Hepatitis B Testing

How is it used?

The main uses for hepatitis B virus (HBV) tests include:

• To determine whether acute signs and symptoms, such as jaundice, fever and fatigue, are due to hepatitis B infection; two tests, hepatitis B surface Ag and hepatitis B core antibody IgM, may be performed as part of an acute viral hepatitis panel along with tests for hepatitis A (HAV) and hepatitis C (HCV) to determine which virus may be causing the infection.
• To diagnose chronic HBV hepatitis
• To monitor chronic hepatitis B infection and its treatment
• To detect a previous, resolved hepatitis B infection, in a person who is immune compromised (when the virus can become reactivated) or who has hepatitis C and in whom treatment is planned

Some of the secondary reasons to perform testing include: to screen for hepatitis B infection in at-risk populations or in blood donors, to determine if someone is a carrier, to detect a resolved infection, and to determine if immunity has developed due to vaccination.

Generally, one set of tests is used as an initial panel of tests to detect HBV infection or to determine the cause of acute symptoms while another set of tests may be used after a diagnosis is made to monitor possible progression of the disease, to detect chronic infection, and/or to determine carrier status.

The following table summarizes the set of tests typically used for initial testing:

The following table summarizes tests that may be used as follow-up after initial tests detect an HBV infection:

While the tests described above are specific for HBV, other liver tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT) may be used to monitor the progress of the disease. In some cases, a liver biopsy may be performed to evaluate how much damage has occurred to the liver.

When is it ordered?

Hepatitis B tests may be ordered when someone has signs and symptoms associated with acute hepatitis to determine if they are due to infection with HBV. Some of these include:

• Fever
• Fatigue
• Loss of appetite
• Nausea, vomiting
• Abdominal pain
• Dark urine
• Pale stools
• Joint pain
• Jaundice

Hepatitis B tests may be done as follow up when routine tests results such as ALT and/or AST are elevated. Sometimes acute forms of hepatitis may be detected this way since they may cause only mild symptoms that can be confused with the flu. Chronic hepatitis more often has no symptoms and is more commonly detected when routine test results are abnormal.

A test for hepatitis B surface antigen (HBsAg) may be used for screening when someone falls into one of the high-risk categories for chronic hepatitis B. Joint guidelines from the Centers for Disease Control and Prevention (CDC) and American College of Physicians were published in December 2017 and recommend the following groups be tested for HBsAg:

• People born in areas of the world that have a greater than 2% prevalence of HbsAg (for example, much of Asia and Africa)
• People born in the U.S. but who were not vaccinated and whose parents are from an area with greater than 8% prevalence of HbsAg
• Men who have sex with men
• People who have elevated liver enzymes (ALT and AST) with no known cause
• People with certain medical conditions that require that their immune system be suppressed, such as organ transplant recipients
• People with end-stage kidney disease
• Pregnant women
• Infants born to women with hepatitis B infection
• People who live with a person with hepatitis B infection (household contact) or who have sexual partners with HBV
• Those infected with HIV or HCV
• Individuals living in correctional facilities
• People who inject drugs
• People who donate blood, plasma, tissue, organs or semen

When hepatitis B tests are used to monitor people with chronic hepatitis B infections, they may be performed on a regular basis. Hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg), often along with HBV DNA, are usually measured about every 6 months to a year since, in some people, HBeAg (and, less commonly, HBsAg) will go away on their own. In those who are being treated for chronic HBV, HBeAg and HBV DNA tests can be used to determine whether the treatment is successful.

What does the test result mean?

The tests for hepatitis B may be ordered individually but are often ordered in some combination, depending on the reason for testing. Results of the tests are typically evaluated together. Sometimes the meaning of one result depends on the result of another test. However, not all tests are performed for all people.

The table below summarizes possible interpretations of some common patterns of results.

*Note: There are some types (strains) of HBV that do not make e-antigen. In areas where these strains of HBV are common (in the Middle East and Asia), testing for HBeAg is not very useful. In these cases, a negative HbeAg result does not necessarily mean that the person is not infectious; it may be that the person is infected with a strain that does not make the e-antigen.

