti-HBc. The serological markers reflect the immune system's response to the virus: anti-HBc develops during acute infection and persists indefinitely, while anti-HBs appears during recovery as the virus is cleared, signaling protective immunity against future infection.

Clinical Implications

• Patients with serological evidence of past infection with HBV, such as those who are HBsAg negative and anti-HBc positive, remain at risk of HBV reactivation in the setting of immunosuppression, as noted in the 2016 study on the prevention of hepatitis B reactivation in the setting of immunosuppression 1
• Isolated anti-HBc-positivity can be detected following HBV infection in persons who have recovered but whose anti-HBs levels have waned
• These individuals are unlikely to transmit infection except under circumstances in which they are the source of a large exposure, such as a blood transfusion 1

From the Research

Serology in Previous Hepatitis B Infection

In a patient with a previous Hepatitis B (Hep B) infection, the following serology would be positive:

• Anti-HBc (antibody to hepatitis B core antigen) [(2,3,4,5,6)]
• Anti-HBs (antibody to hepatitis B surface antigen) [(2,3,4,5,6)]

Interpretation of Serology Results

It is essential to interpret serology results accurately to determine the patient's infection status:

• A positive anti-HBc result indicates a previous or current HBV infection [(2,3,4,5,6)]
• A positive anti-HBs result indicates immunity to HBV, either through vaccination or previous infection [(2,3,4,5,6)]
• The presence of anti-HBc without anti-HBs may indicate a previous infection with loss of immunity or a false positive result 6

Factors Affecting Serology Results

Several factors can affect serology results, including:

• Immunosuppression, which can lead to reactivation of HBV [(2,3,4)]
• HIV-1 infection, which can increase the risk of HBV reactivation or reinfection 4
• Intravenous immunoglobulin (IVIg) infusion, which can cause passive transfer of anti-HBV antibodies 5