Testing for Hepatitis B infection Prior to Immunosuppressive Therapy

After the Choosing Wisely Campaign sought to raise awareness of uncessary testing in medicine, I wondered about the best test(s) to screen patients for hepatitis B prior to immunosuppresion. After polling a few colleagues gave varying responses, I began to learn it isn't just us that are unclear on this topic.

Unfortunately, guidelines from the various societies are also inconsistent on this topic.

The 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis gives this noncommital suggestion (in the footnote under table 4):

Evaluation might include tests for hepatitis B surface antigen, hepatitis B antibodies, hepatitis B core antibodies...

The CDC has a Hepatitis B page that includes a number of resources on this topic:

The tests used to screen persons for HBV should include HBsAg and hepatitis B surface antibody (anti-HBs).

Alternatively, hepatitis B core antibody (anti-HBc) can be utilized as long as those who test positive are further tested for both HBsAg and anti-HBs to differentiate infection from immunity

Persons receiving cytotoxic or immunosuppressive therapy ... should be tested for serologic markers of HBV infection (i.e., HBsAg, anti-HBc, and anti-HBs)

Throughout these guideliness, recommendations for testing of anti-HBc is the most inconsistent part. To recall, the hepatitis B core antibody:

Anti-HBc appears at the onset of symptoms or liver-test abnormalities in acute HBV infection and persists for life in the majority of persons. MMWR

However, an isolated positive hepatitis B core antibody might be a false positive, especially in low-risk populations:

In low-prevalence populations, isolated anti-HBc may be found in 10%--20% of persons with serologic markers of HBV infection, most of whom will demonstrate a primary response after hepatitis B vaccination

They also point out that:

Isolated anti-HBc positivity can represent:

1) resolved HBV infection in persons who have recovered but whose anti-HBs levels have waned, most commonly in high-prevalence populations;

2) chronic infection in which circulating HBsAg is not detectable by commercial serology, most commonly in high-prevalence populations and among persons with HIV or HCV infection (HBV DNA has been isolated from the blood in <5% of persons with isolated anti-HBc); or

3) false-positive reaction.

Unfortunately, the 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis did not give any additional suggestion regarding the isolated hepatitis B core antibody:

The panel did not make recommendations regarding the use of any biologic agent for treatment in RA patients with a history of hepatitis B and a positive hepatitis B core antibody.

After digesting all of this a bit, it seems most reasonable to:

  1. Test for HBsAg and HBsAb in low risk populations.
  2. In higher risk populations, also include anti-HBc

What is your take on this? Should all patients be tested for anti-HBc?