Hepatitis B: Testing Algorithm

for Screening, Diagnosis, and Management

Pregnant women, order: Suspected chronic hepatitis Suspect previous hepatitis Suspected chronic hepatitis Suspected acute hepatitis, Previous hepatitis exposure,
PHSP / Prenatal Hepatitis B virus (HBV),infection, order: B exposure, order HBPES / (type unknown), order: order: AHEP / Acute Hepatitis order: PHEP / Previous Hepatitis
Evaluation, Serum CHBVS / Chronic Hepatitis B Hepatitis B Virus Past CRHEP / Chronic Hepatitis Profile, Serum (Unknown Type), Serum
Screen, Serum Exposure Panel, Serum (Unknown Type), Serum

Result consistent with Results consistent with

■ Acute hepatitis B ■ False-positive results

■ Delayed hepatitis B surface antibody (anti-HBs) response after acute ■ Waning immunity from

HBV infection remote HBV infection

Check in 3 to 6 months*: ■ Past or resolved HBV

■ HBAB / Hepatitis B Surface Antibody, Qualitative/Quantitative, Serum infection

■ HBAG / Hepatitis B Surface Antigen, Serum ■ HBV vaccination

Consider other causes

of hepatitis
■ Positive HBs antigen ■ Negative HBs antigen
■ Negative HBs antibody ■ Positive HBs antibody

Results consistent with

■ Chronic hepatitis B STOP
■ “Flare-up” chronic hepatitis B

■ Occult chronic HBV infection

Order*:
■ EAG / Hepatitis B e Antigen, Serum

■ HEAB / Hepatitis B e Antibody, Serum

■ Order HBVQN / Hepatitis B Virus (HBV) DNA Detection

Results consistent with chronic hepatitis B* and Quantification by Real-Time PCR, Serum
■ Order serum alanine aminotransferase (ALT) level
Positive hepatitis B e (HBe) antigen Negative HBe antigen

ALT level between 1 ALT level >2 times Normal ALT level and Elevated ALT level
Normal ALT level to 2 times the upper the upper limit of HBV DNA <2000 IU/mL
limit of normal range normal range

Observe and Consider liver ■ Consider liver biopsy

monitor ALT level
and HBe antigen
every 6 to 12 months
biopsy ■ Consider HBV drug resistance test
if adult-acquired infection Contact
Mayo Clinic Laboratories to order
Consider HBV genotype test if
■ ■
considering interferon therapy
Contact Mayo Clinic Laboratories
to order
Treatment with nucleos(t)ide
analog and/or IFN-alpha
■ Observe and monitor ALT levels HBV DNA <2000 IU/mL
every 3 months for 1 year
■ Consider monitoring HBV DNA
levels every 3 months for 1 year
■ Consider liver biopsy
using HBVQN
Order HBAGQ / Hepatitis
B Virus Surface Antigen,
Quantitative, Serum
to monitor disease
progression and response
to antiviral therapy
Normal ALT level Elevated ALT level ■ Observe and monitor
ALT and HBV DNA every
6 months
HBV DNA ≥2000 IU/mL
■ Suggest liver biopsy
■ Treat if moderate to
severe inflammation or
significant fibrosis
■ Monitor every 3 to 6
months using HBVQN
■ Monitor annually using
HBAG / Hepatitis B
Surface Antigen, Serum

Monitor ALT annually

■ Monitor treatment response every 3 to with or without HBV
6 months by checking HBVQN DNA levels
■ If resistance to a nucleos(t)ide analog
is suggested, consider ordering HBV
drug resistance test. Contact Mayo
Clinic Laboratories to order.

Result Profile Table

HBs Hepatitis B Hepatitis A
HBs antibody core (HBc) HBc IgM HBe virus (HAV) HAV IgM HCV IgG
Test ID Test Name Antigen (Ab) total Ab Ab Antigen HBe Ab IgG Ab Ab Ab Diagnosis

Acute Hepatitis Profile,

AHEP + + – – Acute hepatitis B
Serum

Chronic Hepatitis + – + – Chronic hepatitis B

CRHEP
(Unknown Type), Serum
Hepatitis B Virus Past
HBPES
Exposure Panel, Serum
Chronic Hepatitis B
CHBVS
Screen, Serum
Previous Hepatitis
PHEP
(Unknown Type), Serum
– ± + – Past/resolved HBV infection
– – – No previous exposure
– – + Remote past exposure with waning immunity to hepatitis B
– + + Past exposure with immunity to hepatitis B
+ – + Chronic hepatitis B
+ + – Chronic hepatitis B, active
+ – + Chronic hepatitis B, inactive
a) Chronic hepatitis B, or
+ – + – –
b) “Flare–up” chronic hepatitis B
a) False-positive results, or
b) Waning immunity from remote HBV infection, or
– – + – –
c) Occult chronic HBV infection, or
d) Delayed anti-HBs response after acute HBV infection
– + + – – Past/resolved HBV infection
– + – – – HBV vaccination

*As recommended by the American Association for the Study of Liver Disease AASLD 2018 Hepatitis B Guidance

© Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. 01/2022