Hepatitis B Testing Order
Order a three-test panel consisting of hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total or IgG, and hepatitis B surface antibody (anti-HBs) for comprehensive screening of patients at risk for hepatitis B infection. 1
Standard Testing Panel
The complete serologic testing comprises three essential markers 1:
- HBsAg (Hepatitis B Surface Antigen): Detects active infection, either acute or chronic 1, 2, 3
- Anti-HBc (Hepatitis B Core Antibody) Total or IgG: Indicates previous or ongoing infection 2, 3
- Anti-HBs (Hepatitis B Surface Antibody): Indicates immunity from vaccination or resolved infection 2, 3
Critical Implementation Details
Order all three tests simultaneously rather than sequentially to avoid delays in diagnosis and management 2, 3. The first dose of hepatitis B vaccine should be administered immediately after blood collection for serologic testing, without waiting for results 1.
For initially reactive HBsAg results, laboratories must perform confirmatory testing using an FDA-licensed neutralizing confirmatory test 1, 3.
Interpretation Algorithm
The three-test panel allows complete assessment of hepatitis B status 2, 3:
| Test Results | Interpretation | Action Required |
|---|---|---|
| HBsAg+, anti-HBc+, anti-HBs- | Active chronic HBV infection | Refer for hepatology evaluation; order HBeAg, anti-HBe, quantitative HBV DNA [2] |
| HBsAg-, anti-HBc+, anti-HBs+ | Resolved past infection | No vaccination needed; immune [2,3] |
| HBsAg-, anti-HBc+, anti-HBs- | Isolated core antibody (possible occult HBV) | Consider quantitative HBV DNA testing [2] |
| HBsAg-, anti-HBc-, anti-HBs+ | Immunity from vaccination | No further action needed [2,3] |
| HBsAg-, anti-HBc-, anti-HBs- | Susceptible to HBV | Vaccinate immediately [2,3] |
Additional Testing When HBsAg Positive
When HBsAg is confirmed positive, immediately order 2:
- HBeAg (Hepatitis B e Antigen): Indicates high viral replication when positive 2
- Anti-HBe (Antibody to HBeAg): Indicates lower replication phase 2
- Quantitative HBV DNA: Measures viral load to guide treatment decisions 2
High-Risk Populations Requiring Testing
Testing is specifically recommended for 1:
- Persons born in countries with HBsAg prevalence ≥2% (Asia, sub-Saharan Africa, Pacific Islands, Eastern Europe, parts of South America) 1, 3
- Household, sexual, or needle-sharing contacts of HBsAg-positive persons 1
- HIV-positive persons 1
- Men who have sex with men 1
- Past or current persons who inject drugs 1
- Hemodialysis patients 1
- Persons with elevated ALT/AST of unknown etiology 1
- Persons needing immunosuppressive therapy (chemotherapy, organ transplantation, immunosuppression for rheumatologic or gastroenterologic disorders) 1
- Pregnant women at first prenatal visit 4, 5
- Donors of blood, plasma, organs, tissues, or semen 1
Critical Timing for Immunosuppression
For patients starting immunosuppressive therapy, order the complete three-test panel before initiating treatment to assess reactivation risk and determine need for prophylactic antiviral therapy 1, 2. This is a critical intervention point to prevent hepatic decompensation and death 2.
Patients who are HBsAg-positive or anti-HBc-positive require prophylactic antiviral therapy before high-risk immunosuppressive regimens 2.
Common Pitfalls to Avoid
- Do not order only HBsAg alone for screening, as this will miss past infections and occult hepatitis B 2, 3
- Do not order IgM anti-HBc for routine screening; reserve this test only when acute hepatitis B is specifically suspected 2
- Do not assume vaccination history eliminates the need for testing, as breakthrough infections can occur 2, 3
- Do not delay cancer or immunosuppressive therapy while waiting for hepatitis B test results; order tests and proceed with treatment planning 2
- Do not interpret isolated anti-HBc positivity as definitively indicating occult infection without ordering quantitative HBV DNA testing 2
- Serologic testing should not be a barrier to vaccination; administer the first vaccine dose during the same visit as blood draw 1
Special Considerations for Pregnancy
For pregnant patients, order the triple-panel test (HBsAg, anti-HBc, anti-HBs) at the initial prenatal visit if not previously documented 4. For subsequent pregnancies with previously documented negative triple-panel, order HBsAg screening alone 4.