What lab tests are needed to follow up on a patient with positive Hepatitis B (HBV) core antibody and Hepatitis B surface antigen (HBsAb) antibody?

Laboratory Testing for Hepatitis B Core Antibody and Surface Antibody Positive Patients

For patients positive for both hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs), the primary interpretation is resolved HBV infection with immunity, and no routine follow-up testing is required unless specific clinical circumstances arise. 1, 2

Initial Interpretation of Your Serologic Pattern

The combination of positive anti-HBc and positive anti-HBs (with negative HBsAg) indicates resolved HBV infection with immunity—meaning the patient had HBV infection in the past, cleared it, and now has protective antibodies. 1, 2

This pattern differs fundamentally from chronic infection and requires different management:

• HBsAg negative + anti-HBc positive + anti-HBs positive = resolved infection with immunity 1, 2
• This is distinct from chronic HBV (which requires HBsAg positivity for >6 months) 1
• No antiviral therapy is indicated for this serologic pattern 1

When Additional Testing IS Required

1. If Immunosuppressive Therapy is Planned

Any patient with positive anti-HBc who will receive immunosuppressive therapy must be evaluated by a hepatologist to rule out occult HBV infection (OBI) and determine need for pre-emptive antiviral prophylaxis. 3

• Occult HBV infection means replication-competent HBV DNA persists in the liver despite negative HBsAg 3
• This creates risk of potentially fatal HBV reactivation during immunosuppression 1, 4
• Testing should include: HBV DNA by sensitive PCR assay 3
• Consider antiviral prophylaxis before starting chemotherapy, rituximab, or other immunosuppressants 3, 1

2. If Liver Enzyme Abnormalities Develop

If ALT/AST become elevated, additional workup is needed: 1, 5

• Repeat HBsAg testing to confirm it remains negative 1
• HBV DNA quantitative PCR to exclude occult HBV reactivation 3, 5
• Anti-HCV antibody and HCV RNA to rule out hepatitis C coinfection 1
• Anti-HDV antibody if any risk factors present 3, 1
• Anti-HIV testing in high-risk populations 1

3. If Anti-HBs Titer Falls Below Protective Levels

• In dialysis patients: Annual anti-HBs testing is required, and booster vaccination is needed if levels fall <10 mIU/mL 3
• In immunocompromised patients: Similar monitoring and booster strategy applies 3
• In immunocompetent individuals: No routine booster testing or vaccination is needed, as immune memory persists despite declining antibody levels 3

What Testing is NOT Needed in Routine Follow-Up

For stable patients with resolved HBV infection (anti-HBc positive, anti-HBs positive, HBsAg negative) and no special circumstances:

• No routine HBV DNA monitoring 1
• No routine HBsAg retesting 1
• No routine liver enzyme monitoring (unless other liver disease present) 1
• No hepatocellular carcinoma surveillance (only needed in chronic HBV or cirrhosis) 1

Additional One-Time Assessments to Consider

Hepatitis A Vaccination Status

• Check IgG anti-HAV if patient is <50 years old 1
• Hepatitis A vaccination is recommended for those without immunity, as HAV coinfection in any patient with history of HBV increases mortality risk 5.6- to 29-fold 3

Confirm Complete Resolution (If Uncertainty Exists)

• If there is any doubt about chronicity versus resolution, repeat HBsAg, anti-HBs, and anti-HBc in 3-6 months to confirm stable resolved status 1

Critical Pitfalls to Avoid

• Never assume immunity is permanent in immunocompromised or dialysis patients—these populations require ongoing anti-HBs monitoring 3
• Never start immunosuppressive therapy without hepatology consultation in any anti-HBc positive patient, regardless of anti-HBs status 3, 1
• Never overlook viral coinfection screening (HCV, HDV, HIV) if any risk factors exist, as coinfection accelerates liver disease 1