Groups at increased risk for hepatitis B virus

Individuals at risk for HBV due to vertical transmission (ie, mother to child transmission)

Individuals born in regions with high (≥8%) or intermediate (≥2%) prevalence rates for HBV, including immigrants and adopted children*
Infants born to pregnant persons who are HBsAg-positive^¶
US-born persons not vaccinated as infants whose parents were born in regions with high HBV endemicity (≥8%)*

Individuals at risk due to horizontal transmission (ie, percutaneous or mucosal exposure to blood or body fluids contaminated with blood)^Δ

Household contacts of HBsAg-positive persons
Needle sharing or sexual contacts of HBsAg-positive persons
Individuals who have ever injected drugs
Individuals with multiple sexual partners and/or history of sexually transmitted infections
Men who have sex with men
Inmates of correctional facilities or other detention settings
Individuals with HIV infection^◊
Individuals with current or past HCV infection^§
Individuals with end-stage kidney disease on maintenance renal dialysis

Other individuals

Individuals with elevated alanine aminotransferase or aspartate aminotransferase levels of unknown origin
Individuals who request HBV testing

In the United States, screening for HBV includes^[4]:

Risk-based screening – For all individuals (including children and adolescents), screen those who have any of the risk factors listed in the table if they might have been susceptible during the period of increased risk^¥. For those with ongoing risk factors (ie, for horizontal transmission) who remain susceptible, continue to test periodically.^Δ
Universal screening – For individuals ≥18 years of age, screen at least once in a lifetime. However, for those without risk factors for HBV, screening is generally not needed if there is documentation of completing a hepatitis B vaccine series and evidence of immunity (anti-HBs ≥10 milli-international units/mL) after vaccination.^‡
Pregnancy screening – Screen all pregnant people during each pregnancy, regardless of vaccination status of history of prior testing.

Refer to UpToDate content on screening and diagnosis of HBV, HBV immunization, and HBV and pregnancy for more detailed information on screening and vaccination.

HBV: hepatitis B virus; HBsAg: hepatitis B surface antigen; US: United States; HIV: human immunodeficiency virus; HCV: hepatitis C virus; anti-HBs: hepatitis B surface antibody; anti-HBc: hepatitis B core antibodies; HBIG: hepatitis B immune globulin.

* If HBsAg-positive persons are found in first-generation immigrants of a family, subsequent generations should be tested.

¶ To reduce the risk of perinatal transmission, infants born to HBsAg-positive mothers should receive HBIG and hepatitis B vaccine as soon as possible and within 12 hours of birth and then complete the hepatitis B series. Post-vaccination serology should be obtained at 9 to 12 months. Refer to the UpToDate topic that discusses HBV immunization in infants.

Δ In unvaccinated individuals with ongoing HBV risk through percutaneous or mucosal exposure, hepatitis B vaccine should be initiated at the time of screening; the need for subsequent doses will depend upon the results. Post-vaccination serology should be performed to ensure immunity. For at-risk persons who do not complete the vaccine series, repeat testing should be performed periodically (eg, every 1 to 2 years).

◊ The presence of HBV coinfection informs the choice of antiretroviral regimen. In addition, patients with HIV who are not immune should be vaccinated regardless of age or risk factors, since HBV infection has an accelerated course in coinfected patients.

§ Patients with chronic HBV are at risk for HBV reactivation with direct-acting antiviral therapy for hepatitis C. Refer to the UpToDate topic that provides an overview of the management of hepatitis C infection.

¥ Susceptible persons include those who have never been infected with HBV (ie, HBsAg-negative, total anti-HBc-negative, and anti-HBs-negative) and either did not complete a HepB vaccine series per the Advisory Committee on Immunization Practices recommendations or who are known to be vaccine nonresponders.

‡ For most patients who remain without risk factors for acquiring HBV, repeat screening is not warranted. However, screening prior to blood, plasma, organ, tissue, or semen donation is routinely performed, regardless of the person's prior history. In addition, screening is warranted prior to initiating immunosuppressive therapy (eg, corticosteroids, biologics, cancer chemotherapy, anti-rejection therapies) since persons with HBV are at risk for HBV reactivation. Refer to the UpToDate topic on HBV reactivation.

References:

Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep 2008; 57:1.
Abara WE, Qaseem A, Schillie S, et al. Hepatitis B vaccination, screening, and linkage to care: Best practice advice from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2017; 167:794.
Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560.
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; 72:1.

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Groups at increased risk for hepatitis B virus