What is the recommended initial screening and management approach for a patient undergoing a Hepatitis B (HBV) screen?

Hepatitis B Initial Screening

All adults aged 18 years and older should be screened for hepatitis B using three serologic tests: HBsAg, anti-HBc (total IgG or total Ig), and anti-HBs. 1

Core Screening Panel

The initial screening requires a three-test panel to comprehensively assess HBV status 1:

• HBsAg (Hepatitis B surface antigen) - identifies current chronic or acute infection 1
• Anti-HBc (Hepatitis B core antibody, total or IgG) - detects past or current exposure 1
• Anti-HBs (Antibody to hepatitis B surface antigen) - indicates immunity from vaccination or resolved infection 1

This universal screening approach is strongly recommended over risk-based screening, as 21-27% of patients with chronic or past HBV infection have no identifiable risk factors, making selective screening inefficient and impractical. 1

Interpretation of Initial Screening Results

Chronic HBV Infection (Requires Immediate Action)

• Pattern: HBsAg positive, anti-HBc positive, anti-HBs negative 1
• Next steps: Immediately order HBV DNA quantitative testing, HBeAg/anti-HBe, and complete metabolic panel including ALT/AST 1
• Additional evaluation: Check for co-infections (anti-HCV, anti-HDV if injection drug use history, anti-HIV in high-risk groups) 1

Past/Resolved HBV Infection

• Pattern: HBsAg negative, anti-HBc positive, anti-HBs positive 1
• Interpretation: Natural immunity from prior infection 1
• Action: No treatment needed unless immunosuppression is planned 1, 2

Isolated Anti-HBc Positive (Requires Further Testing)

• Pattern: HBsAg negative, anti-HBc positive, anti-HBs negative 1, 3
• Next step: Order HBV DNA testing to rule out occult hepatitis B infection 1, 3
• Possible explanations: Resolved infection with waning anti-HBs, false-positive anti-HBc (especially after IVIG administration), or occult HBV 1, 2

Vaccine-Induced Immunity

• Pattern: HBsAg negative, anti-HBc negative, anti-HBs positive (≥10 mIU/mL) 1, 4
• Action: No further testing or management needed 1, 4

Susceptible (No Immunity)

• Pattern: All three tests negative 1
• Action: Offer hepatitis B vaccination series 1

Additional Baseline Evaluation for Chronic HBV

When HBsAg is positive, complete the following baseline assessment 1:

Laboratory tests:

• Complete blood count 1
• Comprehensive metabolic panel: AST/ALT, alkaline phosphatase, bilirubin, albumin, creatinine, prothrombin time 1
• HBV DNA quantitative testing 1
• HBeAg and anti-HBe 1

Screening for complications:

• Abdominal ultrasound and alpha-fetoprotein for hepatocellular carcinoma screening 1
• Assessment for cirrhosis (may include liver biopsy or non-invasive fibrosis assessment) 1

Vaccination status:

• IgG anti-HAV in patients younger than 50 years to determine need for hepatitis A vaccination 1

Critical Pitfalls to Avoid

Do not rely on risk-based screening alone - this approach misses 21-27% of infected patients who lack traditional risk factors. 1

Beware of false-positive anti-HBc after IVIG administration - passive transfer occurs in 15% of cases and can persist for 3-6 months. 1, 2 If IVIG was recently given, repeat testing after antibody clearance. 3

Never assume resolved infection without HBV DNA testing when anti-HBc is positive but anti-HBs is negative or low, especially if immunosuppression is planned. 3, 2

Do not delay cancer or immunosuppressive therapy for screening results, but ensure testing is completed before or at initiation of treatment. 1

Special Populations Requiring Screening

Beyond universal adult screening, prioritize testing in 1:

• All pregnant women at first prenatal visit 5
• Patients before initiating immunosuppressive therapy or chemotherapy 1
• Patients with elevated liver enzymes of unknown etiology 1
• Household and sexual contacts of HBsAg-positive individuals 2