Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV). A significant challenge with hepatitis B is that over half of those infected are unaware they have it. Alarmingly, for acute hepatitis B infections, a large proportion, between 50% and 70%, experience no symptoms at all. This silent nature of HBV infection is a major public health concern because, without proper testing, individuals can unknowingly transmit the virus to others.
Chronic HBV infection poses substantial risks, potentially leading to severe liver disease and even death. However, the good news is that reliable and affordable screening tests can detect chronic HBV infection long before serious liver damage occurs. Early detection through routine monitoring and timely treatment are crucial for managing chronic HBV infection, significantly reducing the risks of complications and mortality. Therefore, identifying HBV infection early is of paramount importance.
Beyond individual health, diagnosing hepatitis B plays a vital role in preventing further transmission. Effective management of chronic infections, coupled with robust prevention strategies, can break the chain of transmission and protect communities.
For those seeking general information about hepatitis B testing, resources are readily available to guide you through the process and understand your options.
Deciding When to Test or Screen for Hepatitis B
Understanding the difference between screening and testing is important. Screening typically involves testing asymptomatic individuals who are not known to be at high risk for HBV exposure. Conversely, testing is generally conducted on people who are exhibiting symptoms of hepatitis or are identified as being at an increased risk of HBV exposure.
Hepatitis B Testing Recommendations for Different Groups
Adults: The Centers for Disease Control and Prevention (CDC) recommends that all adults aged 18 years and older undergo hepatitis B screening at least once in their lifetime. This screening should be performed using a comprehensive triple panel test. To improve access to testing, it is recommended that HBV testing should be provided to anyone who requests it, regardless of whether they disclose any specific risk factors. This is because many individuals may be hesitant to reveal stigmatizing behaviors or exposures.
Infants: For infants, the CDC recommends specific testing protocols for those born to mothers who are positive for the Hepatitis B surface antigen (HBsAg). These infants should be tested for both HBsAg and antibody to hepatitis B surface antigen (anti-HBs) seromarkers.
Pregnant Women: Universal screening for hepatitis B is crucial during pregnancy. The CDC recommends that all pregnant women be screened for HBsAg during each pregnancy, ideally during the first trimester. This recommendation applies regardless of their vaccination status or previous testing history. However, pregnant women who have had a timely triple panel screening and have not had any new HBV exposures since then only require HBsAg screening.
Who is at Increased Risk for Hepatitis B Infection?
Periodic testing is recommended for susceptible individuals who have ongoing risk factors for HBV exposure, regardless of their age. Susceptible individuals are defined as those who have never been infected with HBV and have either not completed a full hepatitis B vaccine (HepB) series as recommended, or are known to be non-responders to the vaccine. Groups at increased risk include:
- Individuals with a history of sexually transmitted infections (STIs) or multiple sexual partners: Sexual contact is a primary mode of hepatitis B transmission.
- People with a history of past or current Hepatitis C Virus (HCV) infection: Co-infection with HBV and HCV is possible and can complicate disease management.
- People who are currently or formerly incarcerated: Correctional facilities can present environments with higher risk of HBV transmission.
- Infants born to HBsAg-positive mothers: Vertical transmission from mother to child during birth is a significant concern.
- People born in regions with high HBV prevalence (≥2%): Certain geographic areas have a higher prevalence of chronic HBV infection.
- US-born individuals, unvaccinated as infants, with parents from high HBV prevalence regions (≥8% HBsAg prevalence): These individuals may be at increased risk due to family history and potential exposure.
- People who inject drugs (PWID) or have a history of injection drug use: Sharing needles and injection equipment is a major risk factor for HBV transmission.
- People with Human Immunodeficiency Virus (HIV) infection: HIV and HBV co-infection is common and can lead to more severe liver disease.
- Men who have sex with men (MSM): MSM are considered a high-risk group due to sexual transmission routes.
- Household contacts or former household contacts of individuals with known HBV infection: Close household contact can facilitate HBV transmission.
- People who have shared needles or had sexual contact with individuals with known HBV infection: Direct exposure to infected blood or body fluids increases risk.
- People on maintenance dialysis: Dialysis patients are at risk due to potential blood exposure and immunocompromised status.
- People with elevated liver enzymes: Unexplained elevated liver enzymes may indicate underlying liver conditions, including hepatitis B.
Recommended Hepatitis B Tests: Utilizing the Triple Panel
The CDC currently recommends the use of a triple panel test for comprehensive hepatitis B screening and diagnosis. This panel includes testing for three key serological markers:
- Hepatitis B surface antigen (HBsAg): HBsAg is a protein found on the surface of the HBV. Its presence indicates that a person is currently infected with hepatitis B, either acutely or chronically.
- Antibody to hepatitis B surface antigen (anti-HBs): The presence of anti-HBs indicates immunity to hepatitis B. This immunity can be due to successful vaccination against hepatitis B or recovery from a past HBV infection.
- Total antibody to hepatitis B core antigen (total anti-HBc): Anti-HBc appears during acute HBV infection and persists for life, indicating past or present HBV infection. It does not appear after vaccination.
For any follow-up testing after the initial triple panel, the specific tests used will depend on the results of the triple panel and the clinical context.
Incorporating HBV screening and testing into clinic workflow.
Understanding Hepatitis B Test Results: Interpretation of Serologic Markers
Different combinations of hepatitis B serologic markers help to identify the various stages of HBV infection. These markers can determine if a person has an acute or chronic infection, has immunity from prior infection or vaccination, or is susceptible to infection. Key markers and their interpretations include:
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Hepatitis B surface antigen (HBsAg): HBsAg is detectable in the blood during both acute and chronic HBV infection. Its presence signifies that the person is infectious. It’s important to note a possible exception: HBsAg might be transiently positive within 30 days after hepatitis B vaccination. The body typically produces antibodies to HBsAg (anti-HBs) as a natural immune response. HBsAg is the antigen used in the hepatitis B vaccine.
