Screening

Screening of high-risk people may reduce incidence and prevalence, and early diagnosis and treatment may prevent progression to cirrhosis and hepatocellular carcinoma. Universal screening of adults is cost-effective compared with risk-based screening and reduces the risk of liver disease and death.[96]​​

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:[96]

  • 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 recommend in:[96]

  • People with a history of risk for hepatitis B 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 hepatitis B virus infection:

    • Infants born to a HBsAg-positive mother

    • People born in regions with a hepatitis B virus infection prevalence of ≥2%

    • US-born people not vaccinated as infants whose parents were born in regions with a hepatitis B virus 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 with HIV infection

    • People with a current or past hepatitis C virus 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 hepatitis B virus infection

    • Needle-sharing or sexual contacts of people with known hepatitis B virus infection

    • People on maintenance dialysis (including in-center or at-home haemodialysis and peritoneal dialysis)

    • People with elevated alanine aminotransferase or aspartate aminotransferase 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 serologic 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 hepatitis B virus 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 hepatitis B virus 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 with HIV infection

  • 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 hepatitis B virus 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 hepatitis B virus 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 hepatitis B virus exposure).

US Preventive Services Task Force (USPSTF)

The USPSTF recommends screening adolescents and adults at increased risk of infection with HBsAg tests.[97]​ They also recommend that all pregnant women be screened for hepatitis B virus infection.[97]

American Society of Clinical Oncology (ASCO)

ASCO recommends that all patients receiving systemic anti-cancer therapy should be screened due to the risk of hepatitis B reactivation. Testing should not delay anti-cancer therapy.[98]

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.[66]

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