Screening
Screening of high-risk people may reduce the incidence and prevalence of hepatitis B virus (HBV) infection, and early diagnosis and treatment may prevent progression to cirrhosis and hepatocellular carcinoma (HCC). Universal screening of adults is cost-effective compared with risk-based screening and reduces the risk of liver disease and death.[104]
Hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs) are recommended for screening. Antibody to hepatitis B core antigen (anti-HBc) may also be recommended by some organisations.
Recommendations and guidance from different organisations may vary. Consult your local guidelines for more information.
Centers for Disease Control and Prevention (CDC)
The CDC recommends screening (using a triple panel of HBsAg, anti-HBs, and total anti-HBc) in the following people:[104]
All adults ≥18 years of age at least once during their lifetime (universal screening)
All pregnant women during each pregnancy (preferably in the first trimester), regardless of vaccination status or history of testing (pregnant women with a history of appropriately timed triple panel screening and without subsequent risk for exposure only need HBsAg screening).
Risk-based testing is recommended in:[104]
People with a history of risk for HBV infection if they might have been susceptible during the period of risk, and susceptible people with ongoing risk while the risk persists (periodic testing), regardless of age.
People who have an increased risk of acquiring HBV infection:
Infants born to a HBsAg-positive mother
People born in regions with a HBV infection prevalence of ≥2%
US-born people not vaccinated as infants whose parents were born in regions with a HBV infection prevalence of ≥8%
Injecting drug users or people who have a history of injection drug use
Incarcerated people or people formerly incarcerated in a jail, prison, or other detention setting
People living with HIV
People living with a current or past hepatitis C virus (HCV) infection
People with a current or past sexually-transmitted infection or multiple sex partners
Men who have sex with men
Current or former household contacts of people with known HBV infection
Needle-sharing or sexual contacts of people with known HBV infection
People on maintenance dialysis (including in-center or at-home haemodialysis and peritoneal dialysis)
People with elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels of unknown origin
Anyone who requests testing, regardless of disclosure risk.
People who have not completed a hepatitis B vaccine series should be offered vaccination as per current recommendations, after the collection of blood for serological testing.
American Association for the Study of Liver Diseases (AASLD)
The AASLD recommend the following people be screened:[2]
People born in regions of intermediate or high HBV infection endemicity (i.e., prevalence of HBsAg ≥2%)
US-born people not vaccinated as an infant, and whose parents were born in regions with high HBV infection endemicity (i.e., ≥8%)
People who have ever injected drugs
Men who have sex with men
People with multiple sexual partners
People on immunosuppressive therapy
People with elevated liver function tests of unknown etiology
Blood, plasma, organ, tissue, or semen donors
People with end-stage renal disease who require dialysis
Pregnant women
Infants born to HBsAg-positive mothers
People with chronic liver disease
People living with HIV
Contacts (e.g., household, sexual, needle-sharing) of HBsAg-positive people
People seeking treatment for a sexually-transmitted infection
Healthcare workers or public safety workers at risk for occupational exposure
Residents and staff of facilities for developmentally disabled persons
Travellers to countries with an intermediate or high prevalence of HBV infection
Inmates of correctional facilities
Unvaccinated people with diabetes aged 19-59 years
People who are the source of blood or body fluid exposures that may require post-exposure prophylaxis.
Anti-HBs-negative people should be vaccinated.
The AASLD guidance is primarily based on previous recommendations from the CDC that have since been updated in 2023 (see section above). Current AASLD guidance differs from the new CDC guidance by recommending screening of: unvaccinated people with diabetes aged 19-59 years; travellers to countries with an intermediate or high prevalence of HBV infection; and residents and staff of facilities for developmentally disabled persons. AASLD only recommends anti-HBc testing for certain groups (i.e., as long as those who test positive are tested further for HBsAg and anti-HBs to differentiate current infection from previous HBV exposure).
European Association for the Study of the Liver (EASL)
The EASL recommend screening (with HbsAg and anti-HBc) in people with:[29]
Elevated liver enzymes and/or clinical signs of liver disease
Cirrhosis/fibrosis of the liver
Liver cancer (HCC or biliary tract cancer)
Extrahepatic manifestations possibly related to HBV
End-stage kidney disease undergoing haemodialysis
HIV
HCV infection
An increased risk of exposure to HBV, including:
People from regions with intermediate to high HBsAg prevalence
Family or household members of HBV-infected individuals
Sexual partners of HBV-infected individuals
People in care/correctional facilities
People with multiple sexual partners
People who seek examination or treatment for sexually transmitted infections
People with non-medical exposure to body fluids
Active and former people who inject drugs
Congenital immunodeficiency
Screening is also recommended in people being considered for (or undergoing) immunosuppressive/immunomodulatory therapy or chemotherapy, or stem cell/bone marrow or organ transplants and recipients of such transplants.
Screening (with HBsAg only) is recommended in blood, tissue, semen, and organ donors, healthcare workers, and pregnant women to prevent transmission.
Population-based screening beyond risk groups is advocated in order to identify unknown cases, especially in countries with intermediate to high endemicity.
US Preventive Services Task Force (USPSTF)
The USPSTF recommends screening adolescents and adults at increased risk of infection with HBsAg tests.[105] They also recommend that all pregnant women be screened for HBV infection.[105]
American Society of Clinical Oncology (ASCO)
ASCO recommends that all patients receiving systemic anti-cancer therapy should be screened due to the risk of HBV reactivation. Testing should not delay anti-cancer therapy.[106]
The American College of Obstetricians and Gynecologists (ACOG)
ACOG recommends early universal antenatal screening for HBsAg in all pregnant women in each pregnancy, regardless of testing history or vaccination status. ACOG recommends triple panel screening (i.e., HBsAg, anti-HBs, and total anti-HBc) for all pregnant women who do not have a documented negative triple screen result after aged 18 years, or who have not completed a hepatitis B vaccine series, or in patients with ongoing risk factors for HBV infection, regardless of testing history or vaccination status.[77]
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