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Antibody to hepatitis B surface antigen (anti-HBs): The presence of anti-HBs generally indicates recovery from HBV infection and subsequent immunity. Anti-HBs also develops after successful hepatitis B vaccination. While anti-HBs levels may decrease over time in vaccinated individuals, most remain protected and will respond upon HBV re-exposure.
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Antibody to hepatitis B core antigen (anti-HBc): Anti-HBc appears at the onset of symptoms in acute hepatitis B and persists for life. It indicates previous or ongoing HBV infection, but doesn’t specify the timeframe. Importantly, individuals who have immunity due to vaccination will not develop anti-HBc.
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IgM antibody to hepatitis B core antigen (IgM anti-HBc): IgM anti-HBc positivity indicates a recent HBV infection, typically within the last 6 months, signifying acute infection. This test is usually ordered when acute HBV infection is suspected. It’s worth noting that IgM anti-HBc can sometimes be positive in chronic HBV infection during flares or reactivation.
The following table summarizes common test result patterns, their interpretations, and recommended actions:
| Test outcome | Interpretation | Action |
|---|---|---|
| HBsAg — Positive Total anti-HBc — Positive IgM anti-HBc — Positive* Anti-HBs — Negative |
Acute infection | Link to hepatitis B care |
| HBsAg — Positive Total anti-HBc — Positive IgM anti-HBc — Negative Anti-HBs — Negative |
Chronic infection | Link to hepatitis B care |
| HBsAg — Negative Total anti-HBc — Positive Anti-HBs — Positive |
Resolved infection | Counsel about HBV infection reactivation risk |
| HBsAg — Negative Total anti-HBc — Negative Anti-HBs — Positive† |
Immune from receipt of prior vaccination (if documented complete series) | If not vaccinated, then complete vaccine series |
| HBsAg — Negative Total anti-HBc — Positive Anti-HBs — Negative |
Only core antibody is positive. See possible interpretations and corresponding actions.
Resolved infection where anti-HBs levels have waned Occult infection Passive transfer of anti-HBc to an infant born to an HBsAg-positive gestational parent False positive, thus patient is susceptible A mutant HBsAg strain that is not detectable by laboratory assay |
Counsel about HBV infection reactivation risk
Link to hepatitis B care No action Offer HepB vaccine per ACIP Link to hepatitis B care |
| HBsAg — Negative Total anti-HBc — Negative Anti-HBs — Negative‡ |
Susceptible, never infected (if no documentation of HepB vaccine series completion) | Offer HepB vaccine per ACIP recommendations |
* IgM anti-HBc also might be positive in persons with chronic infection during severe HBV infection flares or reactivation.
† Immune if anti-HBs concentration is >10 mIU/mL after vaccine series completion.
‡ Anti-HBs concentrations might wane over time among vaccine responders. People with a documented, complete HepB vaccine series typically do not need to be revaccinated, except for special populations like patients on hemodialysis or health care personnel.
Diagnosing Hepatitis B Infection: The Role of Total Anti-HBc
The presence of total anti-HBc is essential for diagnosing a hepatitis B infection. While total anti-HBc indicates current or past infection, the results of the HBsAg, anti-HBs, and IgM anti-HBc tests are crucial in determining the specific type of hepatitis B infection (acute or chronic) and whether a person has developed immunity.
What to Do Following a Hepatitis B Diagnosis
Upon receiving a Hepatitis B Diagnosis, the CDC recommends the following steps:
- Medical Evaluation: Individuals should receive a comprehensive medical evaluation. This can be performed by a primary care physician or a specialist in liver diseases (hepatologist). Evaluation includes assessment for treatment and ongoing monitoring of liver health.
- Symptom Management: Supportive care should be provided to manage any symptoms experienced during acute infection.
For detailed CDC guidance on testing, management, and treatment of hepatitis B, refer to the Hepatitis B Clinical Care & Treatment resources.
Reporting Hepatitis B Cases: Public Health Surveillance
Hepatitis B, in its acute, chronic, and perinatal forms, is a nationally notifiable condition according to the National Notifiable Diseases Surveillance System (NNDSS).
Healthcare providers are required to report suspected cases of healthcare-associated HBV infection to state and local public health authorities. This reporting is crucial for prompt investigation and public health response.
When reporting a case, specific event codes are required to classify the hepatitis B condition:
- Acute hepatitis B: 10100
- Perinatal hepatitis B: 10104
- Chronic hepatitis B: 10105
Case classifications can be updated as needed before annual surveillance data finalization.
In 2024, the Council of State and Territorial Epidemiologists updated surveillance case definitions for acute and chronic hepatitis B. These definitions guide case classification and reporting to the CDC. Surveillance data plays a vital role in monitoring disease trends, understanding the community burden of hepatitis B, identifying risk factors, detecting outbreaks, and evaluating prevention strategies. For the most current guidance, consult: Viral Hepatitis Surveillance and Case Management Guidance for State, Territorial, and Local Health Departments
Resources for Further Information
Scientific Guidelines and Recommendations
- Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023
- MMWR. Recommendations and Reports / Vol. 72 / No. 1 / P. 1–25
- Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices
- MMWR. Recommendations and Reports / Vol. 67 / No. 1 / P. 1–31
Additional Resources
- HBV Screening, Testing, and Diagnosis
- University of Washington Infectious Diseases & Assessment (IDEA) program.
- Universal Screening and Vaccination in Primary Care
- Driving Hepatitis B Management from Medscape
- Immunize.org Fact Sheet
- Hepatitis B Facts: Testing and Vaccination from Immunize.org
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