Hepatitis B virus (HBV) is often referred to as a silent killer—an apt moniker because chronically infected patients may be asymptomatic for years despite ongoing liver damage. Recent data suggest that up to 1.4 million individuals in the United States may be unaware of their chronic hepatitis B (CHB) serostatus.1 These individuals reflect an ongoing struggle not only to improve immunization rates, but also to increase physician awareness of which patients to screen for HBV and why.

Victor Ankoma-Sey, MD

Victor Ankoma-Sey, MD, director, Liver Associates of Texas PA in Houston, offered advice for developing a clinical suspicion to test for HBV based on patient history. “We start off by asking [patients] about their ethnicity or if their parents were foreign born—most of the the world has high endemicity for HBV. We also ask patients if they or their parents have a history of liver problems or jaundice,” he said.

There also are differences in common modes of transmission among patient demographics. Most individuals are infected with HBV by perinatal transmission or through contact with infected body fluids including blood during childhood.2 Olusegun Adeonigbagbe, MD, a gastroenterologist and internist with practice locations in Brooklyn and Queens, New York, primarily treats immigrants from Africa and the Caribbean as well as Hispanic individuals. The patients in his practice tend to become infected through less common modes of transmission such as IV drug use or unprotected sex,2 thus speaking to the importance of thoroughly questioning patients about their lifestyle.

Olusegun Adeonigbagbe, MD

Dr. Ankoma-Sey makes sure that he discusses additional lifestyle risk factors such as tattoos from a used needle or shared ink source, or blood transfusions from a country that does not effectively screen for communicable diseases.2

Beyond patient risk factors, abnormal liver function also may inform physicians that a patient has liver disease; however, normal test results do not rule out a diagnosis of CHB infection.3,4

“Some physicians say ‘this patient’s liver function test is only 2 points above normal,’ and they don’t worry about HBV until these levels are 2 times or higher. But you can have normal liver function tests and still have CHB, so I always tell them they need to screen patients based on the CDC guidelines [see Figure],”3 said Dr. Adeonigbagbe.

Figure. CDC screening recommendations.
The CDC now recommends testing all individuals born in regions of intermediate or high endemicity (ie, ≥2% prevalence of hepatitis B surface antigen [HbsAg]) or the unvaccinated children of parents born in these regions.
Additional populations to screen include family and household members of individuals with HBV; infants born to mothers infected with HBV; hemodialysis patients; individuals receiving cytotoxic or immunosuppressive therapy; patients with unexplained elevated liver enzyme levels; and all pregnant women.
Disclaimer: This is a partial list of the CDC’s complete screening recommendations for CHB infection.
Based on reference 3.

Some abnormal liver test results, such as elevated serum alanine aminotransferase levels, indicate that a patient is experiencing hepatic inflammation caused by the liver attacking HBV-infected hepatocytes, referred to as the immune clearance stage of CHB infection.4 During the course of CHB infection, patients may experience periods of undetectable HBV DNA and normal liver function followed by a return to the immune clearance phase as viral replication is reactivated.4

According to Dr. Ankoma-Sey, a prolonged cycle of inflammation and hepatic regeneration increases the risk for fibrosis, cirrhosis, or hepatocellular carcinoma.4 “The virus also integrates into the DNA of your liver cells and, because it’s a carcinogen, raises patients’ risk for liver cancer,” said Dr. Ankoma-Sey.

Due to this latent, recurring cycle of activity, any combination of patient risk factors and liver function results should inform physicians to run an HBV blood panel. These panels test for the presence of hepatitis B surface antigen (HBsAg) and HBs antibody.5 Positive results for HBs antibody and negative results for HBsAg indicate that an individual has cleared an acute infection or has been successfully immunized against HBV; patients who test positive for HBsAg for 6 months or more have developed CHB infection.5

Patients often are diagnosed with CHB only after developing advanced cases of liver disease and its corresponding symptoms.2 An earlier diagnosis, however, allows patients to initiate early management and treatment, where appropriate, to reduce the risk for liver damage.1

“Most adults, unless they work in health care, are not immunized. And once a patient has a risk factor for CHB, you have to run the blood tests,” said Dr. Adeonigbagbe. “Testing for HBV should be introduced into the normal blood panels when patients present for their yearly physical.”


  1. Cohen C, Holmberg SD, McMahon BJ, et al. Is chronic hepatitis B undertreated in the United States? J Viral Hepat. 2010;18(6):377-383.
  2. Centers for Disease Control and Prevention. http://www.cdc.gov/​vaccines/​pubs/​pinkbook/​hepb.html. Accessed March 19, 2013.
  3. Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR. 2008;57(RR-8):1-28.
  4. Chen CJ, Yang HI. Natural history of chronic hepatitis B REVEALed. J Gastroenterol Hepatol. 2011;26(4):628-638.
  5. Asian Liver Center at Stanford University. http://liver.stanford.edu/​media/​publications/​Handbook/​2012Handbook.pdf. Accessed March 19, 2013.
Myth vs Fact
Myth Fact
‘I have no symptoms. I can’t possibly have HBV’ CHB is mostly asymptomatic; patients may have few or no symptoms*
HBV is transmitted by sneezing, kissing, coughing, or eating food prepared by a person infected with HBV Many transmissions occur during infancy or early childhood as a result of vertical transmission or direct blood-to-blood contact.** Less common routes of transmission may include engaging in unprotected sex or IV drug use***
CHB does not cause liver cancer People who have CHB have a higher rate of liver cancer than those in the general population*
Patients who have CHB do not need to see their health care provider on a regular basis Patients with CHB will need regular follow up visits with their physicians*
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001324/. Accessed March 19, 2013.
http://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html. Accessed March 19, 2013.
http://www.cdc.gov/hepatitis/b/bfaq.htm#bFAQ10. Accessed March 19, 2013.