When is a Hepatitis B (HBV) panel test, including HBsAg (Hepatitis B surface antigen), anti-HBs (Hepatitis B surface antibody), HBeAg (Hepatitis B e-antigen), anti-HBe (Hepatitis B e-antibody), and anti-HBc (Hepatitis B core antibody), indicated for individuals at high risk of infection, such as healthcare workers, injection drug users, or those with multiple sexual partners?

Hepatitis B Panel Testing Indications

Primary Recommendation

Hepatitis B panel testing (HBsAg at minimum) should be performed routinely for all adults aged ≥18 years at least once in their lifetime, with expanded testing for specific high-risk populations including healthcare workers, injection drug users, and persons with multiple sexual partners. 1

Universal Screening Populations

One-Time Screening for All Adults

• All adults aged ≥18 years should receive hepatitis B screening at least once during their lifetime using three laboratory tests: HBsAg, anti-HBs, and anti-HBc 1
• This universal approach addresses the fact that up to 60% of HBV-infected persons are unaware of their infection and remain asymptomatic until cirrhosis or end-stage liver disease develops 2

High-Risk Populations Requiring Testing

Geographic Risk Factors

• Persons born in countries/regions with HBsAg prevalence ≥2% (including Asia, Africa, Pacific Islands, parts of South America) should be screened regardless of vaccination history 3
• U.S.-born persons not vaccinated as infants whose parents were born in regions with HBsAg prevalence ≥8% require testing due to high perinatal transmission risk 3

Behavioral and Occupational Risk Factors

• Injection drug users (current or past) represent a high-prevalence population requiring screening 3
• Men who have sex with men should receive routine HBsAg testing 3
• Healthcare workers require screening, particularly those with potential exposure to blood or body fluids 3
• Persons with multiple sexual partners or history of sexually transmitted infections should be tested 3, 1

Contact and Exposure-Based Testing

• Household contacts, sex partners, and needle-sharing contacts of HBsAg-positive persons require immediate testing 3
• Persons who are the source of blood/body fluid exposures (e.g., needlestick injuries, sexual assault) warrant testing 3

Medical Conditions Requiring Testing

• HIV-positive persons should be screened for HBV infection 3
• Persons with hepatitis C virus infection require HBV testing 1
• Persons incarcerated or formerly incarcerated in jails, prisons, or detention settings 1

Periodic Screening Recommendations

Persons with continued risk exposure require periodic rescreening, including:

• Current injection drug users should receive ongoing periodic testing 3
• Men who have sex with men with ongoing risk behaviors need repeated screening 3
• Healthcare workers and dialysis patients require annual testing after vaccination to monitor antibody levels 3, 4

Testing Regardless of Vaccination History

Critical Populations to Test Despite Prior Vaccination

• All persons born in regions with HBV prevalence >2% should be tested even if vaccinated in their country of origin, because most were born before full implementation of routine infant vaccination programs 3
• Persons vaccinated as adolescents or adults after initiating risk behaviors (MSM, IDUs) require testing because they may have been exposed before vaccination 3
• Healthcare workers vaccinated in childhood should have anti-HBs measured immediately upon hire; if <10 mIU/mL, they need one additional vaccine dose followed by retesting 4

Testing Approach and Components

Initial Screening Test

• HBsAg testing is the primary screening method to identify chronic HBV infection 3
• Initially reactive HBsAg results require a confirmatory test 3

Complete Panel for Comprehensive Assessment

When performing a full hepatitis B panel, the following markers provide complete diagnostic information 5, 6:

• HBsAg (hepatitis B surface antigen) - indicates active infection
• Anti-HBs (hepatitis B surface antibody) - indicates immunity from vaccination or resolved infection
• Anti-HBc (total and IgM) - distinguishes acute from chronic infection and identifies past exposure 7
• HBeAg/anti-HBe - assesses viral replication status and infectivity 3
• HBV DNA - quantifies viral load for treatment decisions 6

Testing in Specific Settings

Settings Where Universal Vaccination and Testing Are Recommended

• STD/HIV testing and treatment facilities should offer first vaccine dose at time of testing 3
• Drug abuse treatment and prevention settings require integrated screening and vaccination 3
• Correctional facilities should provide testing and vaccination services 3, 1
• Healthcare settings targeting services to IDUs or MSM need comprehensive HBV programs 3

Critical Pitfalls to Avoid

Common Testing Errors

• Never assume protection based solely on vaccination history without serologic confirmation, as documentation does not guarantee current immunity 4
• Do not delay testing until after exposure - pre-exposure testing and vaccination is far superior to post-exposure management 4
• Avoid failing to test contacts of HBsAg-positive individuals, as this leads to missed opportunities for prevention through vaccination 3, 8

Testing Strategy Errors

• Do not restrict testing to those who disclose risk factors - anyone requesting HBV testing should receive it, as many are reluctant to disclose stigmatizing risks 1
• Never skip testing in vaccinated persons from endemic regions - they may have been infected before vaccination programs were implemented 3

Management After Positive Results

Immediate Actions for HBsAg-Positive Results

• Report all HBsAg-positive results to state/local health departments as required 3
• Identify and test all sex partners, household contacts, and needle-sharing contacts immediately 3, 8
• Vaccinate susceptible contacts at the same visit after drawing blood for testing 3
• Refer for hepatology evaluation to assess disease activity, HBV DNA levels, and treatment needs 7

Contact Management Protocol

• Unvaccinated contacts should receive the first vaccine dose immediately after blood draw for serologic testing 3
• Contacts should be tested for HBsAg, anti-HBc, and/or anti-HBs 3
• Susceptible persons must complete the full vaccine series using age-appropriate dosing 3

Special Populations Requiring Enhanced Surveillance

Pregnant Women

• All pregnant women require HBsAg testing at first prenatal visit to enable postexposure prophylaxis for newborns 3, 9
• Infants born to HBsAg-positive mothers need HBIG and hepatitis B vaccine within 24 hours of delivery, which is 95% effective in preventing perinatal transmission 3

Dialysis Patients

• Require dedicated dialysis machines, physical separation from HBV-susceptible patients, and annual anti-HBs testing 4, 8