Hepatitis B: reading the serology, work-up and follow-up of the HBsAg carrier

Laboratory tests

• Hepatitis B serology: HBsAg, anti-HBc antibodies and anti-HBs antibodies

Laboratory tests

• HBeAg and anti-HBe antibodies
• HBV DNA (quantitative viral load)
• Anti-HDV antibodies (hepatitis delta)
• Hepatitis C serology
• HIV serology
• FBC with platelets
• AST
• ALT
• PT
• Serum albumin
• Serum creatinine with eGFR
• HDV RNA (if anti-HDV antibodies positive)if neededAnti-HDV antibodies positive: delta replication is looked for by HDV RNA ^[7]. Covered only if liver involvement is documented ^[3]: often requested by the hepatologist. HDV RNA negative at the initial work-up: check it at 3 and 6 months, and for any unexplained abnormality of the liver function tests ^[7].
• Anti-HAV IgG (if hepatitis A vaccination being considered)if needednon-French guidelineNICE measures anti-HAV IgG at the initial work-up of every HBsAg carrier and the AASLD vaccinates every non-immune person against hepatitis A ^[6,8]. The French schedule recommends this vaccination for patients whose hepatobiliary disease may become chronic, notably because of HBV ^[9]; the HAS (2023) does not address this point in its recommendation ^[1]. The procedure is covered to check long-standing immunity ^[3].
• Liver Doppler ultrasound and elastography (not a laboratory test).
• Contacts (sexual partners, household members, children): hepatitis B serology in their own name, vaccination if negative.

Every 3 to 6 months depending on the phase (see the note)

• ALT

Every 6 to 12 months depending on the phase (see the note)

• HBV DNA (quantitative viral load)
• HBeAg and anti-HBe antibodies (if HBeAg positive)if neededHBeAg-positive infection: HBV DNA and HBeAg every 6 to 12 months ^[1].

Once a year if exposure persists

• Hepatitis C serologyif neededPersistent risk factor (intravenous drug use, unprotected sex, stays in high-endemicity countries) or unexplained rise in transaminases: screening at least once a year ^[1].
• HIV serologyif neededPersistent risk factor (intravenous drug use, unprotected sex, stays in high-endemicity countries) or unexplained rise in transaminases: screening at least once a year ^[1].
• Anti-HDV antibodies (if previous delta serology negative)if neededRepeated exposure to a risk of delta superinfection (regular travel to an endemic area, drug use, sexual risk): annual screening; also to be repeated in the event of an unexplained change in the liver function tests ^[7].
• Reassessment of fibrosis (elastography) and, if risk of hepatocellular carcinoma, ultrasound every 6 months (not a laboratory test).

Every 6 months if screening for hepatocellular carcinoma

• Alpha-fetoprotein (AFP) (if six-monthly ultrasound screening for hepatocellular carcinoma)if neededPatient at risk of hepatocellular carcinoma: NICE combines AFP and ultrasound every 6 months in significant fibrosis or cirrhosis ^[8], the AASLD (2023) also combines the two tests ^[11], and the AFEF (2025) considers the combination probably useful (grade 2+) ^[12]. The HAS (2023) cites ultrasound only ^[1], and the AASLD (2018) judged the evidence insufficient to add AFP ^[6].

As soon as discovered, at the latest before 24 weeks of gestation

• HBV DNA (quantitative viral load)
• AST
• ALT
• HBeAg and anti-HBe antibodies, anti-HDV antibodies, HCV and HIV serology (if not done)if neededDiscovery during pregnancy: initial work-up of the HBsAg carrier ^[1] and testing for HDV in every HBsAg-positive person ^[7].
• Partner: hepatitis B serology and vaccination if negative.
• Newborn: anti-HBs immunoglobulins and first dose of vaccine within 12 hours, then vaccine at 1 and 6 months (and 2 months if < 32 weeks of gestation or < 2 kg).

Child, from 9 months (1 to 4 months after the last dose)

• Child's HBsAg and anti-HBs antibodies (prescription in the child's name)

4 to 8 weeks after the last dose of the schedule

• Anti-HBs antibodies (titration)
• HBsAg and anti-HBc antibodies (if anti-HBs < 10 IU/L, before concluding non-response)if neededAnti-HBs < 10 IU/L after a complete schedule: make sure there is no chronic carriage (HBsAg, anti-HBc) before speaking of non-response ^[16].