Viral Hepatitis Testing
Effective Date: January 1, 2012
Full Guideline in PDF
Recommendations and Topics
This guideline provides guidance for the use of laboratory tests to diagnose acute and chronic viral hepatitis in adults (≥ 19 years) in the primary care setting.
General Considerations for Ordering Laboratory Tests
Prior to ordering tests for hepatitis, consider the patient’s history, age, risk factors (see below), hepatitis vaccination status, and any available previous hepatitis test results.
Risk Factors for Viral Hepatitis include:
- Substance use (includes sharing, drug snorting, smoking or injection equipment)
- High-risk sexual activity or sexual partner with viral hepatitis
- Travel to or from high-risk hepatitis endemic areas or exposure during a local outbreak
- Immigration from hepatitis B and/or C endemic countries
- Household contact with an infected person especially if personal items (e.g., razors, toothbrushes, nail clippers) are shared
- Recipient of unscreened blood products*
- Needle-stick injury or other occupational exposure (e.g., healthcare workers)
- Children born to mothers with chronic hepatitis B or C infection
- Attendance at daycare
- Contaminated food or water (hepatitis A only)
- Tattoos and body piercing
- History of incarceration
- HIV or other sexually transmitted infection
*screening of donated blood products for hepatitis C (anti-HCV) began in 1990 in Canada.1
Types of Viral Hepatitis
Hepatitis A: causes acute but not chronic hepatitis
Hepatitis B: causes acute and chronic hepatitis
Hepatitis C: causes chronic hepatitis but rarely manifests as acute hepatitis
Hepatitis D: rare and only occurs in patients infected with hepatitis B
Hepatitis E: clinically similar to hepatitis A, mostly restricted to endemic areas and occasionally causes chronic infection in immunosuppressed people
Others: e.g., Epstein-Barr Virus (EBV, Mononucleosis) and Cytomegalovirus (CMV) are not addressed within this guideline
Table 1: Diagnostic Testing2
* Patients with a history of prior vaccine induced immunity (anti-HBs >10mIU/mL) will be protected from infection when exposed to HBV or display a booster
(anamnestic) antibody response when revaccinated. If a resolved HBV infection is a consideration, order an anti-HBc total in addition to an anti-HBs.
Occasionally some HBV carriers may be both HBsAg and anti-HBs reactive. These persons should be considered infectious.
Table 2: Interpretation of Results
Diagnosis of HBV infection is usually through serological and virological markers. The incubation period of HBV infection
ranges from 1 to 4 months, and has a wide spectrum of clinical manifestations.3
The results of hepatitis B serologic testing and their corresponding interpretation are shown in Table 3.
Table 3: Hepatitis B Virology Results
+ = reactive; - = non-reactive
* patients with these test profiles can be vaccinated for hepatitis B.
There were 31 reported cases of hepatitis A in British Columbia in 2009 for an incidence of 0.7 per 100,000. A large proportion of hepatitis A cases continue to be identified in persons who have travelled to countries where hepatitis A is common, but were not immunized prior to travel.5 Hepatitis A is usually self-limited, but may be fatal. It does not lead to chronic disease.
In 2009, there were 27 laboratory confirmed cases of acute hepatitis B in British Columbia (0.6 per 100,000) 5. In contrast, there were 1311 reported cases of chronic or undetermined hepatitis B cases (29.5 per 100,000).4 The majority of infections are in persons who have emigrated from a country where hepatitis B is endemic.4 Universal hepatitis B vaccine became available in BC for grade 6 students in 1992, and the infant program was introduced province-wide in 2001.4
Long-term efficacy and booster policy for hepatitis B vaccines have often been a topic of discussion.6 Studies of long-term protective efficacy have yet to determine whether booster doses of vaccine are ever needed. However, routine boosters in immunocompetent persons are generally not necessary. Persons who have had a previously demonstrated protective antibody level will not contract the disease when exposed to HBV, whether or not the antibody is still detectable, because immune memory persists.7 Please see the Public Health Agency of Canada (PHAC), BC Centre for Disease Control (BCCDC) and World Health Organization (WHO) for further information. For current vaccination guidelines, please refer to the BCCDC, www.bccdc.ca.
In 2009, a total of 2,444 cases of hepatitis C were reported for an rate of 54.9 per 100,000.5 Hepatitis C is usually a chronic slowly progressive disease which may progress to cirrhosis and liver cancer after a few decades. Hepatitis C antibodies are not protective and usually indicate active infection. There is no vaccination against hepatitis C.
With the increasing curability of hepatitis C with antiviral therapy and effective hepatitis B antiviral treatments chronically infected hepatitis B or C patients should be considered for referral and treatment. Specific treatments and monitoring are beyond the scope of this guideline.
Hepatitis D and E infections are uncommon in Canada and often in the realm of specialty care.
- Canadian Blood Services. www.bloodservices.ca c1998-2011 cited 2011 May 30. Available from http://www.bloodservices.ca/CentreApps/Internet/UW_V502_MainEngine.nsf/page/E_Hepatitis?OpenDocument
- Hamilton Regional Microbiology Laboratory Protocol for Viral Hepatitis Testing. September 20, 2010.
- Kao, JH. Diagnosis of hepatitis B virus infection through serological and virological markers. Expert Rev. Gastroenterol. Hepatol. 2(4), 553-562 (2008).
- BCCDC Public Health Microbiology & Reference Laboratory, PHSA Laboratories Guide to Programs and Services. September 2010. Available from: www.phsa.ca/AgenciesAndServices/Services/PHSA-Labs/About-PHSA-Labs/BCCDC-Public-Health-Microbiology-Lab.htm
- British Columbia Centre for Disease Control. BC 2009 Annual Summary of Reportable Diseases. [Annual Report] 2010; Aug 18 Available from: www.bccdc.ca/NR/rdonlyres/13B44CDB-740F-4417-90C2-495F6B2424C8/0/2009_CD_Annual_Report_r1.pdf
- Van Damme P, Van herck K. A review of the long-term protection after hepatitis A and B vaccination. Travel Medicine and Infectious Disease. 2007: 5; 79-84.
- Public Health Agency of Canada. Canadian Immunization Guide 2006. Available from: www.phac-aspc.gc.ca/publicat/cig-gci/p04-hepb-eng.php#boost
List of Abbreviations
||Centre for Disease Control
||Public Health Agency of Canada
||World Health Organization
||Hepatitis A virus
||Hepatitis B virus
||Hepatitis C virus
This guideline is based on scientific evidence current as of the Effective Date.
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.
The principles of the Guidelines and Protocols Advisory Committee are to:
- encourage appropriate responses to common medical situations
- recommend actions that are sufficient and efficient, neither excessive nor deficient
- permit exceptions when justified by clinical circumstances.
Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.