Hepatitis B

Screen all adults aged 18 years or older at least once with HBsAg, total anti-HBc, and anti-HBs. Test HBsAg during each pregnancy. A positive HBsAg identifies current infection but does not distinguish acute from chronic disease; order IgM anti-HBc when current infection is identified or clinically suspected.fda+2fdaPotential Hepatitis B Virus (HBV) Device ReclassificationCDCClinical Testing and Diagnosis for Hepatitis B | Hepatitis B | CDCclinicalinfo hivHepatitis B Virus Infection: Adult and Adolescent OIs | NIH

Interpret HBsAg positive, total anti-HBc positive, IgM anti-HBc positive, and anti-HBs negative as acute HBV infection. HBsAg positive, total anti-HBc positive, IgM anti-HBc negative, and anti-HBs negative indicates chronic HBV infection; link either pattern to hepatitis B care rather than treating serology alone as proof of disease activity.CDCCDCClinical Testing and Diagnosis for Hepatitis B | Hepatitis B | CDC

Interpret HBsAg negative, total anti-HBc positive, and anti-HBs positive as resolved infection. Counsel these patients that prior HBV exposure creates reactivation risk, particularly before immunosuppressive therapy. HBsAg negative, total anti-HBc negative, and anti-HBs negative indicates susceptibility when prior completion of a vaccine series is not documented; offer hepatitis B vaccination.fda+1fdaPotential Hepatitis B Virus (HBV) Device ReclassificationCDCClinical Testing and Diagnosis for Hepatitis B | Hepatitis B | CDC

At the first chronic HBV visit, obtain quantitative HBV DNA and HBeAg/anti-HBe, then assess hepatic injury and reserve with CBC, ALT, AST, albumin, total bilirubin, alkaline phosphatase, and INR. Obtain HAV IgG to determine vaccination need; test HCV antibody with reflex HCV RNA if positive; test HDV antibody with reflex HDV RNA if positive. Perform abdominal ultrasound and fibrosis assessment with transient elastography or a serum fibrosis marker; individualize liver biopsy when noninvasive findings and the treatment decision remain discordant.clinicalinfo hivclinicalinfo hivHepatitis B Virus Infection: Adult and Adolescent OIs | NIH

Do not use an apparently normal aminotransferase value to exclude fibrosis. In chronic HBV, guideline-relevant ALT elevations may begin above 30 U/L in men and 19 U/L in women, and significant fibrosis can occur with normal liver enzymes. Use fibrosis staging to distinguish lower-risk infection from active or advanced liver disease requiring treatment consideration.BMJBMJGuidelines on the management of abnormal liver blood tests

Classify disease by HBeAg status, HBV DNA, ALT, and fibrosis rather than using a single measurement. HBeAg positivity or detectable HBV DNA indicates viral replication; anti-HBe generally corresponds to lower replication, but does not exclude HBeAg-negative chronic hepatitis. Repeated HBV DNA and ALT measurements are needed when activity is uncertain or treatment is deferred.CDC+2CDCRecommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus InfectionScienceDirectEASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infectionWileyAASLD guidelines for treatment of chronic hepatitis B

Antiviral therapy is recommended for patients with cirrhosis or with high HBV DNA plus active or advanced liver disease. The practical treatment goal is durable HBV replication suppression to prevent disease progression and HCC; sustained HBsAg loss is the optimal endpoint but is not the usual immediate endpoint of nucleos(t)ide analogue therapy.The Lancet+1The LancetHepatitis BScienceDirectEASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection

For treatment-naive chronic HBV requiring therapy, choose a high-resistance-barrier agent: entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide. Tenofovir and entecavir are preferred because of potency and minimal resistance risk; avoid low-genetic-barrier antivirals when resistance could precipitate decompensation.ScienceDirect+3ScienceDirectEASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infectionWileyAASLD 2018 Hepatitis B Guidancepublications aapHepatitis B | Red BookPubMedAASLD Guidelines for Treatment of Chronic Hepatitis B - PMC

Pegylated interferon alfa can be considered in selected patients with mild to moderate chronic hepatitis B who can tolerate an interferon-based finite course. Do not use pegylated interferon in decompensated cirrhosis; nucleos(t)ide analogues are safer in cirrhosis, and transplant evaluation should proceed concurrently for eligible patients with decompensation.ScienceDirect+1ScienceDirectEASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infectionPubMedAASLD Guidelines for Treatment of Chronic Hepatitis B - PMC

Monitor treated patients for treatment response and adherence, and continue HCC surveillance because antiviral therapy does not eliminate HCC risk. Monitor untreated patients according to their phase and fibrosis risk; at minimum, immune-tolerant adults need ALT testing every 6 months, while compensated cirrhosis with untreated low-level viremia requires HBV DNA and decompensation assessment every 3 to 6 months.ScienceDirect+2ScienceDirectEASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infectionWileyAASLD guidelines for treatment of chronic hepatitis BPubMedAASLD Guidelines for Treatment of Chronic Hepatitis B - PMC

For patients with resolved infection, document anti-HBc positivity and counsel regarding HBV reactivation before future chemotherapy or immunosuppressive therapy. In people with HIV who will receive immunosuppressive therapy, perform triple-panel HBV screening before treatment unless chronic HBV is already known.CDC+1CDCClinical Testing and Diagnosis for Hepatitis B | Hepatitis B | CDCclinicalinfo hivHepatitis B Virus Infection: Adult and Adolescent OIs | NIH

Vaccination prevents chronic carriage and liver cancer at the population level. In Taiwan, universal infant vaccination reduced childhood HBsAg carriage from 10% to less than 1% over 10 years, and childhood HCC incidence declined 6 to 10 years after program initiation. Offer vaccination to susceptible patients identified by triple-panel testing.NEJM+1NEJMUniversal Hepatitis B Vaccination in Taiwan and the Incidence of Hepatocellular Carcinoma in Children | New England Journal of MedicineCDCClinical Testing and Diagnosis for Hepatitis B | Hepatitis B | CDC