Hepatitis is an inflammation of the liver. This is mainly transmitted by various viruses such as the hepatitis A, B or C virus. The hepatitis B virus belongs to the group of DNA viruses. Transmission of the pathogen (route of infection) is sexual, perinatal or parenterally. The risk groups are mainly medical personnel, drug addicts and homosexuals. The risk of infection from a needlestick injury with virus-positive blood is up to 30%. In Germany, approximately 0.6% of the population are chronic carriers of hepatitis B virus. Approximately five percent of those infected with hepatitis B are also infected with the hepatitis D virus. There are also regions Brazil and Romania) where about 40% of hepatitis B infected people are co-infected with hepatitis D. When hepatitis B virus (HBV) infection is suspected, the following laboratory tests should be performed:
- Serology – detection of hepatitis B-specific antigens* .
- Hepatitis B surface antigen (HBsAg) [becomes positive before the onset of clinical symptoms].
- Hepatitis B core antigen (HBcAg).
- Hepatitis B e antigen (HBeAg)
- IgM and IgG antibodies (anti-HBs, anti-HBc, anti-HBe).
- Anti-HBc ELISA (parameter for a fresh or chronic, possibly also healed infection; detection ≥ 1 week later than HBs antigen detection) Note: Anti-HBc ELISA is not positive after vaccination!
- Anti-HBc IgM ELISA (parameter for an acute infection; detection often possible before the appearance of HBs-Ag; persistence: up to 12 months).
- If necessary, detection of hepatitis B PCR (HBV DNA or HBV PCR) – marker for infectivity.
- Liver parameters – alanine aminotransferase (ALT, GPT), aspartate aminotransferase (AST, GOT), glutamate dehydrogenase (GLDH) and gamma-glutamyl transferase (γ-GT, gamma-GT; GGT).
* In accordance with the Protection against Infection Act, suspected illness, illness and death from acute viral hepatitis must be reported. Testing for HDV should be performed in all individuals who have newly diagnosed HBV infection; this should also be followed up in those with known HBV and untested HDV.
Scheme for stepwise diagnosis
| Suspicion of | positive | negative |
| Late incubation phase | HBs antigen1, HBV DNA | Anti-HBs |
| Acute infection | HBs antigen1 + anti-HBc | Anti-HBs |
| HBe antigen2, anti-HBc IgM, if applicable. | ||
| Chronic inactive hepatitis seroconversion of HBe antigen to anti-HBe. | HBs antigen (positive for more than 6 months), anti-HBe, anti-HBc IgG, | HBe antigen2, anti-HBs. |
| HBV DNA (few copies), if necessary. | ||
| Chronic active hepatitis Lack of seroconversion! | HBs antigen (positive for longer than 6 months), HBe antigen2, anti-HBc IgG, HBV DNA. | anti-HB, anti-HBs |
| Infection with healing | Anti-HBs3 (usually persists throughout life), anti-Hbc IgG4 | HBs antigen, HBe antigen |
| Infectivity | HBe antigen2 or HBV DNA | Anti-HBe5 |
| Vaccination (see below) | Anti-HBs3 | Anti-HBc IgG |
Legend
- 1 Routine marker of a fresh infection.
- 2 markers of viral replication (positive during acute and chronic active infection).
- 3 markers for healing and vaccination (see below).
- 4 markers for infection taken place (“seroscar”; lifelong persistence).
- 5 Marker for decreasing viral load (transition to the non-replicative phase; considered a prognostically favorable sign; positive after acute, healed infection for months to (at most) a few years and in chronic infections without significant viral replication).
The procedure
Material needed
- Blood serum (HBs antigen, anti-HBs, anti-HBc, anti-HBc IgM).
- EDTA blood (HBV-PCR)
Preparation of the patient
- Not known
Disruptive factors
- Not known
Standard values
| Parameter | Normal value |
| Anti-HBc | Negative |
| Anti-HBC IgM | Negative |
| Anti-HBe | Negative |
| Anti-HBs | 0-10 U/l After vaccination > 10 U/l |
| HBs antigen | Negative |
| HBe antigen | Negative |
| HBV PCR | Negative |
Indications
- Suspected hepatitis B infection
- Therapy monitoring
Interpretation
Serological parameters in hepatitis B infection.
Overview of the possible constellations of results of laboratory diagnostics and their evaluation.
| HBV DNA | HBsAg | Anti-HBs | Anti-HBc | Anti-HBc IgM | Infection status |
| positive | negative / positive | negative | negative | negative | Acute infection (very early stage) |
| positive | positive | negative | positive | positive | acute infection |
| negative | positive | negative | positive | positive | acute infection |
| negative / positive | negative | negative | positive | positive | Acute infection (late stage) |
| negative / positive | negative | positive | positive | positive | post-acute infection |
| negative | negative | positive | positive | negative | Expired, immunologically controlled infection |
| negative / positive | positive | negative | positive | negative | chronic infection |
| positive | negative | negative | positive | negative | chronic infection (“occult” infection) |
| negative | negative | negative | positive | negative | expired infection |
| negative | negative | positive | negative | negative | Immunity after HBV vaccination |
Further notes
- Vaccination should be given to at-risk groups and children/adolescents; anti-HBs should be determined to monitor vaccination success
- Suspicion of, illness from, and death due to hepatitis are reportable
- Infection with hepatitis B is more severe if there is co-infection with hepatitis D.