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Identification and Management of Hepatitis B Surface Antigen
Persons with chronic hepatitis B virus (HBV) infection are at high risk for chronic liver disease and are a major reservoir
of HBV infection. Foreign-born populations from Africa, Asia, and the Pacific Islands have high rates of chronic HBV
infection (i.e., HBsAg prevalence of >8%). During delivery of recommended hepatitis B vaccination services (e.g., HBsAg screening
of pregnant women and serologic testing to assess susceptibility), vaccination providers will identify persons who are
HBsAg positive. These persons require counseling and medical management for chronic HBV infection to reduce their risk
for chronic liver disease. Their susceptible household, sex, and needle-sharing contacts also should be vaccinated against
Extending screening, referral, and contact vaccination services to persons identified as HBsAg positive can help
prevent serious sequelae in persons with chronic infection and enhance vaccination strategies to eliminate HBV transmission.
This appendix provides guidance for vaccination providers concerning identification and management of persons with
chronic HBV infection. These guidelines are not intended to represent a comprehensive prevention program for persons with
Identification of Persons Who Are Potentially HBsAg Positive
All foreign-born persons (including immigrants, refugees, asylum seekers, and internationally adopted children)
from Africa, Asia, the Pacific Islands, and other regions with high endemicity of HBV infection (Box) should be tested
for HBsAg, regardless of vaccination status.
--- For all persons born in countries in which HBV is highly endemic who are applying for permanent U.S.
residence, HBsAg screening and appropriate follow-up on the basis of HBsAg test results should be
included as part of the required overseas premigration and domestic adjustment-of-visa status medical examination process; information
about this process is available at
HBsAg-positive persons should be considered eligible for migration and adjustment-of-visa status and counseled and recommended for follow-up medical
evaluation and management in U.S. resettlement communities.
--- In all settings that provide health care, providers should identify persons born in countries in which HBV infection is
highly endemic and provide HBsAg testing and follow-up. Retesting of persons who were tested for HBsAg in other
countries should be considered.
Other persons who should be tested for HBsAg as part of vaccination services include
--- all pregnant women (1);
--- persons who receive prevaccination testing for susceptibility and who test positive for anti-HBc (see
Appendix A, Prevaccination Serologic Testing for
--- hemodialysis patients; and
--- nonresponders to vaccination (see Appendix A, Postvaccination Testing for Serologic Response).
Management of Persons Identified as HBsAg Positive
HBsAg-positive persons should be referred for evaluation to a physician experienced in the management of chronic liver
disease; a directory of liver specialists is available at
http://www.hepb.org/resources/other_links_physician.htm. Certain patients
with chronic HBV infection will benefit from early intervention with antiviral
treatment, management of factors that can contribute to disease
progression, or screening to detect hepatocellular carcinoma at an early stage.
Household, sex, and needle-sharing contacts of HBsAg-positive persons should be identified. Unvaccinated sex
partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection (see Appendix
A, Prevaccination Serologic Testing for Susceptibility) and should receive the first dose of
hepatitis B vaccine immediately after collection of blood for serologic testing. Susceptible persons should complete the vaccine series using an
age-appropriate vaccine dose and schedule (see Table 2 and Box 5). Persons who are not fully vaccinated should complete
the vaccine series.
Sex partners of HBsAg-positive persons should be counseled to use methods (e.g., condoms) to protect themselves
from sexual exposure to infectious body fluids (e.g., semen or vaginal secretions) unless they have been demonstrated to
be immune after vaccination (i.e., antibody to HBsAg concentrations of
>10 mIU/mL) or previously infected
(anti-HBc positive). Partners should be made aware that use of condoms and other prevention methods might reduce their risks
for human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs).
To prevent or reduce the risk for transmission to others, HBsAg-positive persons should be advised concerning the
--- perinatal transmission to infants born to
HBsAg-positive women and the need for such infants to
receive hepatitis B vaccine beginning at birth
--- transmission to household, sex, and needle-sharing contacts and the need for such contacts to receive hepatitis
HBsAg-positive persons should also be advised to
--- notify their sex partners about their status;
--- use methods (e.g., condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual
activity until the sex partners can be vaccinated and their immunity documented (persons should be made aware that use
of condoms and other prevention methods might reduce their risks for HIV and other STDs);
--- cover cuts and skin lesions to prevent spread through infectious secretions or blood;
--- refrain from donating blood, plasma, tissue, or semen (organs may be donated to HBV-immune or chronically
infected persons needing a transplant; decisions about organ donation should be made on an individual basis); and
--- refrain from sharing household articles (e.g., toothbrushes, razors, or personal injection equipment) that could
become contaminated with blood.
To protect the liver from further harm, HBsAg-positive persons should be advised to
--- avoid or limit alcohol consumption because of the
effects of alcohol on the liver;
--- refrain from taking any new medicines, including over-the-counter and herbal medicines, without consulting
with their health-care provider; and
--- obtain vaccination against hepatitis A if chronic liver disease is present
When seeking medical or dental care, HBsAg-positive persons should be advised to inform those responsible for their
care of their HBsAg status so that they can be evaluated and their care managed appropriately.
Other counseling messages include the following:
--- HBV is not spread by breastfeeding, kissing, hugging, coughing, ingesting food or water, sharing eating utensils
or drinking glasses, or casual contact.
--- Persons should not be excluded from work, school, play, child care, or other settings on the basis of their HBsAg
status, unless they are prone to biting (3).
--- Involvement with a support group might help patients cope with chronic HBV infection. Information about support groups
is available at http://www.hepprograms.org/support/hepb.asp and
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