Monitoring treatment of chronic infection: If the results from initial and follow-up testing indicate that a person has chronic hepatitis B, then the individual may be treated with medication and the effectiveness of that treatment may be monitored using the tests for HBe and HBs antigen and antibody and HBV DNA:

• If HBsAg becomes negative and anti-HBs becomes positive during treatment, this usually indicates that treatment is effective and that treatment can be discontinued after an additional 6-12 months.
• If HBeAg becomes negative and anti-HBe becomes positive during treatment, this usually indicates that it is effective and that treatment may be discontinued after an additional 6-12 months, although the virus may reappear later, so continued monitoring is needed.
• HBV DNA measures the amount of virus present in the blood. A high result usually means that the virus is actively replicating and that treatment is not effective. A low result or one that is reported as below a lower limit (none detected) means the virus is not present or is present in such low numbers that it cannot be detected. This usually indicates that the therapy is effective in controlling replication of the virus; however, the virus may reappear if the treatment is stopped.

Is there anything else I should know?

Even if you don't have symptoms, an HBV infection can damage your liver and you can spread the infection to others. For this reason, it is important to get tested if you think you have been exposed to HBV.

Blood banks screen all donated blood for the hepatitis B virus (HBV DNA), hepatitis B surface antigen (HbSAg), and hepatitis B core antibody (anti-HBc). Donors are notified of any confirmed positive reactions. People who receive a notice regarding possible infection with hepatitis B after donating should visit their healthcare provider for further testing. The healthcare practitioner will order additional tests to make a proper diagnosis and determine if treatment is necessary.

If exposed to HBV and you haven't been vaccinated, an infection can be avoided by getting a shot of hepatitis B immune globulin (HBIG) within 24 hours and typically you will also be given the first dose of the hepatitis B vaccine.

A test is available to determine the specific type (strain) of hepatitis B virus that is causing a person's infection. This is called HBV genotyping. However, this testing is currently mainly used in research settings and not for clinical purposes.

If it is possible that I have an HBV infection, will I need to have all these tests done?

No. Your healthcare practitioner will determine which test(s) will be appropriate for your symptoms and history.

Should I get the HBV vaccine?

The Centers for Disease Control and Prevention (CDC) recommends that adults in high-risk groups get vaccinated. Some of these groups include people:

• In close contact with someone who has hepatitis B
• Who undergo dialysis
• With chronic liver or kidney disease
• With HIV or who seek treatment for other sexually transmitted diseases or drug treatment
• Who travel to countries where hepatitis B is common
• Who are healthcare workers with potential exposure to HBV

Unless there is something in your medical history to the contrary, it is prudent to get the series of vaccinations. Babies, children and adolescents are routinely given the series of shots; if you have already been vaccinated, you probably are protected for many years, perhaps for life, and will not usually need to get the vaccine again.

How is hepatitis B treated?

There is no specific treatment for acute hepatitis B infections. Symptoms are usually treated with supportive care. This usually involves making sure that you are getting plenty of rest and enough fluids and nutrition by eating and drinking small amounts several times a day.

Chronic forms of hepatitis B may be treated with antiviral medications such as interferon, entecavir, tenofovir, lamivudine, and adefovir. However, some antiviral drugs can have serious side effects and not all people need to be treated. Often, people with chronic hepatitis will be closely monitored to see if they develop cirrhosis or liver cancer. It is important to talk to your healthcare provider about your treatment options and the risks and benefits of those currently available.

What is hepatitis D (HDV) and how is it associated with hepatitis B?

Hepatitis D (HDV) is another virus that can cause liver infections, but only if hepatitis B is also present. A person may become infected with both viruses at the same time (a co-infection) or may first be infected with hepatitis B and then become infected with HDV (a superinfection). In the U.S., the incidence of HDV is low. There is no vaccine for HDV, but since it causes infections only in the presence of HBV, it may be prevented with the HBV vaccine.