Hepatitis B Screening Test Recommendation
Screen for hepatitis B using hepatitis B surface antigen (HBsAg) as the primary test, followed by confirmatory testing for initially reactive results. 1
Recommended Screening Panel
For comprehensive screening, order a three-test panel simultaneously: HBsAg, anti-HBc (total or IgG), and anti-HBs. 2, 3 This approach provides complete information about infection status, past exposure, and immunity in a single draw.
What Each Test Tells You:
- HBsAg detects active infection (acute or chronic) 2, 3
- Anti-HBc (total or IgG) indicates previous or ongoing infection 2, 3
- Anti-HBs indicates immunity from vaccination or resolved infection 2, 3
Who Should Be Screened
Universal screening is now recommended for all adults aged ≥18 years at least once in their lifetime. 2, 3 This represents a shift from risk-based screening, as 21% of chronic HBV patients have no identifiable risk factors, and approximately 90% of patients have at least one risk variable, making selective screening impractical. 3
High-Priority Groups Requiring Screening:
- Persons born in countries with HBsAg prevalence ≥2% (Asia, Africa, Pacific Islands, parts of South America, Eastern Europe) 1, 2
- Persons who inject drugs (current or past) 1, 2
- Men who have sex with men 1, 2
- HIV-positive persons 1, 2
- Household contacts or sexual partners of HBV-infected persons 1, 2
- Anyone starting immunosuppressive therapy (critical timing to prevent reactivation) 2, 3
- U.S.-born persons not vaccinated as infants whose parents were born in regions with ≥8% HBV prevalence 1
Confirmatory Testing Protocol
For initially reactive HBsAg results, perform a licensed neutralizing confirmatory test before diagnosing active infection. 1, 2 This step is essential to avoid false-positive diagnoses.
Interpreting Results
| Test Results | Clinical Interpretation | Action Needed |
|---|---|---|
| HBsAg+, anti-HBc+, anti-HBs- | Active HBV infection (chronic) [2,3] | Refer to specialist; order HBV DNA, HBeAg, anti-HBe [1,3] |
| HBsAg-, anti-HBc+, anti-HBs+ | Resolved past infection [3] | No action; patient has natural immunity |
| HBsAg-, anti-HBc+, anti-HBs- | Isolated core antibody (possible occult HBV) [3] | Consider HBV DNA testing, especially if immunocompromised [1,3] |
| HBsAg-, anti-HBc-, anti-HBs+ | Immunity from vaccination [2,3] | No action needed |
| HBsAg-, anti-HBc-, anti-HBs- | Susceptible to HBV [2,3] | Vaccinate immediately |
Screening Intervals
For patients with ongoing risk factors (current injection drug use, men who have sex with men, multiple sexual partners), perform periodic screening. 1, 2 The specific interval is not defined in guidelines, but clinical judgment should guide frequency based on risk behavior continuation.
Critical Pitfalls to Avoid
- Do not order only HBsAg for screening—this misses past infections and occult HBV, which are critical for patients starting immunosuppression 3
- Do not order IgM anti-HBc for routine screening—reserve this only for suspected acute hepatitis B 3
- Do not assume vaccination history eliminates the need for testing—breakthrough infections occur, and many patients have incomplete or undocumented vaccination 2, 3
- Do not delay screening in patients about to start immunosuppressive therapy—this is the most critical intervention point to prevent HBV reactivation, hepatic decompensation, and death 3
- Be aware that HBsAg mutations can cause false-negative results in rare cases, particularly in vaccinated patients or those on dialysis 4
Special Considerations for Immunosuppression
Before initiating immunosuppressive therapy, screening with the complete three-test panel (HBsAg, anti-HBc, anti-HBs) is mandatory. 3 Patients who are HBsAg-positive or anti-HBc-positive require antiviral prophylaxis to prevent potentially fatal HBV reactivation. 3 Do not delay cancer or immunosuppressive therapy while obtaining results, but ensure testing is ordered immediately. 3