Hepatitis B Virus Screening and Testing Guidelines 2023
Hepatitis B virus (HBV) is transmitted through contact with infected blood or body fluids which may occur during pregnancy or delivery, sexual activity, or injection drug use. An estimated 1.6 to 2.4 million persons are infected with HBV in the United States and two thirds might be unaware of their infection. Persons with chronic HBV infection are at increased risk for premature death from cirrhosis and hepatocellular carcinoma as well as liver failure from HBV reactivation when receiving immunosuppressive therapy or hepatitis C therapy.
Although there is no cure for chronic hepatitis B, most deaths can be prevented with disease monitoring, antiviral therapy, and liver imaging for hepatocellular carcinoma surveillance. Hepatitis B (HepB) vaccination is highly effective in preventing HBV infection but 70% of adults in the United States were unvaccinated as of 2018.
HBV infection can be detected by reliable and inexpensive screening tests before the development of chronic liver disease. A panel of three serologic tests including Hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc). HBsAg can identify people with an active infection, anti-HBsAg can identify people who are immune, and anti-HBc can identify people who have a re- solved infection but may be susceptible to reactivation. People with negative results for all 3 tests are susceptible to HBV infection and need vaccination.
In CDC’s new 2023 recommendations, “screening” refers to serologic testing of asymptomatic persons not known to be at increased risk for exposure to HBV and “testing” refers to serologic testing of persons with symptoms or who are identified to be at increased risk for exposure to HBV.
Screening is recommended for the following persons:
- All adults aged ≥18 years at least once during a lifetime (new recommendation).
- All pregnant persons* during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing
Testing is recommended for the following persons:
- Everyone with a history of risk for HBV infection, regardless of age. Susceptible persons include those who have never been infected with HBV and either did not complete a HepB vaccine series or who are known vaccine nonresponders.
- Susceptible persons with ongoing risk should be tested periodically, while risk persists.
- Anyone who requests HBV testing regardless of disclosure of risk, because they might be reluctant to disclose stigmatizing risks (new recommendation).
- Persons who have an increased risk for acquiring HBV infection, including the following:
- Infants born to HBsAg-positive pregnant persons
- Persons born in regions with HBV infection prevalence of ≥2%
- U.S.-born persons not vaccinated as infants whose parents were born in regions with HBV infection prevalence of ≥8%
- Persons who have a history of injection drug use
- Persons incarcerated or formerly incarcerated in a jail, prison, or other detention setting (new recommendation)
- Persons with HIV infection
- Persons with HCV infection or a past HCV infection (new recommendation)
- Men who have sex with men
- Persons with STIs or past STIs or multiple sex partners (new recommendation)
- Household contacts or former household contacts of persons with known HBV infection
- Needle-sharing or sexual contacts of persons with known HBV infection
- Persons on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis
- Persons with elevated ALT or AST levels of unknown origin
CDC’s new recommendation for universal hepatitis B screening of adults complements the 2022 ACIP recommendation for universal hepatitis B vaccination of adults aged 19 to 59 years, in addition to adults >59 years with risk factors for HBV infection or who request vaccination.
References
Conners EE, Panagiotakopoulos L, Hofmeister MG, et al. Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023. MMWR Recomm Rep 2023;72(No. RR-1):1–25. DOI: http://dx.doi.org/10.15585/mmwr.rr7201a1
So S, Terrault N, Conners EE. Universal Adult Hepatitis B Screening and Vaccination as the Path to Elimination. JAMA Published Online: March 10, 2023. doi:10.1001/jama.2023.2806
